Medicare

The Omnibus Budget Reconciliation Act of 1987 reduced Medicare payments to anesthesiologists when they concurrently direct certified registered nurse anesthetists. Concurrently directed cases are those in which one anesthesiologist is involved in two or more overlapping surgeries. For each surgery, the anesthesiologist must meet several conditions, including being present when the patient enters and leaves anesthesia and providing directions to the nurse anesthetists, who actually do much of the work. GAO found that Medicare still pays substantially more for directed cases than for services provided personally by an anesthesiologist. Because physicians' hourly revenue for concurrently directed services is much higher than for personally provided services, Medicare payments can influence the way in which anesthesia is delivered. GAO concludes that Medicare should set a fair price for anesthesia services and pay that amount regardless of how the service is delivered. GAO believes that the reduced payment was not large enough to cause anesthesiologists to alter their relationship with nurse anesthetists. Other factors that may contribute to maintaining the anesthesiologist-nurse status quo are the (1) shortage of nurse anesthetists and (2) ratio of anesthesiologists to nurse anesthetists in an area.

GAO found that: (1) Medicare is providing an economic incentive for medically directed anesthesia, since it pays more for cases that involve medical direction of CRNA and residents than for cases where the anesthesiologist provides the service; (2) anesthesiologists received higher Medicare payments when they medically direct residents than when they personally provide anesthesia services or direct CRNA, since most Medicare carriers use 15-minute service intervals for time units when anesthesiologists direct residents and 30-minute intervals for direction of CRNA for the same medical procedures; and (3) the act had no discernible effect on CRNA use or employment because there is a nationwide CRNA shortage and decisions to use an anesthesiologist, a CRNA, or both are often dictated by the local availability of those professionals.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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