Medicare
Payment Changes Are Needed for Assistants-at-Surgery Gao ID: GAO-04-97 January 13, 2004Medicare pays for assistant-atsurgery services under both the hospital inpatient prospective payment system and the physician fee schedule. Payments under the physician fee schedule are limited to a few health professions. In 2001, Congress directed GAO to report on the potential impact on the Medicare program of allowing physician fee schedule payments to Certified Registered Nurse First Assistants for assistant-at-surgery services. This report examines: (1) who serves as an assistant-atsurgery, (2) whether health professionals who perform the role must meet a uniform set of professional requirements, and (3) whether Medicare's payment policies for assistants-at-surgery are consistent with the goals of the program and, if not, whether there are alternatives that would help attain those goals. GAO analyzed information provided by physician and other health professional associations and Medicare payment data.
Members of a wide range of health professions serve as assistants-at-surgery, including physicians, residents in training for licensure or board certification in a physician specialty, several different kinds of nurses, and members of several other health professions. Hospitals employ all the types of nonphysician health professionals who perform the role. Hospital employees likely serve as assistants-at-surgery for a majority of the procedures for which the American College of Surgeons says an assistant is "almost always" necessary. The number of assistant-at-surgery services performed by physicians and paid under the Medicare physician fee schedule has declined, while the number of such services performed by nonphysician health professionals eligible to receive payment under the physician fee schedule has increased. There is no widely accepted set of uniform requirements for experience and education that the health professionals who serve as assistants-at-surgery are required to meet. The health professions whose members provide assistant-at-surgery services have varying educational requirements. No state licenses all the health professionals who serve as assistants-at-surgery. Furthermore, the certification programs developed by the various nonphysician health professional groups whose members assist at surgery differ. GAO found that there was insufficient information about the quality of care provided by assistants-at-surgery generally, or by a specific type of health professional, to assess the adequacy of the requirements for members of a particular profession to perform the role. There are three flaws in Medicare's policies for paying assistants-at-surgery that prevent the payment system from meeting the program's goals of making appropriate payment for medically necessary services by qualified providers. First, because Medicare pays for assistant-at-surgery services under both the hospital inpatient prospective payment system and the physician fee schedule, and hospital payments for surgical care are not adjusted when an assistant receives payment under the physician fee schedule, Medicare may be paying too much for some hospital surgical care. Second, paying a health professional under the physician fee schedule to be an assistant-at-surgery, instead of including this payment in an all-inclusive payment, gives neither the hospital nor surgeon an incentive to use an assistant only when one is medically necessary. Third, the distinctions between those health professionals eligible for payment as an assistant-at-surgery under the physician fee schedule and those who are not eligible are not based on surgical education or experience as an assistant. Criteria for determining who should be paid as assistants-at-surgery under the physician fee schedule do not exist. However, hospitals are responsible under health and safety rules to provide quality care for their patients.
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Director: Team: Phone:GAO-04-97, Medicare: Payment Changes Are Needed for Assistants-at-Surgery
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entitled 'Medicare: Payment Changes Are Needed for Assistants-at-
Surgery' which was released on January 13, 2004.
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Report to Congressional Committees:
United States General Accounting Office:
GAO:
January 2004:
Medicare:
Payment Changes Are Needed for Assistants-at-Surgery:
GAO-04-97:
GAO Highlights:
Highlights of GAO-04-97, a report to congressional committees
Why GAO Did This Study:
Medicare pays for assistant-at-surgery services under both the
hospital inpatient prospective payment system and the physician fee
schedule. Payments under the physician fee schedule are limited to a
few health professions. In 2001, Congress directed GAO to report on
the potential impact on the Medicare program of allowing physician fee
schedule payments to Certified Registered Nurse First Assistants for
assistant-at-surgery services. This report examines: (1) who serves
as an assistant-at-surgery, (2) whether health professionals who
perform the role must meet a uniform set of professional requirements,
and (3) whether Medicare‘s payment policies for assistants-at-surgery
are consistent with the goals of the program and, if not, whether
there are alternatives that would help attain those goals. GAO
analyzed information provided by physician and other health
professional associations and Medicare payment data.
What GAO Found:
Members of a wide range of health professions serve as assistants-at-
surgery, including physicians, residents in training for licensure or
board certification in a physician specialty, several different kinds
of nurses, and members of several other health professions. Hospitals
employ all the types of nonphysician health professionals who perform
the role. Hospital employees likely serve as assistants-at-surgery for
a majority of the procedures for which the American College of
Surgeons says an assistant is ’almost always“ necessary. The number of
assistant-at-surgery services performed by physicians and paid under
the Medicare physician fee schedule has declined, while the number of
such services performed by nonphysician health professionals eligible
to receive payment under the physician fee schedule has increased.
There is no widely accepted set of uniform requirements for experience
and education that the health professionals who serve as assistants-at-
surgery are required to meet. The health professions whose members
provide assistant-at-surgery services have varying educational
requirements. No state licenses all the health professionals who serve
as assistants-at-surgery. Furthermore, the certification programs
developed by the various nonphysician health professional groups whose
members assist at surgery differ. GAO found that there was
insufficient information about the quality of care provided by
assistants-at-surgery generally, or by a specific type of health
professional, to assess the adequacy of the requirements for members
of a particular profession to perform the role.
There are three flaws in Medicare‘s policies for paying assistants-at-
surgery that prevent the payment system from meeting the program‘s
goals of making appropriate payment for medically necessary services
by qualified providers. First, because Medicare pays for assistant-at-
surgery services under both the hospital inpatient prospective payment
system and the physician fee schedule, and hospital payments for
surgical care are not adjusted when an assistant receives payment
under the physician fee schedule, Medicare may be paying too much for
some hospital surgical care. Second, paying a health professional
under the physician fee schedule to be an assistant-at-surgery,
instead of including this payment in an all-inclusive payment, gives
neither the hospital nor surgeon an incentive to use an assistant only
when one is medically necessary. Third, the distinctions between those
health professionals eligible for payment as an assistant-at-surgery
under the physician fee schedule and those who are not eligible are
not based on surgical education or experience as an assistant.
Criteria for determining who should be paid as assistants-at-surgery
under the physician fee schedule do not exist. However, hospitals are
responsible under health and safety rules to provide quality care for
their patients.
What GAO Recommends:
GAO suggests that Congress may wish to consider consolidating all
Medicare payments for assistant-at-surgery services under the hospital
inpatient prospective payment system. CMS agreed that payment policy
for assistants-at-surgery could be improved.
www.gao.gov/cgi-bin/getrpt?GAO-04-97.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Majorie Kanof (202)
512-7101.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Various Health Professionals Provide Assistant-at-Surgery Services,
and Hospital Employees Provide Most of These Services:
Widely Accepted Professional Requirements for Assistants-at-Surgery Do
Not Exist:
While Medicare Payments for Assistant-at-Surgery Services Have Flaws,
Paying Hospitals for All These Services Would Correct Them:
Conclusions:
Matter for Congressional Consideration:
Agency Comments:
Appendix I: Professional Associations, Schools, and Hospitals:
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
Tables:
Table 1: Physician Fee Schedule Payments for Health Professionals for
Assistant-at-Surgery Services:
Table 2: Health Professions Whose Members Can Assist at Surgery:
Table 3: Education and State Licensure Requirements for Those Who May
Assist at Surgery:
Table 4: Surgical Education and Experience Requirements for
Certification as an Assistant-at-Surgery:
Figure:
Figure 1: Percentage of Assistant-at-Surgery Services Paid under the
Physician Fee Schedule for Physicians and Nonphysician Health
Professionals, 1997-2002:
Abbreviations:
ACS: American College of Surgeons:
AHA: American Hospital Association:
BBA: Balanced Budget Act of 1997:
CMS: Centers for Medicare & Medicaid Services:
CoP: condition of participation:
CRNFA:Certified Registered Nurse First Assistant:
GME: graduate medical education:
HCFA Health Care Financing Administration:
PPS prospective payment system:
United States General Accounting Office:
Washington, DC 20548:
January 13, 2004:
Congressional Committees:
Ensuring that Medicare beneficiaries receive care from qualified
providers and that payments to providers are for the appropriate amount
and only for medically necessary services are recognized goals of
Medicare. Achieving these goals when paying for assistants-at-
surgery,[Footnote 1] who perform tasks as members of surgical teams
under the direction of surgeons, poses a particular challenge because
of the range of considerations affecting whether hospitals or surgeons
decide an assistant is necessary for a given beneficiary's surgical
procedure and the variation in education and experience of individuals
who serve as assistants.
Medicare pays hospitals, physicians, and certain nonphysician health
professionals for assistant-at-surgery services through the hospital
inpatient prospective payment system (PPS) and the Medicare physician
fee schedule. Medicare makes a single payment to hospitals for all the
services, including assistant-at-surgery services, that a hospital
provides to a beneficiary while an inpatient. The inpatient PPS pays
predetermined fixed amounts for groups, or bundles, of services,
designed to provide incentives to control spending by rewarding
efficiency. Medicare also pays teaching hospitals under the inpatient
PPS for providing graduate medical education (GME) to the residents
employed by the hospital, some of whom assist at surgery.
Medicare also makes payments under the Medicare physician fee schedule
for assistant-at-surgery services performed by physicians and members
of certain nonphysician health professions whose members assist. These
nonphysician health professionals--primarily physician assistants,
nurse practitioners, and clinical nurse specialists--are allowed to
bill Medicare under the physician fee schedule.[Footnote 2] Congress
has been asked to authorize Certified Registered Nurse First Assistants
(CRNFA) and other nonphysician health professional groups whose members
provide assistant-at-surgery services to bill Medicare under the
physician fee schedule for these services.
In 2001, Congress directed us to report on the potential impact on the
Medicare program of allowing physician fee schedule payments to CRNFAs
for assistant-at-surgery services.[Footnote 3] Congress required that
we give special consideration to quality of care, appropriate education
requirements, and appropriate rates of Medicare payment for assistants-
at-surgery. This report examines: (1) who serves as an assistant-at-
surgery, (2) whether health professionals who perform the role must
meet a uniform set of professional requirements, and (3) whether
Medicare's payment policies for assistants-at-surgery are consistent
with the goals of the program and, if not, whether there are
alternatives that would help attain those goals.
To determine who serves as an assistant-at-surgery, we analyzed
Medicare data for 1997 through 2002 from the Part B Extract and Summary
System maintained by the Centers for Medicare & Medicaid Services
(CMS),[Footnote 4] which oversees Medicare. These summary data are
derived from the Medicare Physician/Supplier Procedure Summary Master
Files, which contain procedure-specific billing data for all physician
and supplier services provided to Medicare beneficiaries each year. CMS
contractors edit these data, and data limitations are published
annually. We used our analysis of these data to determine the number,
variety, and location of surgical procedures for which physician and
nonphysician health professional assistants-at-surgery sought Medicare
payment under the physician fee schedule.[Footnote 5] We also analyzed
these data by the categories in the American College of Surgeons' (ACS)
study that classifies each surgical procedure by the likelihood that it
will require an assistant-at-surgery.[Footnote 6] We could not
determine the number of assistants-at-surgery who were paid under the
inpatient PPS because CMS does not collect those data. We interviewed
staff from CMS; representatives of nine large academic teaching
hospitals distributed across the country; and representatives of state
licensing boards, assistant-at-surgery education programs, and
associations of hospitals, physicians, nurses, and other health
professions, including those whose members assist at surgery (see app.
I). We used these interviews to determine whether nonphysician health
professionals who perform the role of assistant-at-surgery must meet a
uniform set of professional requirements. In making this determination,
we also reviewed literature about the licensure and certification of
health professionals who serve as assistants-at-surgery and Medicare
laws and regulations affecting assistants.
We conducted our work from July 2001 through December 2003 in
accordance with generally accepted government auditing standards.
Results in Brief:
Members of a wide range of health professions serve as assistants-at-
surgery, including physicians, residents in training for licensure or
board certification in a physician specialty, several different kinds
of nurses, and members of several other health professions. Hospitals
employ residents, international medical graduates,[Footnote 7] and all
the types of nonphysician health professionals who perform the role.
Hospital employees likely serve as assistants-at-surgery for a majority
of the procedures for which the ACS says an assistant is "almost
always" necessary. Since 1997, the number of assistant-at-surgery
services performed by physicians and paid under the Medicare physician
fee schedule has declined, while the number of such services performed
by nonphysician health professionals eligible to receive payment under
the physician fee schedule has increased.
There is no widely accepted set of uniform requirements for experience
and education that the health professionals who serve as assistants-at-
surgery are required to meet. The health professions whose members
provide assistant-at-surgery services have varying educational
requirements. No state licenses all the health professionals who serve
as assistants-at-surgery, and the health professional licenses that
states do issue typically attest to the completion of broad-based
health care education, rather than education or experience as an
assistant. Furthermore, the certification programs developed by the
various nonphysician health professional groups whose members assist at
surgery differ. We found that there was insufficient information about
the quality of care provided by assistants-at-surgery generally, or by
a specific type of health professional, to assess the adequacy of the
requirements for members of a particular profession to perform the
role.
There are three flaws in Medicare's policies for paying assistants-at-
surgery that prevent the payment system from meeting the program's
goals of making appropriate payment for medically necessary services by
qualified providers. First, because Medicare pays for assistant-at-
surgery services through both the hospital inpatient PPS and the
physician fee schedule, and hospital payments for surgical care are not
adjusted when an assistant receives payment under the physician fee
schedule, Medicare may be paying too much for some hospital surgical
care. Second, paying a health professional under the Medicare physician
fee schedule to be an assistant-at-surgery, instead of including this
payment in an all-inclusive payment, gives neither the hospital nor
surgeon an incentive to use an assistant only when one is medically
necessary. Third, the distinctions between those health professionals
eligible for payment as an assistant-at-surgery under the physician fee
schedule and those who are not eligible are not based on surgical
education or experience as an assistant. Criteria for determining who
should be paid as assistants-at-surgery under the physician fee
schedule do not exist. However, hospitals are responsible under health
and safety rules to provide quality care for their patients.
To help address these flaws and meet Medicare's goals, we suggest that
Congress may wish to consider consolidating all Medicare payments for
assistant-at-surgery services under the hospital inpatient prospective
payment system. We received comments on a draft of this report from
CMS, which agreed that payment policy for assistants-at-surgery could
be improved. CMS also discussed several details related to implementing
payment policy changes.
Background:
Assistants-at-surgery, who serve as members of surgical teams, perform
tasks under the direction of surgeons and aid them in conducting
operations. These tasks may include making initial incisions
("opening"), exposing the surgical site ("retracting"), stemming blood
flow ("hemostasis"), surgically removing veins and arteries to be used
as bypass grafts ("harvesting"), reconnecting tissue ("suturing"), and
completing the operation and reconnecting external tissue ("closing").
Some of these tasks, like retraction, are relatively simple, while
others, such as harvesting, are more complex. An assistant-at-surgery
may perform one or more simple or complex tasks during an operation.
Tasks performed by others on the surgical team differ from those
performed by assistants-at-surgery. Scrub staff work within the sterile
field--the area within the operating room that is kept free from
harmful microorganisms--passing instruments, sponges, and other items
directly to the surgeon and assistant-at-surgery who work within the
sterile field. Circulators work outside the sterile field, responding
to the needs of team members within the sterile field.
Anesthesiologists, or anesthetists, who administer and monitor
anesthesia, painkillers, and other drugs, are also present during an
operation.
Need for Assistants-at-Surgery Depends on Complexity of Operation,
Condition of Patient:
Decisions by a hospital or surgeon to use an assistant-at-surgery
depend on the complexity of the operation and medical condition of the
patient. Physician associations, such as the ACS and the American
Society of General Surgeons, maintain that the surgeon should be
responsible for determining if an assistant-at-surgery is needed,
although some hospitals require the use of an assistant for certain
surgical procedures. Hospitals that employ assistants-at-surgery may
assign them to a procedure without consulting the surgeon performing
the procedure.
Since 1994, the ACS, with other surgical specialty organizations, has
conducted studies to determine which surgical procedures require
physicians as assistants-at-surgery. These studies classify surgical
procedures as "almost always," "sometimes," or "almost never"
requiring an assistant-at-surgery. The 2002 study classifies
approximately 5,000 surgical procedures, about 1,750 of which are
designated as "almost always" requiring a physician to serve as an
assistant-at-surgery.[Footnote 8]
A small number of surgical procedures have accounted for the majority
of the assistant-at-surgery services paid for under the Medicare
physician fee schedule: In 2002, 100 procedures accounted for almost 75
percent of the assistant-at-surgery services that Medicare paid under
the physician fee schedule. ACS designated 81 of these procedures as
"almost always" requiring a physician as an assistant-at-surgery, and
the remaining 19 procedures were designated as "sometimes" requiring a
physician as an assistant.
Medicare Pays for Assistants-at-Surgery as Part of PPS Payments to
Hospitals and under the Physician Fee Schedule:
Medicare pays for medically necessary services, including those
performed by assistants-at-surgery, for eligible elderly and disabled
patients provided by health professionals and institutions meeting
certain requirements. Part A, or Hospital Insurance, pays for inpatient
hospital care, care provided by certain other health care facilities,
and some home health care. Part B, or Supplementary Medical Insurance,
includes payment for the services and items provided by physicians,
certain other nonphysician health professionals, suppliers, outpatient
hospital departments, and home health care agencies.
Medicare makes payments to hospitals under part A through the hospital
inpatient PPS[Footnote 9] for assistants-at-surgery.[Footnote 10] A
fixed payment is made for all the inpatient hospital services,
including assistant-at-surgery services, that a hospital provides to a
beneficiary with a given diagnosis or receiving a particular type of
surgery. Payments under the hospital inpatient PPS reflect the average
bundle of services that beneficiaries with a particular diagnosis
receive as inpatients in similar hospitals. The hospital's payment
for a bundle of services is the same regardless of whether an
assistant-at-surgery is used or who provides the assistant-at-surgery
services.
Prospective payment systems, such as the hospital inpatient PPS, are
designed to promote efficiency: because the payment for a particular
bundle of services is almost always the same, regardless of the
services a particular patient receives, hospitals are discouraged from
providing unnecessary services.[Footnote 11] Providing additional
services would not increase their payments. Consequently, PPS payments
to the hospital are sometimes less and sometimes more than the cost of
providing care.
Payments are also made under the hospital inpatient PPS to teaching
hospitals for providing GME to the residents employed by the
hospital.[Footnote 12] In 2001, about 20 percent of the approximately
5,800 U.S. hospitals were considered teaching hospitals. In 2003,
surgical residents comprised about 20 percent of all residents at these
hospitals.[Footnote 13] There were about 7,500 residents in general
surgery and about 13,000 more surgical residents training for
specialties, such as orthopedics, all of whom were required to serve as
assistants-at-surgery as part of their training. In addition to these
surgical residents, some nonsurgical residents have surgical rotations
during which they serve as assistants-at-surgery.
Medicare makes part B payments to assistants-at-surgery under the
physician fee schedule[Footnote 14] when assistant services are
performed by a physician or by a nonphysician health professional
authorized to receive such payment. In 2002, these payments totaled
about $158 million, less than 2 percent of the $10.5 billion Medicare
paid to surgeons for surgical procedures that year. Medicare also makes
global payments to surgeons under the physician fee schedule that cover
the surgery and some pre-and postoperative services that the surgeons
and their employees perform. Assistant-at-surgery services are not
included in this bundle of services. Generally, the amount Medicare
pays under the physician fee schedule is based on the resources needed
to perform a service: the physician's time and skill, practice expenses
that include the costs of staff, equipment, and supplies, and the cost
of liability insurance. While a surgeon's global fee for a surgical
procedure is set to reflect the resources required to perform the
service, payments under the physician fee schedule for assistant-at-
surgery services are not; they are calculated as a fixed percentage of
the surgeon's global fee. The percentage varies depending on the
profession of the assistant-at-surgery. The Medicare physician fee
schedule pays physicians more than nonphysician health professionals
for assistant-at-surgery services (see table 1).
Table 1: Physician Fee Schedule Payments for Health Professionals for
Assistant-at-Surgery Services:
Health profession: Physician; Payment: 16.0% of surgeon's payment.
Health profession: Clinical nurse specialist; Payment: 13.6% of
surgeon's payment.
Health profession: Nurse practitioner; Payment: 13.6% of surgeon's
payment.
Health profession: Physician assistant; Payment: 13.6% of surgeon's
payment.
Source: 42 C.F.R. §§ 405.502(a)(9), 414.52, 414.56 (2002).
[End of table]
Medicare sets requirements that various health care institutions,
suppliers, and professionals must meet to be paid by the program.
Institutions, such as hospitals, must meet conditions of participation
(CoP)--health and safety rules used to ensure quality of care. Until
1986, HCFA specified some requirements for assistant-at-surgery
services in its hospital CoP. Hospitals were required to have
physicians serve as assistants-at-surgery for procedures "with unusual
hazard to life," while "nurses, aides, or technicians having sufficient
training to properly and adequately assist'' could assist at "lesser
operations."[Footnote 15] In a broad revision of the hospital CoP in
1986, the agency eliminated these requirements: it said the purpose of
the revisions to the surgical services section, which had included the
assistant-at-surgery requirements, was to "delete the overly
prescriptive details" about the operation of surgical services.
[Footnote 16] CMS retains requirements for other surgical team
members, including scrub and circulating staff.[Footnote 17]
CMS also establishes regulatory requirements for the health professions
eligible to receive payment under the Medicare physician fee schedule.
Members of that profession can be paid for providing covered services,
including assistant-at-surgery services.[Footnote 18] Although CMS's
rules include the minimum requirements that these professionals must
meet to receive payment for services, there are no specific
requirements to receive assistant-at-surgery payments in Medicare
regulations. General requirements include education, licensure, and
certification; no surgical education or experience is mandated. For
example, physician assistants must graduate from an accredited
physician assistant education program, pass the National Commission on
Certification of Physician Assistants certification examination, and be
licensed to practice as a physician assistant, but do not have to have
experience as an assistant-at-surgery.
Various Health Professionals Provide Assistant-at-Surgery Services,
and Hospital Employees Provide Most of These Services:
Members of a wide range of health professions serve as assistants-at-
surgery. Hospitals employ residents, international medical graduates,
and all the types of nonphysician health professionals who perform the
role. Hospital employees likely serve as assistants-at-surgery for a
majority of the procedures for which the ACS says an assistant is
"almost always" necessary. The number of assistant-at-surgery services
performed by physicians and paid for under the physician fee schedule
has declined, while the number of such services performed by
nonphysician health professionals eligible to receive payment under the
physician fee schedule has increased.
Members of a Variety of Health Professions Serve as Assistants-at-
Surgery:
Physicians, residents in training for licensure or board certification
in a physician specialty, several different kinds of nurses, and
members of several other health professions serve as assistants-at-
surgery (see table 2). Surgical associations state that surgeons or
residents are preferred as assistants-at-surgery, but surgeons are
often not available to assist at surgery.
Table 2: Health Professions Whose Members Can Assist at Surgery:
Health profession: Physician:
Health profession: Physician (postresidency); Total number of
members[A]: 850,000.
Health profession: Resident; Total number of members[A]: 100,000.
Health profession: Nurse:
Health profession: Registered nurse, including those in surgical
specialties, such as orthopedics or plastic surgical nurses; Total
number of members[A]: 3.1 million[B].
Health profession: Licensed practical/vocational nurse; Total number of
members[A]: 900,000.
Health profession: Nurse practitioner; Total number of members[A]:
130,000[C].
Health profession: Clinical nurse specialist; Total number of
members[A]: 69,000[C].
Health profession: Certified registered nurse first assistant; Total
number of members[A]: 1,700.
Health profession: Other health professions:
Health profession: Surgical technologist; Total number of members[A]:
71,000.
Health profession: Physician assistant; Total number of members[A]:
46,000.
Health profession: Ophthalmic assistant/technician/medical
technologist; Total number of members[A]: 30,000-40,000.
Health profession: Surgical assistant; Total number of members[A]:
5,000-6,000.
Health profession: Orthopedic technologist; Total number of members[A]:
3,000.
Health profession: Orthopedic physician assistant; Total number of
members[A]: 2,500.
Health profession: International medical graduate; Total number of
members[A]: Unknown.
Source: Health professional associations.
[A] Numbers are the most recent data available, typically for 2000.
[B] Includes nurse practitioners, clinical nurse specialists, and
CRNFAs. The table also includes separate counts for each of these
groups.
[C] The numbers for nurse practitioners and clinical nurse specialists
include some nurses who have qualified as both.
[End of table]
Hospitals Employ the Full Range of Health Professions Whose Members
Serve as Assistants-at-Surgery:
Hospitals employ the gamut of health professionals who serve as
assistants-at-surgery to perform the role. Some hospitals tend to hire
assistants-at-surgery from a particular health profession, sometimes
offering training courses in assistant services for that profession, to
ensure that the hospital has a sufficient number of assistants. To
encourage surgeons to use their operating rooms, hospitals may (1)
employ assistants-at-surgery, eliminating the need for the surgeons to
hire their own assistants, or (2) arrange for health professionals in
independent practice to serve as assistants.
While teaching hospitals use residents as assistants-at-surgery, these
hospitals may also hire nonphysician health professionals to perform
the role. In a recent survey of neurosurgery residency program
directors, nearly all cited the need to hire nonphysician health
professional staff, such as physician assistants, in response to the
weekly 80-hour work limit for residents.[Footnote 19] Teaching
hospitals with other surgical specialty programs may also need to hire
nonphysician health professionals as assistants-at-surgery because of
the limit on resident hours.
Hospital Employees Likely Perform More than Half of All Assistant-at-
Surgery Services:
Because hospitals are not required to keep records on the use of
assistants-at-surgery to receive Medicare payment under the inpatient
PPS, the number and cost of such services provided by all hospital
employees are unknown. Still, hospital employees likely serve as
assistants-at-surgery for the majority of the surgeries performed on
Medicare patients. In 2002, Medicare made payments under the physician
fee schedule to assistants-at-surgery about 36 percent of the time that
the program made payments to surgeons for the surgical procedures that
ACS designated in its most recent study as "almost always" requiring an
assistant-at-surgery.[Footnote 20] Since the remaining 64 percent of
those surgical procedures were likely to have had assistants-at-
surgery, hospital employees would likely have performed this role. In
its final regulation revising the physician fee schedule for 2000, HCFA
relied upon the results of the American Hospital Association's (AHA)
National Hospital Panel Survey that found that only 11 percent of
responding hospitals said it was a regular practice for physicians to
bring their own staff to the hospital to serve as assistants-at-surgery
or to perform other functions.[Footnote 21] A representative of the AHA
told us that most assistants-at-surgery, including residents and
nonphysician staff, are hospital employees.
Nonphysicians Are Performing an Increased Share of Assistant-at-Surgery
Services Paid under the Physician Fee Schedule:
The percentage of assistant-at-surgery services paid to physicians
under the physician fee schedule has declined, and the percentage of
these services paid to nonphysician health professionals has increased,
particularly since enactment of the Balanced Budget Act of 1997 (BBA).
The act raised the amount paid for assistant-at-surgery services to
these nonphysician health professionals under the physician fee
schedule, extended billing by clinical nurse specialists and nurse
practitioners to urban areas (such billing had been limited to rural
areas), and allowed physician assistants to contract with surgeons to
be an assistant without having to be employees of the surgeon.[Footnote
22] The number of assistant-at-surgery services paid for under the
physician fee schedule and provided by nonphysician health
professionals increased more than 200 percent from 1997 through 2002,
while the number of services provided by physicians serving as
assistants declined about 23 percent.[Footnote 23] During this period,
the percentage of Medicare-paid assistant-at-surgery services
performed by nonphysician health professionals increased by 25
percentage points (see fig. 1).
The amount paid to nonphysicians for these services has also increased.
Prior to 1987, nonphysicians could not be paid as assistants-at-
surgery. In 1997, nonphysicians were paid only $16 million for
assistant-at-surgery services; in 2002, they were paid about $54
million. In comparison, physicians were paid $295 million for
assistant-at-surgery services in 1986; $166 million in 1997; and $104
million in 2002.
Figure 1: Percentage of Assistant-at-Surgery Services Paid under the
Physician Fee Schedule for Physicians and Nonphysician Health
Professionals, 1997-2002:
[See PDF for image]
[End of figure]
Widely Accepted Professional Requirements for Assistants-at-Surgery Do
Not Exist:
There is no widely accepted set of standards for the education and
experience required to serve as an assistant-at-surgery. The health
care professions whose members provide assistant-at-surgery services
have varying educational requirements. No state licenses all the types
of health professionals who serve as assistants-at-surgery. And the
licenses they issue typically attest to the completion of broad-based
health care education, making them of limited value in determining
which health professionals have the education and experience to serve
as an assistant-at-surgery. Furthermore, the certification programs
developed by the various nonphysician health professional groups whose
members assist at surgery differ. We found that there was insufficient
information about the quality of care provided by assistants-at-
surgery--either generally or by members of specific health professions-
-to assess the adequacy of the requirements for a particular
profession.
Health Professions Whose Members Assist at Surgery Have Varying
Educational Requirements:
The health professions whose members serve as assistants-at-surgery
have varying educational requirements (see table 3). For example, a
licensed practical nurse typically completes a 1-year educational
program, while a clinical nurse specialist must have a master's of
science degree in nursing. In some cases, experience can substitute for
education: orthopedic physician assistants may have associate degrees
or certificates from military or nondegree programs or 5 years of
experience working for an orthopedic surgeon.
Table 3: Education and State Licensure Requirements for Those Who May
Assist at Surgery:
Health profession: Physician:
Health profession: Physician (postresidency); General education
requirements: Doctor of medicine or osteopathy; Licensure requirements
in all states: Yes.
Health profession: Resident; General education requirements: Doctor of
medicine or osteopathy; Licensure requirements in all states: Yes[A].
Health profession: Nurse:
Health profession: Registered nurse, including those in surgical
specialties, such as orthopedics and plastic surgical nurses; General
education requirements: Associate's or bachelor's degree in nursing or
nondegree hospital diploma; Licensure requirements in all states: Yes.
Health profession: Licensed practical/vocational nurse; General
education requirements: 1-year program; Licensure requirements in all
states: Yes.
Health profession: Nurse practitioner; General education requirements:
Master's of science in nursing or nondegree certificate; Licensure
requirements in all states: Yes[B].
Health profession: Clinical nurse specialist; General education
requirements: Master's of science in nursing; Licensure requirements in
all states: Yes[B].
Health profession: Certified registered nurse first assistant; General
education requirements: Bachelor's degree and certification program;
Licensure requirements in all states: Yes.
Health profession: Other health professions:
Health profession: Surgical technologist; General education
requirements: Associate's degree, military or nondegree certificate;
Licensure requirements in all states: No[C].
Health profession: Physician assistant; General education
requirements: Associate's or bachelor's degree or nondegree
certificate; Licensure requirements in all states: Yes.
Health profession: Ophthalmic assistant/technician/medical
technologist; General education requirements: Certificate programs or
work experience; Licensure requirements in all states: No.
Health profession: Surgical assistant; General education requirements:
Bachelor's degree or nondegree certificate[D]; Licensure requirements
in all states: No[E].
Health profession: Orthopedic technologist; General education
requirements: 1-year certificate program, 2 years of experience, or
combination; Licensure requirements in all states: No.
Health profession: Orthopedic physician assistant; General education
requirements: Associate's degree, military or nondegree certificate, or
5 years of experience; Licensure requirements in all states: No[F].
Health profession: International medical graduate; General education
requirements: Non-U.S. degree in medicine; Licensure requirements in
all states: No.
Source: Health professional associations.
[A] Residents typically become licensed during their residency
training.
[B] Some states require an additional license as an advanced practice
nurse.
[C] Only two states have laws that regulate this profession: Texas
established a licensure program in 2001 for "licensed surgical
assistants," and beginning July 1, 2004, surgical technologists are
required to meet registration requirements to practice in Illinois
(2003 Ill. Laws 93-0280, adding 225 Ill. Stat. 130/1 - 130/170).
[D] Some international medical graduates who have not obtained a
residency or qualified for a license choose to become certified as
surgical assistants.
[E] Only two states have laws that regulate this profession: Texas
established a licensure program in 2001 for "licensed surgical
assistants," and beginning July 1, 2004, surgical assistants are
required to meet registration requirements to practice in Illinois
(2003 Ill. Laws 93-0280, adding 225 Ill. Stat. 130/1 - 130/170).
[F] Licensure is required in Tennessee (Tenn. Code Ann. § 63-19-202
(2003)) and New York (N.Y. Educ. §§ 6540 - 6548 (2001)). In California,
some orthopedic physician assistants who were licensed as physician
assistants have been grandfathered in as physician assistants.
[End of table]
State Licenses Typically Do Not Require Education and Experience as
Assistants-at-Surgery:
While state licenses for health professionals, including those eligible
for payment as assistants-at-surgery under the physician fee schedule,
typically have "scopes of practice" that include assistant-at-surgery
services, education and experience as an assistant are not necessarily
required to obtain a license: the licenses for these health professions
attest to the completion of broad-based health care education, which
may not include courses in surgery.
No state licenses all the health professions whose members assist at
surgery in its jurisdiction. For example, orthopedic physician
assistants and surgical assistants are licensed in only a few states.
Only one state, Texas, has a specific assistant-at-surgery license.
Members of different health professions may qualify for this license,
which requires surgical education and experience.[Footnote 24]
Nevertheless, a license is not required to serve as an assistant-at-
surgery in Texas.
Nonphysician Health Professions' Certification Programs for
Assistants-at-Surgery Vary:
Certification programs for assistants-at-surgery generally require
completion of a certain level of education or experience and passage of
an examination. Each certification program created by a group of
nonphysician health professionals for its members who serve as
assistants-at-surgery has different requirements (see table 4).
Certification programs for some nonphysician health professions not
eligible for payment under the physician fee schedule are for a wide
range of surgical services; others are specific to a particular type of
surgery. For example, a CRNFA, in addition to being licensed as a
registered nurse and earning a bachelor's degree in nursing,[Footnote
25] must obtain certification as an operating room nurse, complete an
approved program, have 2,000 hours of experience as an assistant-at-
surgery, and pass an examination. For a surgical technologist to
receive certification as an assistant-at-surgery, he/she must have a
surgical technologist certification, complete an approved program or
have 2 years of experience as an assistant, and pass the examination.
Certifications for those who are eligible for payment under the
physician fee schedule as an assistant-at-surgery are typically for a
broad range of services and are not specifically surgery-related. For
example, the American Nurses Credentialing Center awards certifications
to nurse practitioners for acute, adult, family, gerontological,
pediatric, adult psychiatric and mental health, and family psychiatric
and mental health care.
Table 4: Surgical Education and Experience Requirements for
Certification as an Assistant-at-Surgery:
Health profession: Nurse:
Health profession: Registered nurse, surgery-related certification[A];
Surgical education requirements for certification: Requirements vary by
certification program, but surgical education is not required for
certain surgical-related certifications; Surgical experience
requirements for certification: Requirements vary by certification
program, but surgical experience is not required for certain surgical-
related certifications.
Health profession: Certified registered nurse first assistant; Surgical
education requirements for certification: Two to three surgical
classes; Surgical experience requirements for certification: 2,400
hours of operating room experience in the scrub or circulating role and
2,000 hours as assistant-at-surgery.
Health profession: Other health professions:
Health profession: Surgical assistant[B]; Surgical education
requirements for certification: Completion of an approved surgical
assistant education program or an international medical education
program, unless surgical experience is substituted; Surgical experience
requirements for certification: 2 to 3 years of surgical assistant
experience, depending on certification program.
Health profession: Orthopedic physician assistant[C]; Surgical
education requirements for certification: Three permissible
educational paths for certification: completion of an orthopedic
physician assistant program that includes surgical education; a primary
care physician assistant program that may have minimal surgical
education; and a nurse practitioner program that may or may not include
surgical education, unless surgical experience is substituted; Surgical
experience requirements for certification: 5 years of experience that
includes surgical assisting.
Health profession: Surgical technologist[D]; Surgical education
requirements for certification: Completion of an approved surgical
education program that includes instruction and supervised surgical
experience, unless surgical experience is substituted; Surgical
experience requirements for certification: 2 years of surgical
experience.
Health profession: Orthopedic technologist[E]; Surgical education
requirements for certification: Completion of an approved surgical
education program that includes an operating room rotation, unless
surgical experience is substituted; Surgical experience requirements
for certification: 1 year of surgical experience.
Health profession: Ophthalmic assistant/ technician/medical
technologist[F]; Surgical education requirements for certification:
Completion of an approved education program that includes instruction
and supervised surgical experience, unless surgical experience is
substituted; Surgical experience requirements for certification: 18
months of surgical experience.
Source: Health professional associations.
[A] A variety of surgery-related certifications are available to
registered nurses. Some of these are for surgical specialties, such as
orthopedic nurse certified (ONC) or certified plastic surgical nursing
(CPSN). While the ONC requires 1,000 hours of experience as an
orthopedic nurse and the CPSN requires 2 years' experience of plastic
surgical nursing, both of which may include operating room experience,
neither program requires operating room experience.
[B] Certified Surgical Assistant (CSA), Surgical Assistant-Certified
(SA-C).
[C] Orthopedic Physician's Assistant, Certified (OPA-C).
[D] Certified Surgical Assistant/Certified First Assistant (CST/CFA).
[E] Orthopedic Technologist-Surgery Certified (OT-SC).
[F] Certified Ophthalmic Assistant (COA), Technician (COT), or Medical
Technologist (COMT)-Ophthalmic Surgical Assisting.
[End of table]
No National Consensus on Requirements for Assistants-at-Surgery Exists:
While some national physician and accreditation organizations say
assistants-at-surgery should have to meet some requirements, there is
no consensus about what those requirements should be. For example, ACS
has stated that when surgeons or residents are unavailable to serve as
assistants-at-surgery, nonphysician health professionals should be
allowed to perform the role if they meet the "national standards" for
their health profession or have "additional specialized training."
Similarly, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), a private organization that accredits health
care organizations, including hospitals, requires hospitals to
credential their staff (i.e., establish requirements, such as
licensure, certification, and experience for physicians and certain
nonphysician health professionals) and ensure that those requirements
are used when personnel decisions are made. But JCAHO does not suggest
the type or length of education or experience to be used in
credentialing hospital staff who serve as assistants-at-surgery.
Literature on Assistants-at-Surgery Is Insufficient to Evaluate Quality
of Care:
We found little evidence about the quality of care provided by
assistants-at-surgery. Our February 2003 search of relevant literature
maintained by the National Library of Medicine found only six articles
dealing with the quality of care provided by assistants-at-surgery.
None of the articles compares the quality of assistant-at-surgery
services provided by one nonphysician health profession with that
provided by another nonphysician health profession or physicians, and
only one deals specifically with the influence of assistants on
surgical outcomes.
While Medicare Payments for Assistant-at-Surgery Services Have Flaws,
Paying Hospitals for All These Services Would Correct Them:
There are three flaws in Medicare's policies for paying assistants-at-
surgery that prevent the payment system from meeting the program's
goals of making appropriate payment for medically necessary services by
qualified providers. First, because Medicare pays for assistant-at-
surgery services under both the hospital inpatient PPS and the
physician fee schedule, and hospital payments for surgical care are not
adjusted when an assistant receives payment under the physician fee
schedule, Medicare may be paying too much for some hospital surgical
care. Second, paying a health professional under the Medicare physician
fee schedule to be an assistant-at-surgery, instead of including this
payment in an all-inclusive payment, gives neither the hospital nor the
surgeon an incentive to use an assistant only when one is medically
necessary. Third, the distinctions between those health professionals
eligible for payment as an assistant-at-surgery under the physician fee
schedule and those who are not eligible
are not based on surgical education or experience as an assistant.
Criteria for determining who should be paid as assistants-at-surgery
under the physician fee schedule do not exist. However, hospitals are
responsible under health and safety rules to provide quality care for
their patients.
Medicare Payments for Assistants-at-Surgery Are Flawed:
Medicare's policy of paying hospitals for the services associated with
inpatient surgical care that may include assistant-at-surgery services
and also paying physicians and certain nonphysician health
professionals for those services is flawed. When Medicare pays under
the hospital inpatient PPS and under the physician fee schedule for
assistant-at-surgery services delivered to a particular patient,
Medicare may pay too much for the assistant services because the
hospital is not paid less when the assistant receives payment under the
physician fee schedule. In addition, a hospital that uses an assistant-
at-surgery who is eligible for payment under the physician fee schedule
has a financial advantage in the form of lower labor costs over a
hospital that uses assistants who cannot be paid under the physician
fee schedule.
Given the discretion that hospitals and surgeons have in determining
when and how an assistant-at-surgery is used, it is especially
important that Medicare's payment policy create incentives to help
ensure that assistant services are provided for Medicare patients only
when medically necessary.[Footnote 26] Allowing physician fee schedule
payments to certain assistants-at-surgery, however, creates an
incentive for hospitals to use them, rather than those who cannot be
paid under the fee schedule. Because neither the hospital nor the
surgeon incurs a cost when an assistant-at-surgery is paid under the
physician fee schedule, neither has a financial incentive to use an
assistant only when one is necessary. The lack of this incentive is of
concern because assistant-at-surgery services receive little review to
determine the medical necessity of the services. A 2001 report by the
Department of Health and Human Services Office of Inspector
General[Footnote 27] found that most contractors used by Medicare to
pay for part B services do not have any mechanism to ensure that
assistant-at-surgery requests for payment for nonphysician health
professionals are reviewed for medical necessity before they are paid.
Medicare routinely requires submission of documentation of medical
necessity for medical review for only 1 percent of assistant-at-surgery
services paid under the physician fee schedule.
Because the requirements for those authorized to be paid as assistants-
at-surgery under the Medicare physician fee schedule do not include
assistant-at-surgery education or experience, payments can be made to
assistants with no such education or experience. For example, about 23
percent of physician assistants work in surgical specialties. Other
physician assistants working in nonsurgical specialties, however, may
be paid as assistants-at-surgery under the Medicare physician fee
schedule, and their only surgical experience may be a 6-week surgical
rotation. On the other hand, nonphysician health professionals, such as
surgical technologists, CRNFAs, and orthopedic physician assistants,
all of whom have certification programs requiring education and
experience as an assistant-at-surgery, cannot be paid by Medicare for
their services under the physician fee schedule.
One way to address a concern associated with the physician fee schedule
payments for assistants-at-surgery is to expand the number of
nonphysician health professions eligible for payment. But this would
not ensure that only those with the appropriate education and
experience serve as assistants-at-surgery unless CMS also sets
standards for all those who serve as assistants. There is no consensus,
however, on what such standards should include.
Bundling Payments for Assistant-at-Surgery Services into Hospital
Payments Would Be Preferable to Bundling into Surgeons' Fees:
Bundling all payments for assistants-at-surgery into either the
inpatient hospital PPS or the surgeon's global fee would address the
flaws of the current payment system. The possibility of paying too much
for assistant-at-surgery services would be eliminated because Medicare
would make only one payment--to either the hospital or the surgeon--for
the service. The hospital or surgeon would have a financial incentive
to use the most appropriate assistant-at-surgery--and to use one only
when necessary--because the payment would be the same regardless of
whether an assistant was used. The lack of a relationship between the
nonphysician health professionals eligible for assistant-at-surgery
payments under the physician fee schedule and their education and
experience would be moot because payments would no longer be made to
individuals performing the role; payments would be made, as part of a
larger payment for a bundle of services, to hospitals or surgeons, who
would have the responsibility to determine the education and
experience that an assistant-at-surgery needs and when an assistant is
needed.
Folding payments for assistant-at-surgery services into inpatient PPS
payments has some advantages that would not accrue if payments were
folded into the surgeon's global fee. Hospitals would continue to have
incentives to use assistants-at-surgery when they are necessary, and to
use the most appropriate assistant. Hospitals are already responsible-
-under the hospital CoP--for ensuring the health and safety of their
patients and that necessary services are provided, including assistant-
at-surgery services. Most hospitals already have credentialing
processes for their employees. Also, since hospitals likely employ most
assistants-at-surgery, limiting payments for assistant services to
those made under the inpatient PPS would disrupt the employment
relationships for far fewer assistants than would be the case if
payment was made to surgeons.
There is precedent for Congress approving legislation that no longer
allows a service to be paid for separately under part B, but instead
requires that the service be included in a bundle of services under
part A. In 1997, Congress passed legislation that requires virtually
all kinds of services or items furnished to beneficiaries residing in
skilled nursing facilities (SNF) that had been paid for separately
under part B, instead be included in a bundle of services paid for
under part A.[Footnote 28] Prior to implementation of the provision,
SNFs could permit a nonphysician health professional or supplier to
seek payment under part B for ancillary services or items furnished
directly to SNF residents, as long as the SNF did not include the
service or item in its part A bill. The legislation, however, prevents
this "unbundling" by including in Medicare SNF PPS payments ancillary
services or items a SNF resident may require that previously had been
paid under part B.
Bundling assistant-at-surgery services into the package of services
covered by the surgeon's global payment based on the Medicare physician
fee schedule has significant drawbacks. First, because the amount paid
under the inpatient hospital PPS for assistants-at-surgery is unknown,
the total amount to be added to the physician fee schedule for
providing assistants is unknown. Second, a payment amount for
assistant-at-surgery services would have to be determined for each
surgical procedure. Since data are not collected on how often each
surgeon uses assistants-at-surgery for each surgical procedure, the
bundled payment would presumably include an allotment for the expected
average cost of assistants for all surgeons performing the procedure.
Using this approach, surgeons with an unusually high number of
procedures requiring assistants would be paid too little, while those
with an unusually low number of procedures requiring assistants would
be paid too much. In addition, a surgeon would have a financial
incentive to use an assistant-at-surgery less frequently for surgical
procedures for which ACS says that an assistant may be needed, even
when the condition of the beneficiary indicates that an assistant would
be desirable. Because there is a difference in costs to a surgeon
depending on whether an assistant-at-surgery is used, a surgeon's
bundled payment amount could be adjusted when an assistant is used.
Doing so, however, would provide no financial incentive for surgeons to
use an assistant-at-surgery only when one is medically necessary.
Conclusions:
Decisions to use an assistant-at-surgery should not be influenced by
payment; they should be based on medical necessity. The majority of
assistants-at-surgery are likely employed by hospitals, where the
inpatient hospital PPS pays for their services. If Congress were to
consolidate Medicare physician fee schedule payments for assistant-at-
surgery services into the inpatient hospital PPS, this would give
hospitals an incentive to use assistants only when they are necessary.
Meanwhile, the hospital CoP would continue to give hospitals an
incentive to assure that the most appropriate assistants-at-surgery are
used as part of their responsibility to provide quality care for their
patients. Paying for assistants under the physician fee schedule
provides no such incentive.
Matter for Congressional Consideration:
We suggest that Congress may wish to consider consolidating all
Medicare payments for assistant-at-surgery services under the hospital
inpatient prospective payment system.
Agency Comments:
We received comments on a draft of this report from CMS, which agreed
that payment policy for assistants-at-surgery could be improved. CMS
noted that it would be helpful to describe the ongoing review process
that CMS uses to assign relative values to physician fee schedule
services. However, as we state in this report assistants-at-surgery are
not paid on the basis of the resources they use to perform their work,
but are instead paid a percentage of the amount paid the surgeon. CMS
also discussed several details related to implementing payment changes
for assistants-at-surgery. Addressing these points was beyond the scope
of this report. CMS's comments appear in appendix II. In addition, we
obtained oral comments on a draft of this report from representatives
of the American Medical Association, the American College of Surgeons,
the American Society of General Surgeons, the American Association of
Orthopaedic Surgeons, the Society of Thoracic Surgeons, the American
Academy of Nurse Practitioners, the American Academy of Physician
Assistants, the Association of periOperative Registered Nurses, and the
American Hospital Association. We have modified the report, as
appropriate, in response to their comments.
We are sending copies of this report to the Acting Administrator of
CMS, appropriate congressional committees, and other interested
parties. We will also make copies available to others upon request.
This report will be available at no charge on GAO's Web site at http:/
/www.gao.gov.
If you or your staffs have any questions about this report, please call
me at (202) 512-7101. Lisanne Bradley and Michael Rose were major
contributors to this report.
Marjorie Kanof:
Director, Health Care--Clinical Health Care Issues:
Signed by Marjorie Kanof:
List of Committees:
The Honorable Charles E. Grassley: Chairman: The Honorable Max Baucus:
Ranking Minority Member: Committee on Finance: United States Senate:
The Honorable W.J. "Billy" Tauzin: Chairman: The Honorable John D.
Dingell: Ranking Minority Member: Committee on Energy and Commerce: House
of Representatives:
The Honorable Bill Thomas: Chairman: The Honorable Charles B. Rangel
Ranking Minority Member Committee on Ways and Means House of
Representatives:
[End of section]
Appendix I: Professional Associations, Schools, and Hospitals:
To obtain information about assistants-at-surgery and their services we
contacted subject matter experts. We interviewed representatives of:
American Academy of Nurse Practitioners;
American Academy of Physician Assistants;
American Association of Orthopaedic Surgeons;
American Board of Surgical Assistants;
American College of Surgeons;
American Hospital Association;
American Medical Association;
American Nurses Association;
American Nurses Credentialing Center;
American Society of General Surgeons;
American Society of Plastic Surgical Nurses;
Anne Arundel Community College, Department of Nursing;
Association of periOperative Registered Nurses;
Association of Surgical Technologists;
BJC HealthCare;
Centers for Medicare & Medicaid Services;
Certification Board Perioperative Nursing;
Commission on Accreditation of Allied Health Education Programs;
Duke University Hospital;
Educational Commission for Foreign Medical Graduates;
Ft. Sam Houston, Academy of Health Sciences, U.S. Army;
Inova Fairfax Hospital;
Johns Hopkins University, School of Medicine;
Joint Commission on Allied Health Personnel in Ophthalmology;
Massachusetts General Hospital;
Mayo Clinic;
Medical Group Management Association;
Montgomery College Surgical Technology Program;
National Association of Clinical Nurse Specialists;
National Association of Orthopaedic Nurses;
National Board for Certification of Orthopaedic Technologists;
National Commission for Certifying Agencies/National Organization for
Competency Assurance;
National Rural Health Association;
National Surgical Assistant Association;
Naval School of Health Sciences New York State Board for Medicine;
Office of the Surgeon General of the Air Force;
Office of the Chief, Medical Corps, U.S. Navy;
Stanford University Hospital;
Texas State Board of Medical Examiners;
The American Society of Orthopaedic Physician's Assistants;
The Cleveland Clinic;
The Society of Thoracic Surgeons;
University of California at Los Angeles School of Nursing;
University of Maryland School of Nursing;
University of Michigan Hospital;
University of Washington Medical Center.
[End of section]
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services:
Administrator
Washington, DC 20201:
TO: Marjorie Kanof:
Director, Health Care-Clinical Health Care Issues General Accounting
Office:
FROM: Dennis G. Smith;
Acting Administrator Centers for Medicare & Medicaid Services:
Signed by Dennis G. Smith:
SUBJECT: General Accounting Office Draft Report: "Medicare: Payment
Changes Are Needed For Assistants-at-Surgery, "(GAO-04-97):
Thank you for the opportunity to comment on the General Accounting
Office's (GAO) draft report entitled, Medicare: Payment Changes are
Needed for Assistants-at-Surgery.
In this report, GAO examines: (1) who serves as an assistant-at-
surgery; (2) whether health professionals who perform the role must
meet a uniform set of professional requirements; and (3) whether
Medicare's payment policies for assistants-at-surgery are consistent
with the goals of the program and, if not, whether there are
alternatives that would help attain those goals.
The GAO suggests that the Congress may wish to consider consolidating
all Medicare payment for assistant-at-surgery services under the
hospital inpatient prospective payment system (IPPS).
The CMS has the following comments:
The CMS agrees that payment policy in this area could be improved.
However, many of the policy changes envisioned, such as changing IPPS
rates, would require Congressional action.
We understand GAO's concerns regarding the qualifications of
assistants-at-surgery. In the report, GAO may want to balance this
concern with the importance of a surgeon's medical judgment and
practice preferences. For example, in some cases, shifting payment for
these services to IPPS rates may be disruptive to surgeons that have
built up relationships with their assistant-at-surgery staff. If a
physician insists on using his or her own staff, it is not clear how
this assistant-at-surgery would be reimbursed or whether the hospital
would even permit the assistant to perform services. GAO may want to
address this issue in their report.
It might be helpful if GAO further explained how the construction of
the IPPS rates and physician fee schedule (PFS) rates creates the
potential for duplicate payment.
* In GAO's discussion on why assistant-at-surgery cases should not be
bundled into the PFS payment rates, it cites several drawbacks. It may
be helpful to describe the ongoing review process CMS uses to assign
relative values to PFS services, since this process addresses several
of the concerns GAO raised in this section.
* The GAO may want to consider the effect of the Sustainable Growth Rate
(SGR) system in their analysis of this issue. If Congress were to move
assistant-at-surgery expenses into the bundled PPS rates or into the
PFS rates, the SGR could play a role in determining total actual
savings to the Government.
* It is important to note that total PFS payments, including assistant-
at-surgery payments under the PFS, grow at a predetermined amount based
on a formula set in law. Whether or not these payments are made under
the PFS, the total amount of money spent under the PFS remains the
same.
* Any changes to the IPPS rates would require Congressional action.
[End of section]
FOOTNOTES
[1] An assistant-at-surgery is sometimes referred to as a first
assistant or second assistant.
[2] Members of a few other health professions, such as nurse midwives,
can also be paid as assistants-at-surgery under the physician fee
schedule. Assistant-at-surgery services performed by these
professionals accounted for less than 1 percent of such Medicare-paid
assistant services in 2002. When discussing payments for assistants-at-
surgery under the physician fee schedule, this report focuses on
physicians, physician assistants, nurse practitioners, and clinical
nurse specialists.
[3] Medicare, Medicaid, and SCHIP Benefits Improvement and Protection
Act of 2000, Pub. L. No. 106-554, App. F, § 433, 114 Stat. 2763, 2763A-
526.
[4] On July 1, 2001, the agency that administers the Medicare program
was renamed from the Health Care Financing Administration (HCFA) to
CMS. This report refers to the agency as HCFA when discussing actions
taken before the name change and as CMS when discussing actions taken
after the name change.
[5] Of the assistant-at-surgery services paid under the physician fee
schedule in 2002, almost 90 percent were for hospital inpatients, about
10 percent were for surgeries on hospital outpatients, and about 1
percent for surgeries in ambulatory surgical centers. Less than one-
half of 1 percent of services allowed under the physician fee schedule
for assistant-at-surgery services occurred in a nonfacility setting,
such as a physician's office.
[6] American College of Surgeons (ACS), Physicians as Assistants at
Surgery: 2002 Study, 4th edition (Chicago, Ill.: 2002). ACS members and
members of 14 other surgical specialty organizations reviewed
procedures applicable to their specialties and determined how often
each surgical procedure requires the use of a physician as an
assistant-at-surgery.
[7] International medical graduates are physicians who have graduated
from a medical school outside the United States, Puerto Rico, or
Canada. For purposes of this report, international medical graduates do
not include individuals who are in U.S. residency programs or who are
physicians licensed in the United States, but may include some who are
certified as surgical assistants.
[8] Approximately 1,550 surgical procedures are designated as
"sometimes" requiring a physician as an assistant-at-surgery. In
addition to procedures designated as "almost always" or "sometimes"
requiring a physician to serve as an assistant-at-surgery, the
remaining procedures are designated as "almost never" requiring a
physician to serve as an assistant.
[9] 42 U.S.C. § 1395ww (2000).
[10] The bundle of services for which hospital inpatient payments are
made generally does not include physician services provided by
physicians, physician assistants, nurse practitioners, and clinical
nurse specialists. 42 U.S.C. § 1395x(b)(4), (s)(2)(K) (2000).
[11] Additional payments are made for cases in which inpatient hospital
care has been extraordinarily costly. About 7 percent of inpatient
hospital PPS payments in fiscal year 2002 were for these cases.
[12] Teaching hospitals are paid an amount for each resident that
covers the costs associated with providing services. 42 U.S.C. §
1395ww(h) (2000).
[13] For purposes of this report, surgical residencies are defined as
those in colon and rectal surgery, neurological surgery, obstetrics and
gynecology, ophthalmology, orthopedic surgery, adult reconstructive
orthopedics, foot and ankle orthopedics, hand surgery, musculoskeletal
oncology, orthopedic sports medicine, orthopedic surgery of the spine,
orthopedic trauma, pediatric orthopedics, otolaryngology, neurotology,
pediatric otolaryngology, plastic surgery, craniofacial surgery,
general surgery, pediatric surgery, surgical critical care, urology,
pediatric urology, vascular surgery, and thoracic surgery.
[14] 42 U.S.C. § 1395w-4(a) (2000).
[15] 20 C.F.R. § 405.1031(a) (1967), redesignated as 42 C.F.R. §
405.1031(a) in 1977.
[16] Medicare and Medicaid Programs; Conditions of Participation for
Hospitals, 51 Fed. Reg. 22010, 22027, 22042 (1986) (codified at 42
C.F.R. part 482).
[17] 42 C.F.R. § 482.51(a)(2), (3) (2002).
[18] 42 C.F.R. §§ 410.20(b), 410.74(c), 410.75(b), 410.76(b) (2002),
rules for physicians, physician assistants, nurse practitioners, and
clinical nurse specialists, respectively. Medicare may pay for any
medically necessary service that an eligible health professional may
perform under state law.
[19] Dongwoo John Chang, M.D., and Susan Bell, R.N., "Restricted: The
Impact of Residents' 80-Hour Workweek on Neurosurgical Resident
Training and Patient Care," American Association of Neurological
Surgeons Bulletin: The Socioeconomic and Professional Quarterly for
AANS Members, 12:2:7-10 (2003).
[20] In 2002, about 75 percent of these Medicare-paid services for
assistants-at-surgery were for surgical procedures determined by ACS as
"almost always" requiring a physician as an assistant, about 24 percent
for procedures ACS determined to "sometimes" require an assistant, and
the remaining payments were for procedures determined as "almost never"
requiring an assistant or for surgical procedures with no designation.
[21] Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule for Calendar Year 2000, 64 Fed. Reg. 59401
(1999).
[22] Pub.L.No. 105-33, §§ 4511-4512, 111 Stat. 251, 442-443. These
provisions apply to services performed after 1997.
[23] In 1997, Medicare paid 1,246,817 assistant-at-surgery services,
1,100,919 of which were provided by physicians. In 2002, Medicare paid
1,356,244 assistant-at-surgery services, 848,314 of which were provided
by physicians.
[24] Effective September 2001, Texas established a license category for
"licensed surgical assistants." (Texas Acts 2001 Tex. Gen. Laws ch.
1014, adding Tex. Occupations Code Ann., ch. 206.) Licensure
requirements include 2,000 hours of experience, completion of a
surgical training program with courses in specified areas such as
anatomy and aseptic technique, an associate's degree, and certification
by a national organization recognized by the Texas State Board of
Medical Examiners.
[25] As of January 1, 2000, only registered nurses who have a
bachelor's degree in nursing can be newly certified as CRNFAs. In 2002,
less than 20 percent of CRNFAs had such a degree.
[26] No Medicare payment may be made for any expenses incurred for
items or services that "are not reasonable and necessary for the
diagnosis or treatment of illness or injury—." 42 U.S.C. §
1395y(a)(1)(A) (2000).
[27] Department of Health and Human Services, Office of Inspector
General, Medicare Coverage of Non-Physician Practitioner Services, OEI-
02-00-00290, June 2001.
[28] BBA, § 4432, 111 Stat. 414.
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