Medicare Physician Payments
Medicare and Private Payment Differences for Anesthesia Services Gao ID: GAO-07-463 July 27, 2007In 2005 Medicare paid over $1.4 billion for anesthesia services. These services are generally provided by anesthesia practitioners, such as anesthesiologists and certified registered nurse anesthetists (CRNAs). A government-sponsored study found that Medicare payments for anesthesia services are lower than private payments. Congress is concerned that this difference may create regional discrepancies in the supply of anesthesia practitioners, and asked GAO to explore this issue. GAO examined (1) the extent to which Medicare payments for anesthesia services were lower than private payments across Medicare payment localities in 2004, (2) whether the supply of anesthesia practitioners across Medicare payment localities in 2004 was related to the differences between Medicare and private payments for anesthesia services or the concentration of Medicare beneficiaries, and (3) compensation levels for anesthesia practitioners in 2005 and trends in graduate training. GAO used claims data from two anesthesia service billing companies that bill private insurance payers and Medicare to calculate payments by payer for seven anesthesia services in 41 Medicare payment localities. GAO also used data from the Centers for Medicare & Medicaid Services (CMS) and other sources to determine practitioner supply and Medicare beneficiary concentration in 87 Medicare payment localities.
GAO found that in 2004 average Medicare payments for a set of seven anesthesia services provided by anesthesiologists alone were 67 percent lower than average private insurance payments in 41 Medicare payment localities--geographic areas established by CMS to account for geographic variations in the relative costs of providing physician services. In 2004, there was no correlation between the overall supply of anesthesia practitioners--that is, the total number of both anesthesiologists and CRNAs per 100,000 people--and either the difference between Medicare and private insurance payments for anesthesia services or the concentration of Medicare beneficiaries in the Medicare payment localities included in GAO's analyses. However, when GAO examined the supply of anesthesiologists and CRNAs separately, GAO found correlations between practitioner supply and payment differences and practitioner supply and beneficiary concentration. Specifically, GAO found that in 2004, the supply of CRNAs tended to decrease as the difference between Medicare and private insurance payments for anesthesia services increased in 41 Medicare payment localities. GAO also found that in 2004 the supply of anesthesiologists tended to decrease as the concentration of Medicare beneficiaries increased across 87 Medicare payment localities, while the supply of CRNAs tended to increase as the concentration of Medicare beneficiaries increased across these Medicare payment localities. For 2005, compensation for anesthesia practitioners was reported to compare favorably with other practitioners, according to information from medical group practices from across the country that responded to a survey of Medical Group Management Association (MGMA) member organizations. The 2005 median annual compensation for general anesthesiologists--approximately $354,240--was over 10 percent higher than the median annual compensation for specialists and over twice the compensation for generalists. For 2005, MGMA-reported median annual compensation for CRNAs-approximately $131,400--was over 40 percent higher than the MGMA-reported median annual compensation for either nurse midwives or nurse practitioners and over 35 percent higher than the MGMA-reported median annual compensation for physician assistants. The number of anesthesiology residency positions offered through the National Resident Matching Program and the number of nurse anesthesia graduates have increased in recent years. CMS stated that the study provided a good summary of information collected from a variety of sources on anesthesia payments and the supply of anesthesia practitioners.
GAO-07-463, Medicare Physician Payments: Medicare and Private Payment Differences for Anesthesia Services
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Report to the Subcommittee on Health, Committee on Ways and Means,
House of Representatives:
United States Government Accountability Office:
GAO:
July 2007:
Medicare Physician Payments:
Medicare and Private Payment Differences for Anesthesia Services:
Medicare Anesthesia Payments:
GAO-07-463:
GAO Highlights:
Highlights of GAO-07-463, a report to the Subcommittee on Health,
Committee on Ways and Means, House of Representatives
Why GAO Did This Study:
In 2005 Medicare paid over
$1.4 billion for anesthesia services. These services are generally
provided by anesthesia practitioners, such as anesthesiologists and
certified registered nurse anesthetists (CRNAs). A government-sponsored
study found that Medicare payments for anesthesia services are lower
than private payments. Congress is concerned that this difference may
create regional discrepancies in the supply of anesthesia
practitioners, and asked GAO to explore this issue.
GAO examined (1) the extent to which Medicare payments for anesthesia
services were lower than private payments across Medicare payment
localities in 2004, (2) whether the supply of anesthesia practitioners
across Medicare payment localities in 2004 was related to the
differences between Medicare and private payments for anesthesia
services or the concentration of Medicare beneficiaries, and (3)
compensation levels for anesthesia practitioners in 2005 and trends in
graduate training. GAO used claims data from two anesthesia service
billing companies that bill private insurance payers and Medicare to
calculate payments by payer for seven anesthesia services in 41
Medicare payment localities. GAO also used data from the Centers for
Medicare & Medicaid Services (CMS) and other sources to determine
practitioner supply and Medicare beneficiary concentration in 87
Medicare payment localities.
What GAO Found:
GAO found that in 2004 average Medicare payments for a set of seven
anesthesia services provided by anesthesiologists alone were 67 percent
lower than average private insurance payments in 41 Medicare payment
localities”geographic areas established by CMS to account for
geographic variations in the relative costs of providing physician
services.
In 2004, there was no correlation between the overall supply of
anesthesia practitioners”that is, the total number of both
anesthesiologists and CRNAs per 100,000 people”and either the
difference between Medicare and private insurance payments for
anesthesia services or the concentration of Medicare beneficiaries in
the Medicare payment localities included in GAO‘s analyses. However,
when GAO examined the supply of anesthesiologists and CRNAs separately,
GAO found correlations between practitioner supply and payment
differences and practitioner supply and beneficiary concentration.
Specifically, GAO found that in 2004, the supply of CRNAs tended to
decrease as the difference between Medicare and private insurance
payments for anesthesia services increased in 41 Medicare payment
localities. GAO also found that in 2004 the supply of anesthesiologists
tended to decrease as the concentration of Medicare beneficiaries
increased across 87 Medicare payment localities, while the supply of
CRNAs tended to increase as the concentration of Medicare beneficiaries
increased across these Medicare payment localities.
For 2005, compensation for anesthesia practitioners was reported to
compare favorably with other practitioners, according to information
from medical group practices from across the country that responded to
a survey of Medical Group Management Association (MGMA) member
organizations. The 2005 median annual compensation for general
anesthesiologists--approximately $354,240--was over 10 percent higher
than the median annual compensation for specialists and over twice the
compensation for generalists. For 2005, MGMA-reported median annual
compensation for CRNAs–approximately $131,400--was over 40 percent
higher than the MGMA-reported median annual compensation for either
nurse midwives or nurse practitioners and over 35 percent higher than
the MGMA-reported median annual compensation for physician assistants.
The number of anesthesiology residency positions offered through the
National Resident Matching Program and the number of nurse anesthesia
graduates have increased in recent years.
CMS stated that the study provided a good summary of information
collected from a variety of sources on anesthesia payments and the
supply of anesthesia practitioners.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-1001].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Susan Fleming at (202)
512-2834 or flemings@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Average Medicare Payments for Anesthesia Services Provided by
Anesthesiologists Alone Ranged from 51 Percent to 77 Percent Lower than
Average Private Payments:
Overall Supply of Anesthesiologists and CRNAs Combined Was Not
Correlated with Payment Differences for Anesthesia Services or
Concentration of Medicare Beneficiaries:
Compensation of Anesthesia Practitioners Was Reported to Compare
Favorably with Other Practitioners, and Anesthesiology Residencies and
Nurse Anesthesia Graduates Have Increased:
Agency and External Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
Appendix III: GAO Contacts and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Description, Number of Cases, and Weights for Seven Anesthesia
Services included in Calculation of Anesthesia Service Payment
Difference:
Table 2: Average and Range of Anesthesia Practitioner Supply per
100,000 People, 2004:
Table 3: Average and Range of Medicare Beneficiary Concentration, 2004:
Table 4: Correlation Coefficients between Supply of Anesthesia
Practitioners and Average Medicare and Private Payment Differences, by
Medicare Payment Locality, 2004:
Table 5: Correlation Coefficients between Supply of Anesthesia
Practitioner and Medicare Beneficiary Concentration, by Medicare
Payment Locality, 2004:
Figures:
Figure 1: Example of a Medicare Payment for an Anesthesia Service
Associated with Lens Surgery in the Connecticut Medicare Payment
Locality, 2004:
Figure 2: Distribution of Percent Difference in Medicare and Private
Payments for Seven Anesthesia Services Provided by Anesthesiologists
Alone across 41 Medicare Payment Localities, 2004:
Abbreviations:
AA: Anesthesiologist Assistant:
AANA: American Association of Nurse Anesthetists:
AMA: American Medical Association:
ASA: American Society of Anesthesiologists:
BESS: Medicare Part B Extract Summary System:
CCNA: Council on Certification of Nurse Anesthetists:
CMS: Centers for Medicare & Medicaid Services:
CRNA: Certified Registered Nurse Anesthetist:
HMO: Health Maintenance Organization:
MedPAC: Medicare Payment Advisory Commission:
MGMA: Medical Group Management Association:
NRMP: National Resident Matching Program:
PPRC: Physician Payment Review Commission:
RVU: relative value unit:
United States Government Accountability Office:
Washington, DC 20548:
July 27, 2007:
The Honorable Pete Stark Chairman The Honorable Dave Camp Ranking
Minority Member Subcommittee on Health Committee on Ways and Means
House of Representatives:
In 2005, Medicare--the federal program that helps pay for physician and
other health care services furnished to the nation's elderly and
disabled--paid over $1.4 billion for anesthesia services, which are
services associated with the administration of anesthesia to patients
undergoing surgical or other invasive procedures.[Footnote 1]
Anesthesia services can be delivered in a variety of settings and are
generally provided by anesthesia practitioners, which include
anesthesiologists and certified registered nurse anesthetists (CRNAs).
Before 1992, Medicare paid for physician services, which include
anesthesia services, using a methodology based on physicians'
historical charges. In 1992, this methodology was replaced by a
physician fee schedule that based payments for physician services on
the amount of resources used to provide each service relative to all
other services, adjusted for differences in the costs of providing the
service across geographic areas, known as Medicare payment
localities.[Footnote 2] Under the new physician fee schedule, Medicare
payments for some specialties were expected to increase while payments
for other specialties, including anesthesiology, were expected to
decrease compared with the payments based on physicians' historical
charges. After the first year the physician fee schedule was in effect,
Medicare payments for some physician specialties--such as general and
family practice--increased while payments for other specialties--such
as surgery--decreased. An analysis of 1992 data by the Physician
Payment Review Commission (PPRC) found that Medicare payments per
service for general and family practitioners increased by 10 percent,
while payments per service for surgical specialties decreased by 8
percent overall during this time period.[Footnote 3]
While there have been increases in Medicare payments for anesthesia
services since the implementation of the physician fee
schedule,[Footnote 4] anesthesia practitioners have maintained that
Medicare payments for anesthesia services are too low, especially when
compared with the payments for such services made by private insurance
payers.[Footnote 5] In a 2002 survey of health plans sponsored by the
Medicare Payment Advisory Commission (MedPAC), researchers estimated
that Medicare payments for anesthesia services were about 61 percent
lower than private insurance payments.[Footnote 6],[Footnote
7],[Footnote 8] In contrast, a more recent analysis conducted for
MedPAC of 2004 claims data found that Medicare payments for physician
services, excluding anesthesia services, were, on average, 17 percent
lower than private payments.[Footnote 9]
Congress is concerned that regional differences between Medicare and
private payments for anesthesia services may create discrepancies in
the supply of anesthesia practitioners, which in turn could adversely
affect access to services for Medicare beneficiaries in some areas. In
particular, there is a concern that anesthesia practitioners will
choose to practice in areas where private payments for anesthesia
services are highest relative to Medicare payments and avoid areas
where Medicare beneficiaries are more concentrated relative to the
general population. While we previously reported on the impact of
income--of which Medicare payments are one source--on physicians'
decisions on where to locate and on Medicare beneficiary access to
physician services, our work did not focus on specific specialists such
as anesthesiologists or nonphysician practitioners such as CRNAs. In
2005 we reported that physician income, regardless of its source, was
generally not a primary factor influencing physicians' decisions to
locate in rural areas,[Footnote 10] and in 2006 we reported evidence of
recent increases in Medicare beneficiary access to physician
services.[Footnote 11] However, the difference between Medicare and
private payments for anesthesia services is larger than the difference
in payments for other physician services, raising the concern that
Medicare payment levels could affect where anesthesia practitioners
locate and more generally whether interest in anesthesiology as a
profession is also affected.
You asked us to examine the difference between Medicare and private
payments for anesthesia services, and whether the supply of
anesthesiologists in an area relative to the general population is
related to the concentration of Medicare beneficiaries in the area. In
this report, we describe (1) the extent to which Medicare payments for
anesthesia services were lower than private payments across Medicare
payment localities in 2004, (2) whether the supply of anesthesia
practitioners across Medicare payment localities in 2004 was related to
the differences between Medicare and private payments for anesthesia
services or to the concentration of Medicare beneficiaries in these
localities, and (3) compensation levels for anesthesia practitioners
compared to other health care practitioners in 2005 and trends in the
number of anesthesiology residency positions and the number of
graduates of nurse anesthesia programs.
To examine the extent to which Medicare payments for anesthesia
services were lower than private payments, we used 2004 anesthesia
service claims data from two billing companies that bill and track
payments from private payers and Medicare on behalf of anesthesia
practitioners. The two billing companies together provided billing
services on behalf of over 10 percent of all anesthesiologists in the
country in 2004. Although the anesthesia service claims data from the
two companies may not be generalizeable to all anesthesia services
provided by anesthesiologists, billing company officials stated that
their claims data were generally representative of other companies that
provide billing for anesthesia services and that anesthesia
practitioner groups that did not use billing services were not that
different from groups that did use billing services.[Footnote 12] We
ranked the anesthesia service codes present in the claims data in order
of prevalence across the Medicare payment localities represented in the
billing companies' claims data. Based on the rankings and prevalence
across localities, we identified a set of seven anesthesia services
provided by anesthesiologists alone that were most prevalent and well
represented across the Medicare payment localities included in the
claims data.[Footnote 13],[Footnote 14] We retained claims data for all
seven of these anesthesia services in 41 of Medicare's 89 payment
localities to include in our analyses. See table 1 in appendix I for
descriptions of the seven selected anesthesia services. Using these
data, we calculated payment differences--that is, the percentage by
which Medicare payments were lower than private payments, calculated as
the difference between average private and Medicare payments as a
percentage of average private payments--for the seven selected
anesthesia services in each of the 41 Medicare payment localities.
To determine whether the supply--that is, the number--of anesthesia
practitioners was related to the differences between Medicare and
private payments for anesthesia services, we examined the correlation
between the payment differences for the set of seven anesthesia
services provided in the 41 Medicare payment localities and the supply
of anesthesia practitioners in the same 41 localities and determined
whether they were statistically significant.[Footnote 15] Due to data
limitations, our analyses of payment differences were based on
anesthesia services performed by anesthesiologists alone. However, we
included CRNA supply in our analysis of anesthesia practitioner supply
because we had sufficient data on their supply and because they are
major providers of anesthesia services to Medicare
beneficiaries.[Footnote 16] To estimate the supply of anesthesia
practitioners, we used 2004 data from the American Medical Association
(AMA), the American Association of Nurse Anesthetists (AANA), the U.S.
Census Bureau, and Centers for Medicare & Medicaid Services (CMS) to
determine the number of anesthesia practitioners--both
anesthesiologists and CRNAs, separately and combined--per 100,000
people. To determine whether the supply of anesthesia practitioners was
related to the concentration of Medicare beneficiaries,[Footnote 17] we
examined the correlation between the supply of anesthesia practitioners
and the concentration of Medicare beneficiaries in the general
population across 87 of Medicare's payment localities and determined
whether they were statistically significant.[Footnote 18]
To compare compensation levels of anesthesia practitioners with those
of certain other physicians and nonphysician practitioners, we obtained
2005 compensation information from the Medical Group Management
Association's (MGMA) Physician Compensation and Production Survey, 2006
Report Based on 2005 Data. The MGMA report contains compensation
information for physicians and nonphysician practitioners from MGMA
member organizations that participated in the survey. MGMA member
organizations include medical group practices from across the country.
To examine selected trends in the number of anesthesiology residency
positions and in the number of graduates of nurse anesthesia programs,
we used data from the National Resident Matching Program (NRMP) and the
Council on Certification of Nurse Anesthetists (CCNA).[Footnote 19] We
used these data to examine the number of anesthesiology residency
positions offered and filled through the NRMP between 2000 and 2006 and
to examine trends in the number of newly graduated nurse anesthetists
between 1999 and 2006.
Our analyses aggregated data to the Medicare payment locality level and
as a result may not capture variations in payment differences,
anesthesia practitioner supply, and Medicare beneficiary concentration
that might exist below the locality level. Additionally, we do not know
if the payment differences, anesthesia practitioner supply, or Medicare
beneficiary concentrations calculated at the locality level are
representative of all areas within a locality, particularly for
localities that encompass entire states. We limited our correlation
analyses to determining whether a statistically significant association
existed between the supply of anesthesia practitioners and payment
differences or Medicare beneficiary concentration. However,
practitioners' decisions on where to locate could be influenced by many
other factors and at levels not captured by our analysis at the
Medicare payment locality level.
To ensure the reliability of the data we used, we interviewed officials
from the billing companies and other organizations that provided us
with data, and reviewed documentation relating to anesthesia service
claims, anesthesia practitioner supply, and Medicare beneficiary
information. We tested the internal consistency and reliability of all
the data and determined they were adequate for our purposes. For more
information on our scope and methodology and on the reliability of our
data, see appendix I. We performed our work from September 2004 through
May 2007 in accordance with generally accepted government auditing
standards.
Results in Brief:
In 2004, average Medicare payments for a set of seven anesthesia
services provided by anesthesiologists alone were lower than average
private payments in 41 Medicare payment localities, and ranged, on
average, from 51 percent lower to 77 percent lower than private
payments. For all 41 payment localities, Medicare payments were lower
than private payments by an average of 67 percent. In 2004, average
Medicare payments for the set of seven anesthesia services ranged from
$177 to $303 across the 41 payment localities, a range of 71 percent.
In contrast, average private payments for the same set of seven
anesthesia services in that same year ranged from $472 to over $1,300
across these localities, a range of 177 percent.
In 2004, there was no correlation between the overall supply of
anesthesia practitioners--that is, the total number of both
anesthesiologists and CRNAs per 100,000 people--and either the
difference between Medicare and private insurance payments for
anesthesia services or the concentration of Medicare beneficiaries in
the Medicare payment localities included in our analyses. However, when
we examined the supply of anesthesiologists and CRNAs separately, we
found correlations between practitioner supply and payment differences
and practitioner supply and beneficiary concentration. Specifically, we
found that in 2004, the supply of CRNAs tended to decrease as the
difference between Medicare and private insurance payments for
anesthesia services increased in 41 Medicare payment localities. We
also found that in 2004, the supply of anesthesiologists tended to
decrease as the concentration of Medicare beneficiaries increased
across 87 Medicare payment localities, while the supply of CRNAs tended
to increase as the concentration of Medicare beneficiaries increased
across these Medicare payment localities.
For 2005, compensation for anesthesia practitioners was reported to
compare favorably with other practitioners, according to information
from medical group practices from across the country that responded to
a survey of MGMA member organizations. The 2005 median annual
compensation for general anesthesiologists--approximately $354,240--
was over 10 percent higher than the median annual compensation for
specialists and over twice the compensation for generalists. For 2005,
MGMA-reported median annual compensation for CRNAs--approximately
$131,400--was over 40 percent higher than the MGMA-reported median
annual compensation for either nurse midwives or nurse practitioners
and over 35 percent higher than the MGMA-reported median annual
compensation for physician assistants. The number of anesthesiology
residency positions offered through the NRMP and the number of nurse
anesthesia graduates have increased in recent years.
We provided a draft of this report to CMS and to two external
commenters for their review. CMS stated that our study provides a good
summary of information collected from a variety of sources on
anesthesia payments and the supply of anesthesia practitioners. One of
the external commenters generally agreed with our findings, while the
other agreed with our finding concerning payment differences for
anesthesia services but expressed concern with our finding dealing with
supply. CMS' written comments appear in appendix II.
Background:
Anesthesia services are generally administered by anesthesia
practitioners, such as anesthesiologists and CRNAs. In 2004, there were
approximately 42,000 anesthesiologists and 30,000 CRNAs in the United
States. Anesthesiologists are physicians who have completed a
bachelor's degree, medical school, and an anesthesiology residency,
typically 4 years in length. CRNAs are licensed as registered
professional nurses and have completed a bachelor's degree and a 2-or 3-
year nurse anesthesia graduate program. In our prior work, we showed
that physician specialists, who include anesthesiologists, tend to
locate in metropolitan areas.[Footnote 20],[Footnote 21]
Anesthesia services can be provided in several ways. Anesthesia
services can be provided by anesthesiologists alone, by
anesthesiologists working with CRNAs or other practitioners,[Footnote
22] or by CRNAs alone. In 2004, proportionally more anesthesia services
provided to Medicare beneficiaries were provided by anesthesiologists
working as the sole anesthesia practitioner and by anesthesiologists
working with another practitioner, such as a CRNA, compared to the
proportion of anesthesia services provided by CRNAs as the sole
anesthesia practitioner.[Footnote 23]
CRNAs can directly bill Medicare for the provision of anesthesia
services.[Footnote 24] In order to receive Medicare payment for
anesthesia services, CRNAs generally are required to practice under the
supervision of a physician or an anesthesiologist, except in states
that have obtained an exemption from this requirement from
CMS.[Footnote 25] As of May 2007, CMS reports that 14 states had
requested and obtained this exemption, which would allow CRNAs to
practice independently without physician supervision in a variety of
inpatient and outpatient settings.[Footnote 26]
Medicare's Calculation of Payments for Anesthesia Services:
Anesthesiologists derive approximately 28 percent of their income from
Medicare.[Footnote 27] CRNAs derive approximately 35 percent of their
patient mix from Medicare.[Footnote 28] In the Omnibus Budget
Reconciliation Act of 1989,[Footnote 29] Congress required the
establishment of a national Medicare physician fee schedule which sets
payment rates for services provided by physicians and other
practitioners. Under the Medicare physician fee schedule, Medicare
payments for anesthesia services are generally the lesser of the actual
charge for the service or the anesthesia fee schedule amount. Payments
for anesthesia services are subject to the same annual updates as all
other services paid under the physician fee schedule. However, Medicare
payments for anesthesia services are calculated differently than
payments for other services covered by the physician fee schedule.
Specifically, Medicare fee schedule payments for anesthesia services
are calculated using both "base" and "time" units. The relative
complexity of an anesthesia service is measured by base units; the more
activities that are involved, the more base units assigned by
Medicare.[Footnote 30] The time spent performing an anesthesia service
is measured continuously from when the anesthesia practitioner begins
preparing the patient for services and ends when the patient may be
safely placed in postoperative care and is measured by 15-minute units
of time with portions of time units rounded to one decimal place. The
sum of the base and time units are converted into a dollar payment
amount by multiplying the sum by an anesthesia service-specific
conversion factor, which also accounts for regional differences in the
cost of providing services.[Footnote 31] As such, each Medicare payment
locality has a unique anesthesia conversion factor assigned by CMS.
The calculation of the Medicare payment for an anesthesia service
associated with a lens surgery--the most common anesthesia service
provided to Medicare beneficiaries in 2004--performed by an
anesthesiologist or a CRNA working without another anesthesia
practitioner is shown in figure 1. Subject to certain exceptions,
Medicare payments for anesthesia services provided by anesthesiologists
and CRNAs are equal in most situations.[Footnote 32] For illustrative
purposes, we assumed that the service was provided in the Connecticut
payment locality and took 21 minutes to perform. In 2004, the total
Medicare payment for this service would have been $99.31, which was
equal to the product of the anesthesia service conversion factor
specific to the locality ($18.39) and the sum of the base and time
units associated with the anesthesia service (5.4 total units).
Figure 1: Example of a Medicare Payment for an Anesthesia Service
Associated with Lens Surgery in the Connecticut Medicare Payment
Locality, 2004:
[See PDF for image]
Source: GAO.
Note: This hypothetical payment includes beneficiary obligations.
[End of figure]
In contrast, Medicare payments for other physician services are
calculated using relative value units (RVUs) that correspond to the
different resources required to provide physician services. The RVUs
are each adjusted to account for geographic differences in the cost of
providing services, summed, and then multiplied by a general fee
schedule conversion factor, which is applicable across all Medicare
payment localities.
Physician Acceptance of Medicare's Payment as Payment in Full:
Physicians who bill Medicare for services can accept Medicare's payment
as payment in full (with the exception of the ability to bill a
Medicare beneficiary for 20 percent coinsurance plus any unmet
deductible). This is known as accepting assignment. Or they may
exercise an option to bill a Medicare beneficiary for the difference
between Medicare's payment and its limiting charge. This is known as
balance billing.[Footnote 33] High rates of assignment may serve as an
indicator of physicians' willingness to serve Medicare beneficiaries.
In April 2004, 99.4 percent of the anesthesia services provided by
anesthesiologists to Medicare beneficiaries were provided by
anesthesiologists who accepted Medicare payment as payment in full. The
anesthesiologists' assignment rate for anesthesia services was
comparable to rates for other hospital-based specialists, such as
pathologists (99.4 percent) and radiologists (99.6 percent), and was
higher than the rate for all other physicians (98.8 percent).[Footnote
34]
Anesthesia Practitioners Can also Provide Other Physician Services:
In addition to anesthesia services, anesthesiologists and CRNAs can
also provide other nonanesthesia types of physician services covered by
Medicare. Payments for these other physician services--which can
include medical services such as office visits, and procedures such as
pain management services--represented approximately 31 percent of
anesthesiologists' and 2 percent of CRNAs' revenue from Medicare in
2004.[Footnote 35] Because payment for these services is determined by
a different formula than anesthesia services, a significant portion of
these Medicare payments are closer to private payments levels for the
same services, in contrast to the difference in payments for anesthesia
services. According to a MedPAC-sponsored analysis, the average
difference between Medicare and private payments for medical services
such as office visits and for procedures provided in 2001 was 5 percent
and 25 percent, respectively.[Footnote 36]
Market Factors Influence Private Payments:
Most private payers, like Medicare, determine payments for anesthesia
services using base units, time units, and anesthesia-specific
conversion factors. Unlike the Medicare program, however, private
payers can set their fees in response to market forces such as managed
care prevalence and the extent of competition among providers. For
example, private anesthesia conversion factors are generally negotiated
between payers and anesthesia practitioners. In addition, some private
payers use different methods to determine time units, such as rounding
up fractional time units to the next whole number or using 10-minute
increments for each time unit, which can result in higher anesthesia
payments. When setting payment rates, some private payers also allow
higher payments for certain patient-related factors such as extremes in
age.
In our prior work we found that private payments for physician
services, excluding anesthesia and some other services, differed by
about 100 percent between the lowest-and the highest-priced
metropolitan areas and were responsive to market forces, such as
regional differences in the extent of competition among hospitals and
health maintenance organizations' (HMOs) ability to leverage
prices.[Footnote 37] For example, we found that areas with less
competition and lower levels of HMO price leverage had higher payments
than areas with more competition and greater levels of HMO price
leverage. We have also reported that because private payers can adjust
their payment levels to account for market forces, their payment levels
vary more than Medicare payments across geographic areas.[Footnote 38]
Average Medicare Payments for Anesthesia Services Provided by
Anesthesiologists Alone Ranged from 51 Percent to 77 Percent Lower than
Average Private Payments:
We found that average Medicare payments for a set of seven anesthesia
services provided by anesthesiologists alone were lower than average
private payments in 41 Medicare payment localities in 2004, and ranged,
on average, from 51 percent lower to 77 percent lower than private
payments (see fig. 2). For all 41 payment localities, Medicare payments
were lower than private payments by an average of 67 percent. In 2004,
the average Medicare payment for a set of seven anesthesia services was
$216, and the average private payment for the same set of anesthesia
services was $658.
Figure 2: Distribution of Percent Difference in Medicare and Private
Payments for Seven Anesthesia Services Provided by Anesthesiologists
Alone across 41 Medicare Payment Localities, 2004:
[See PDF for image]
Source: GAO analysis of 2004 claims data from two anesthesia service
billing companies.
[End of figure]
Medicare payments varied less than private payments across the 41
payment localities. In 2004, average Medicare payments for the set of
seven anesthesia services ranged from $177 to $303 across the 41
payment localities, a range of 71 percent. In contrast, average private
payments for the same set of seven anesthesia services in that same
year ranged from $472 to over $1,300 across these localities, a range
of 177 percent.
Overall Supply of Anesthesiologists and CRNAs Combined Was Not
Correlated with Payment Differences for Anesthesia Services or
Concentration of Medicare Beneficiaries:
In 2004, there was no correlation between the overall supply of
anesthesia practitioners--that is, the total number of both
anesthesiologists and CRNAs per 100,000 people--and either the
difference between Medicare and private payments for anesthesia
services or the concentration of Medicare beneficiaries in the Medicare
payment localities included in our analyses.[Footnote 39] However, when
we examined the supply of anesthesiologists and CRNAs separately, we
found correlations between practitioner supply and payment differences
and practitioner supply and beneficiary concentration. Specifically, we
found that in 2004, the supply of CRNAs tended to decrease as the
difference between Medicare and private payments for anesthesia
services increased in 41 Medicare payment localities. We also found
that in 2004, the supply of anesthesiologists tended to decrease as the
concentration of Medicare beneficiaries increased across 87 Medicare
payment localities, while the supply of CRNAs tended to increase as the
concentration of Medicare beneficiaries increased across these Medicare
payment localities.
Overall Supply of Anesthesia Practitioners Was Not Correlated with
Payment Differences for Anesthesia Services, While Supply of CRNAs Was
Related:
We found no correlation between the overall supply of anesthesia
practitioners per 100,000 people and the difference in Medicare and
private payments for anesthesia services across 41 of Medicare's
payment localities in 2004. The supply of anesthesia practitioners
varied across the 41 localities independent of the payment differences
in these localities and the payment differences varied independently of
the supply of anesthesia practitioners in the localities. When we
considered anesthesiologists and CRNAs separately, we found a
relationship between the supply of CRNAs and the payment differences
for anesthesia services across the 41 Medicare payment localities in
2004. Specifically, there tended to be fewer CRNAs in the localities
with the larger differences between Medicare and private payments for
anesthesia service. For example, on average, there were about 11.5
CRNAs per 100,000 people in the localities where private payments
exceeded Medicare payments by about 59 percent, while there were fewer
CRNAs--on average, about 7.5 per 100,000 people--in the localities
where private payments exceeded Medicare payments by about 73 percent.
In contrast, we did not find an association between the supply of
anesthesiologists and the differences between Medicare and private
payments for anesthesia services across the same 41 localities.
Overall Supply of Anesthesia Practitioners Was Not Correlated with
Concentration of Medicare Beneficiaries, While Supply of
Anesthesiologists and CRNAs Was Related:
We found no correlation between the overall supply of anesthesia
practitioners and the concentration of Medicare beneficiaries across 87
Medicare payment localities in 2004. The overall supply of anesthesia
practitioners--the number of both anesthesiologists and CRNAs combined
per 100,000 people--varied across the 87 localities independent of the
number of Medicare beneficiaries in these localities.
We found that the supply of anesthesiologists and the supply of CRNAs
were each correlated with the concentration of Medicare beneficiaries
across 87 payment localities in 2004. However, we found the opposite
relationship between the concentration of Medicare beneficiaries and
the supply of anesthesiologists and the supply of CRNAs. We generally
found fewer anesthesiologists in localities with a greater
concentration of Medicare beneficiaries. For example, in 2004, in
localities where on average 17 percent of the population was made up of
Medicare beneficiaries, there were 13 anesthesiologists per 100,000
people. For localities where, on average, 11 percent of the population
was made up of Medicare beneficiaries, the supply of anesthesiologists
was relatively higher at 16 per 100,000 people. In contrast, we
generally found more CRNAs in localities with higher concentrations of
Medicare beneficiaries. For example, in 2004, on average, there were 14
CRNAs per 100,000 people in localities where the proportion of Medicare
beneficiaries was 17 percent, on average, but half that supply--7 CRNAs
per 100,000 people--in localities where 11 percent of the population
was Medicare beneficiaries. The larger supply of CRNAs in localities
with greater concentrations of Medicare beneficiaries appeared to
offset the smaller anesthesiologist supply in these localities so that,
in total, there was no relationship between the overall supply of
anesthesia practitioners and the concentration of Medicare
beneficiaries across the 87 localities in 2004.
Compensation of Anesthesia Practitioners Was Reported to Compare
Favorably with Other Practitioners, and Anesthesiology Residencies and
Nurse Anesthesia Graduates Have Increased:
For 2005, compensation for anesthesia practitioners was reported to
compare favorably to that of other physicians and nonphysician
practitioners, according to information from medical group practices
from across the country that responded to a survey of MGMA member
organizations. The 2005 median annual compensation for general
anesthesiologists--approximately $354,240--was over 10 percent higher
than the median annual compensation for specialists and over twice the
compensation for generalists.[Footnote 40],[Footnote 41] When compared
to other hospital-based specialists, the MGMA-reported median annual
compensation for general anesthesiologists was higher than that for
three categories of pathologists and less than that for three
categories of radiologists.[Footnote 42] For example, the MGMA-reported
median annual compensation for general anesthesiologists was
approximately 10 percent higher than the MGMA-reported median annual
compensation for anatomic and clinical pathologists. MGMA data also
showed that the median annual compensation for pain management
anesthesiologists and pediatric anesthesiologists exceeded the median
annual compensation for general anesthesiologists and all categories of
pathologists and radiologists. Similarly, for 2005, the MGMA-reported
median annual compensation for CRNAs--approximately $131,400--was
higher than the MGMA-reported median annual compensation for other
nonphysician practitioners such as nurse practitioners, nurse midwives,
and physician assistants. For example, the MGMA-reported median annual
compensation for CRNAs was over 40 percent higher than the MGMA-
reported median annual compensation for either nurse midwives or nurse
practitioners and over 35 percent higher than the MGMA-reported median
annual compensation for physician assistants.
The number of anesthesiology residency positions offered through the
NRMP and the number of nurse anesthesia graduates have increased in
recent years. From 2000 to 2006 the number of residency positions
available in anesthesiology through the NRMP increased from 1,005 to
1,311, and the number of these positions that were filled increased
from 802 to 1,287. By 2006, the anesthesiology residency match rate--
the percentage of positions that have been filled--was 98 percent. This
rate was higher than the rate for pathologists, radiologists, and all
physicians in 2006. In addition, there has been a significant increase
in the number of newly graduated nurse anesthetists. According to the
Council on Certification of Nurse Anesthetists (CCNA), in 1999, nurse
anesthesia programs produced 948 new graduates; in 2005, that number
had increased to 1,790, an overall increase of 89 percent.
Agency and External Comments and Our Evaluation:
We provided a draft of this report to CMS and to two external
commenters that represent anesthesia service practitioners; the AANA
and the American Society of Anesthesiologists (ASA). CMS's written
comments are reprinted in appendix II.
CMS stated that our study provides a good summary of information
collected from a variety of sources on anesthesia payments and the
supply of anesthesia practitioners but was concerned that our analysis
of payment differences for anesthesia services did not include four of
the top five Medicare anesthesia services in terms of Medicare
payments. CMS noted that private payer rates are not a criterion under
the law to determine whether Medicare physician payments are reasonable
and stated that the Medicare and private payment differences for
anesthesia services do not necessarily indicate a deficiency in
Medicare payment rates. CMS also suggested that the report should
mention that the services of CRNAs in most rural hospitals and critical
access hospitals are paid on a reasonable cost basis--not under the
physician fee schedule--and that payments based on reasonable costs
could affect Medicare and private payment differences for anesthesia
services in these areas.
One of the external commenters generally agreed with our findings. The
other external commenter agreed with our finding regarding payment
differences for anesthesia services, but like CMS questioned our choice
of the anesthesia services included in our analysis of payment
differences. This external commenter was also concerned regarding our
finding related to supply of anesthesia practitioners and believed that
we overestimated the supply of anesthesiologists based on analysis of
its own association membership counts. Both external commenters stated
that we should have addressed aspects of payments to anesthesia service
practitioners that were not included in our analysis. Specifically, one
external commenter stated we should have examined the use of stipends
by hospitals to augment anesthesiologists' compensation. The other
external commenter stated we should have included analysis of Medicare
and private anesthesia service payments to CRNAs, including analysis of
anesthesia services during which CRNAs work with anesthesiologists or
provide the services as the sole anesthesia practitioner.
We carefully considered which anesthesia services to include in our
analysis of Medicare and private payment differences for anesthesia
services, but were not able to include all of the high-volume Medicare
anesthesia services. In order to calculate the difference between
Medicare and private payments for anesthesia services and include the
maximum number of localities in our analysis, it was essential to
include anesthesia services that were high volume for both Medicare and
the private sector. Some anesthesia services that were high volume for
Medicare beneficiaries, for example anesthesia for lens surgery, were
not as high volume for private patients and were not included for that
reason. We agree with CMS that differences between Medicare and private
payments for anesthesia services are not a statutory criterion for
determining Medicare payments for these services and added this
clarification to our report. We also clarified that Medicare payments
for CRNA anesthesia services provided in rural and critical access
hospitals could be paid on a reasonable cost basis and added a
statement to the report stating this fact. However, we did not
determine the extent to which Medicare and private payments to CRNAs
practicing in rural and critical access hospitals differed as this was
beyond the scope of our study.
In response to the external commenter's concern regarding the accuracy
of our estimate of the supply of anesthesiologists, we believe the AMA
data that we used to calculate the supply of anesthesiologists
represent the most complete and accurate data source for analyzing
physician supply, and that the external commenter estimates of supply
based on association membership counts may underestimate supply because
it is likely that some anesthesiologists do not belong to the
association. Additionally, we checked our calculations regarding the
supply of anesthesiologists and verified that we had removed inactive
and nonpracticing anesthesiologists from our supply estimates. We did
not include a discussion of stipends paid by hospitals to anesthesia
service practitioners. Stipends are reported to be paid to a variety of
specialists, including anesthesiologists, for several reasons,
including to compensate specialists for treating a high proportion of
Medicare beneficiaries, 24-hour coverage of trauma units, and to help
cover costs associated with treating uninsured patients. As our study
focused on Medicare and private payments for anesthesia services and
overall compensation for anesthesia practitioners, it was beyond the
scope of our study to examine this issue in further detail. We agree
with the external commenter that it would have been preferable to
include payments for CRNA anesthesia services in our analysis, but were
not able to do this due to data limitations.
The external commenters provided us with technical comments and
clarifications, which we incorporated as appropriate.
As arranged with your offices, unless you publicly announce the
contents of this report earlier, we plan no further distribution of it
until 30 days from the date of this letter. We are sending copies of
this report to the Administrator of CMS and interested congressional
committees. We will also make copies available to others upon request.
The report is available at no charge on the GAO Web site at http://
www.gao.gov.
If you or your staffs have any questions, please contact me at (202)
512-7114 or kingk@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. Staff members that made major contributions to
this report are listed in appendix III.
Signed by:
Kathleen M. King:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
This appendix describes in detail the data and methods we used to
calculate differences in Medicare and private anesthesia service
payments, anesthesia practitioner supply, and Medicare beneficiary
concentration. It also describes the correlation analyses we conducted
to determine the relationship between anesthesia practitioner supply
measures, differences in anesthesia service payments, and Medicare
beneficiary concentration. Finally, this appendix addresses data
reliability issues and limitations related to our studies.
Difference in Medicare and Private Payments for Anesthesia Services:
To examine the extent to which Medicare payments for anesthesia
services were lower than private payments across Medicare payment
localities in 2004,[Footnote 43] we used anesthesia service claims data
from two billing companies that bill and track payments from private
payers and Medicare and calculated payments by payer for services
provided by anesthesiologists alone at the Medicare payment locality
level. This provided us with average Medicare and private payments for
a set of anesthesia services. We then calculated payment differences--
that is, the percentage by which Medicare payments were lower than
private payments, calculated as the difference between average private
and Medicare payments as a percent of average private payments--for
each of the localities included in our analysis.
To calculate the difference between Medicare and private payments for
anesthesia services, we used 2004 anesthesia service claims data from
two companies that bill private payers and Medicare on behalf of
anesthesia practitioners.[Footnote 44] We obtained names of several
billing companies from interviews with industry experts who were
knowledgeable about industry billing practices. We chose to use
anesthesia service claims data from billing companies because such data
contain claims from many different insurers in an area. The two billing
companies from which we obtained claims data together provided billing
services on behalf of over 10 percent of all anesthesiologists in the
country in 2004. Although the anesthesia service claims data from the
two companies may not be generalizeable to all anesthesia services
provided by anesthesiologists, billing company officials stated that
their claims data were generally representative of other companies that
provided billing for anesthesia services and that anesthesia practioner
groups that did not use billing services were not that different from
groups that did use billing services.
The billing companies provided us with claims data for anesthesia
services provided in 2004, including payment information for the 27
highest-expenditure anesthesia services paid for by Medicare in 2003,
which accounted for approximately 70 percent of Medicare anesthesia
service expenditures in 2003.[Footnote 45] The specific information the
billing companies provided included data on the type of payer; the
anesthesia service code; payment modifiers that specified the type of
anesthesia practitioner involved; total minutes of time required to
perform the service; payments, including insurer and beneficiary
payments; and the Medicare payment locality in which the service was
provided. Due to the proprietary nature of the data and concerns about
identification of providers or beneficiaries, the billing companies
could not provide payment information at a smaller geographic level.
Therefore, Medicare payment localities were the smallest areas for
which we could examine payments for anesthesia services. Only claims
for which fee-for-service Medicare was the payer were included in our
calculation of Medicare payments. For our calculation of private
payments for these services, we included fee-for-service, preferred
provider organization, and managed care claims from all commercial
payers. Average payments included payments made by insurers as well as
patient obligations such as deductibles and coinsurance payments.
Because our study compared Medicare and private payments only, we
excluded the billing companies' claims from other payers of anesthesia
services, such as Medicaid and workers' compensation funds. We also
excluded any claims for which we could not definitively identify the
payer.
Although both billing companies provided claims data, one company
provided information at the individual claims level while the other
company provided claims information summarized to the case level. For
the individual claims-level data, we excluded claims from the analysis
if the average anesthesia service payment was greater than or less than
3 standard deviations from the log of the average anesthesia service
payment, specific to each anesthesia service, Medicare payment
locality, and payer. We applied similar criteria to anesthesia service
conversion factors (which we calculated as the total payment for the
service divided by the sum of the base and time units associated with
the service) in the individual claims-level data. Because data from the
other company were summarized, we were not able to apply similar
exclusion criteria. Instead, prior to providing the claims data to us,
the billing company excluded claims if an individual Medicare or
private anesthesia service payment was less than 10 percent of the
Medicare allowable payment for the locality in which the service was
provided or if the receivable was greater than $50.[Footnote
46],[Footnote 47] We excluded claims paid by Medicare from the data
provided by either billing company if the Medicare anesthesia
conversion factor did not match any of the Centers for Medicare &
Medicaid Services' (CMS) established conversion factors, based on the
localities present in the data. We examined descriptive statistics for
both data sets after all exclusions were applied and determined that it
would be appropriate to merge the two data sets to calculate payment
differences.
After applying these and other exclusion criteria, we ranked the
anesthesia service codes in order of prevalence across the Medicare
payment localities represented in the billing companies' claims data.
Based on the rankings and prevalence across localities, we identified a
set of seven anesthesia services that were most prevalent and well
represented across the Medicare payment localities included in the
claims data. We balanced the need for maximizing the number of
localities with having a set of anesthesia services that were prevalent
in all of the localities chosen. In our final data set we retained
billing company claims data for all seven of these anesthesia services
in 41 different Medicare payment localities.[Footnote 48] These seven
anesthesia services were services provided by anesthesiologists only.
We did not have a sufficient volume of claims for anesthesia services
provided by certified registered nurse anesthetists (CRNAs) alone to
include data from CRNA-performed services in our analysis. We also did
not include data for anesthesia services provided by anesthesiologists
with the involvement of other anesthesia practitioners because the
billing data for these services from the two billing companies were not
consistent and we therefore determined them to be not reliable.
Medicare and private payments were both weighted to account for the
relative national expenditures for each of the seven anesthesia
services by Medicare in 2003 (see table 1). For example, because
anesthesia services for intraperitoneal procedures in the upper abdomen
including laparoscopy accounted for approximately one-third of Medicare
expenditures for the seven selected codes combined, approximately one-
third of the overall average payment we calculated for each locality
was based on payments for this service. There were far fewer Medicare
expenditures associated with anesthesia for hernia repairs in the lower
abdomen, not otherwise specified and therefore payments for these
services had a much smaller weight in overall average payment
calculations. Over 136,000 Medicare and private anesthesia service
cases were included in our calculation of payment differences.
Table 1: Description, Number of Cases, and Weights for Seven Anesthesia
Services included in Calculation of Anesthesia Service Payment
Difference:
Anesthesia service description: Anesthesia for intraperitoneal
procedures in upper abdomen including laparoscopy; not otherwise
specified;
Number of cases in claims data set: 27,447;
Weight based on Medicare expenditures: .32.
Anesthesia service description: Anesthesia for intraperitoneal
procedures in lower abdomen including laparoscopy; not otherwise
specified;
Number of cases in claims data set: 35,664;
Weight based on Medicare expenditures: .22.
Anesthesia service description: Anesthesia for procedures on the
integumentary system on the extremities, anterior trunk and perineum,
not otherwise specified;
Number of cases in claims data set: 23,318;
Weight based on Medicare expenditures: .12.
Anesthesia service description: Anesthesia for transurethral procedures
(including urethrocystoscopy); not otherwise specified;
Number of cases in claims data set: 12,783;
Weight based on Medicare expenditures: .09.
Anesthesia service description: Anesthesia for open procedures on bones
of lower leg, ankle, and foot; not otherwise specified;
Number of cases in claims data set: 16,827;
Weight based on Medicare expenditures: .09.
Anesthesia service description: Anesthesia for all procedures on
esophagus, thyroid, larynx, trachea, and lymphatic system of neck; not
otherwise specified, age 1 year or older;
Number of cases in claims data set: 8,340;
Weight based on Medicare expenditures: .09.
Anesthesia service description: Anesthesia for hernia repairs in lower
abdomen; not otherwise specified;
Number of cases in claims data set: 11,930;
Weight based on Medicare expenditures: .07.
Anesthesia service description: Total;
Number of cases in claims data set: 136,309;
Weight based on Medicare expenditures: 1.00.
Sources: American Medical Association, Current Procedural Terminology,
CPT 2003; GAO analysis of 2004 claims data from two anesthesia service
billing companies; and GAO analysis of BESS data, 2003.
Using the weighted average Medicare and private payments, we calculated
payment differences for each of the 41 Medicare payment localities
included in our analysis. We also calculated an overall average payment
difference inclusive of data from all 41 localities.
To examine a payment variable that was not influenced by variation in
time,[Footnote 49] we examined the difference in conversion factors for
Medicare and private anesthesia services, using the seven services
provided by anesthesiologists in the 41 Medicare payment localities.
The average difference in conversion factors was 69 percent, an amount
very similar to the difference in Medicare and private payments.
Therefore, we focused our analyses on the difference in Medicare and
private payments.
Supply of Anesthesia Practitioners:
To estimate anesthesia practitioner supply at the locality level, we
used data from the American Medical Association (AMA), the American
Association of Nurse Anesthetists (AANA), the U.S. Census Bureau, and
CMS. Only active anesthesiologists and CRNAs practicing in the 50
states and the District of Columbia were included in our
analysis.[Footnote 50],[Footnote 51] We assigned anesthesia
practitioners and the number of total U.S. general population residents
to 87 Medicare payment localities.[Footnote 52],[Footnote 53],[Footnote
54] To determine supply per 100,000 people, we divided the number of
anesthesia practitioners in each locality by the total resident
population in the same locality, multiplied by 100,000. (See table 2).
Table 2: Average and Range of Anesthesia Practitioner Supply per
100,000 People, 2004:
Anesthesia practitioner supply per 100,000 people: Anesthesiologist
supply;
Average: 15.12;
Minimum: 4.32;
Maximum: 46.91.
Anesthesia practitioner supply per 100,000 people: CRNA supply;
Average: 10.47;
Minimum: 1.66;
Maximum: 31.52.
Anesthesia practitioner supply per 100,000 people: Total anesthesia
practitioner supply;
Average: 25.59;
Minimum: 12.47;
Maximum: 52.15.
Source: GAO analysis of AMA, AANA, U.S. Census Bureau, and CMS data.
Note: N=87 Medicare payment localities.
[End of table]
Concentration of Medicare Beneficiaries:
To estimate the concentration of Medicare beneficiaries at the locality
level, we used CMS and U.S. Census Bureau data. Using a geographic
crosswalk file, we assigned the number of beneficiaries enrolled in
Medicare and the number of total U.S. general population residents to
Medicare payment localities. We then computed the percentage of
Medicare beneficiaries in the general population to estimate the
concentration of Medicare beneficiaries in each Medicare payment
locality. (See table 3).
Table 3: Average and Range of Medicare Beneficiary Concentration, 2004:
Variable: Medicare beneficiary concentration (percent);
Average: 14;
Minimum: 8;
Maximum: 20.
Source: GAO analysis of U.S. Census Bureau and CMS data.
Note: N=87 Medicare payment localities.
[End of table]
Correlation Analysis:
To measure the relationship between the supply of anesthesia
practitioners, the difference in average Medicare and private payments,
and the concentration of Medicare beneficiaries at the locality level,
we performed correlation analyses. A correlation coefficient measures
the strength and direction of linear association between two variables
without controlling for the effects of other characteristics as in a
multivariate analysis.[Footnote 55]
We calculated correlations between three measures of anesthesia
practitioner supply--anesthesiologists, CRNAs, and total
(anesthesiologists and CRNAs combined)--and differences in payments in
41 Medicare payment localities. We also calculated correlations between
the three supply measures and the concentration of Medicare
beneficiaries in 87 Medicare payment localities. (See tables 4 and 5
below.)
Table 4: Correlation Coefficients between Supply of Anesthesia
Practitioners and Average Medicare and Private Payment Differences, by
Medicare Payment Locality, 2004:
(Continued From Previous Page)
Anesthesia practitioner supply: Anesthesiologist;
Payment differences: Correlation coefficients: 0.16.
Anesthesia practitioner supply: CRNA;
Payment differences: Correlation coefficients: -0.35**.
Anesthesia practitioner supply: Total anesthesia practitioner;
Payment differences: Correlation coefficients: -0.09.
Sources: GAO analysis of anesthesia service claims data from two
billing companies, AMA, AANA, U.S. Census Bureau, and CMS.
Notes: N=41 Medicare payment localities. ** = statistically significant
at the 5 percent level.
[End of table]
Table 5: Correlation Coefficients between Supply of Anesthesia
Practitioners and Medicare Beneficiary Concentration, by Medicare
Payment Locality, 2004:
Anesthesia practitioner supply: Anesthesiologist;
Medicare beneficiary concentration: Correlation coefficients: -0.21*.
Anesthesia practitioner supply: CRNA;
Medicare beneficiary concentration: Correlation coefficients: 0.40***.
Total anesthesia practitioner;
Medicare beneficiary concentration: Correlation coefficients: 0.14.
Sources: GAO analysis of AMA, AANA, U.S. Census Bureau, and CMS.
Notes: N=87 Medicare payment localities.
* = statistically significant at the 10 percent level.
*** = statistically significant at the 1 percent level.
[End of table]
Data Reliability and Study Limitations:
We used a variety of data sources in our analysis, including anesthesia
service claims data from two billing companies, the AMA, the AANA, the
U.S. Census Bureau, CMS, the National Resident Matching Program (NRMP),
and the Medical Group Management Association (MGMA). We tested the
internal consistency and reliability of all our data sources and
determined they were adequate for our purposes. The files containing
the billing company data, which were used by the two companies to
record bills and payments, were subjected to various internal controls,
including spot checks, batch totals, and balancing controls as reported
by the two companies. Although we did not review these internal
controls, we did assess the reliability of the billing company data. We
conducted extensive interviews with representatives from both companies
to gain an understanding of the completeness and accuracy of the data
the companies provided. We also reviewed all information provided to us
concerning the data, including data dictionaries and file layouts.
Additionally, we examined the data for errors, missing values, and
values outside of expected range and computed payment differences from
each company's data separately and found them to be comparable.
Finally, we determined that our calculation of anesthesia service
payment differences was comparable with the results of a MedPAC-
sponsored study. We also assessed the reliability of median
compensation information reported by MGMA. Although multiple
compensation surveys are available, we chose to use MGMA as our data
source because it has been used as a source in a number of peer-
reviewed articles, and it contains comprehensive information on various
aspects of physician compensation. Through interviews with MGMA
officials, we learned of the steps taken by MGMA to ensure the
reliability of the data the association published on median
compensation, including comparisons with other industry studies on
physician and nonphysician compensation and year-to-year analyses of
respondents.
We identified several potential limitations of our analyses. First,
while we used payment data from 41 different Medicare payment
localities, we do not know if the payment data are representative of
all 89 of Medicare's payment localities. Second, we did not have
sufficient payment information to calculate payment differences for
anesthesia services provided by anesthesiologists working with other
anesthesia practitioners or anesthesia services provided solely by
CRNAs. As a result, we do not know if payment differences for services
provided in these ways would have been different than payment
differences for anesthesia services provided by anesthesiologists
alone. Third, we limited our analyses to determining whether the supply
of anesthesia practitioners was linearly associated with payment
differences or Medicare beneficiary concentration. However,
practitioners' decisions on where to locate could be influenced by many
other factors not included in our analyses. We also identified
potential limitations with MGMA's compensation data. The data were
based on a survey of MGMA member organizations which are reported to
overrepresent large medical groups. In addition, the MGMA survey
response rate of 16 percent raises the possibility that their
compensation data may not be representative of the compensation of all
physician and nonphysician practitioners. We performed our work from
September 2004 through May 2007 in accordance with generally accepted
government auditing standards.
[End of section]
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
Department Of Health & Human Services:
Centers for Medicare and Medicaid Services:
200 Independence Avenue SW:
Washington, DC 20201:
Date: June 15, 2007:
To: Kathleen M. King:
Director, Health Care:
Government Accountability 0ffice:
From: Leslie V. Norwalk, Esq.:
Acting Administrator:
Subject: Government Accountability Office (Gao) Draft Report: "Medicare
Physician Payments: Medicare and Private Payment Differences for
Anesthesia Services" (GAO-07-463):
Thank you for the opportunity to review and comment on the subject GAO
report. The GAO performed this study in response to Congressional
concern that differentials in anesthesia payments between Medicare and
private payers may be causing imbalances in the distribution of
anesthesia providers in the United States.
Pursuant to section I 848(b)(2)(B), anesthesia services are paid under
the physician fee schedule but on a different basis than other medical
and surgical services. Anesthesia services are paid on the basis of an
anesthesia code-specific base unit and time units that vary based on
the actual anesthesia time of the case. The number of time units is
computed by dividing the anesthesia time reported on the claim by a
standard time unit of 15 minutes. The sum of allowable base and time
units is multiplied by the locality specific anesthesia conversion
factor to compute the Medicare allowance for the anesthesia service.
The work of anesthesia services, as the work of all other physician fee
schedule services, is subject to a five year review process.
Recommendations for changes in the work of physician fee schedule
services, including anesthesia services, are provided by the American
Medical Association Relative Value Update Committee (AMA RUC).
Anesthesia services furnished by CRNAs are also paid using anesthesia
base and time units. However, certain qualified hospitals, largely
rural hospital and critical access hospitals (CAHs), may make an annual
election to have the services of their CRNAs paid on a reasonable cost
basis by the intermediary instead of by the carrier on a fee schedule
basis.
The GAO examined three issues as requested by the Congress. These are:
1. Reviewing the differences in anesthesia payments between Medicare
and private payers across the Medicare payment localities in 2004;
2. Determining whether the supply of anesthesia practitioners is
influenced by these payment differentials;
3. Reviewing the levels of compensation for anesthesia practitioners in
2005 and trends in training of Certified Registered Nurse Anesthetists
(CRNAs) and anesthesiologists.
The report does not provide any specific recommendations to the Centers
for Medicare & Medicaid Services, but presents findings based on
information collected from private and Medicare Part B claims data
sources, MGMA compensation sources, and other sources on the supply of
anesthesia providers. Specifically, the report found:
* In 2004, Medicare payments for a set of seven anesthesia services
provided by anesthesiologists alone were lower than the private
payments for the same set of services for each of the 41 Medicare
payment localities reviewed.
* In 2004, there was no correlation between the overall supply of
anesthesia practitioners and either the difference between Medicare and
private insurance payments for anesthesia services or the concentration
of Medicare beneficiaries in the Medicare payment localities included
in this analysis.
* In 2005, compensation for anesthesia practitioners was reported to
compare favorably with other practitioners, according to a MGMA member
organization survey. The median annual compensation for
anesthesiologists was 10 percent higher than the median compensation
level for specialists and over twice the median compensation for
generalists. Similarly, the median annual compensation for CRNAs was
higher than the median annual compensation for other non- physician
practitioners, such as nurse practitioners, nurse midwifes, and
physician assistants. Further, the number of anesthesiology residency
positions offered through the National Resident Matching Program and
the number of nurse anesthesia graduates have increased in recent
years.
We appreciate the work the GAO did on this study and believe it
provides a good summary of information collected from a variety of
sources on anesthesia payments and the supply of anesthesia
practitioners.
For the past several years, CMS has been engaged in an effort to refine
the payment rates for anesthesia services. In last year's final
physician fee schedule rule, CMS asked the AMA RUC to work with the ASA
to develop a recommendation regarding the valuation of the work of
anesthesia services. In specific, CMS asked the RUC to review the
"building block" approach used previously in the second five year
review. CMS was particularly interested in the valuation of the work of
anesthesia services in the post induction time period. This represents
the longest period of the anesthesia service and is an area that the
ASA thought that the RUC had previously underestimated. The ASA also
had other concerns, such as the valuation of all anesthesia services,
not just the limited number of high volume anesthesia services reviewed
as part of the building block approach.
The AMA RUC examined this issue earlier this year and CMS anticipates
receiving their recommendations soon. If possible, we will address any
recommendations we receive from the RUC in the upcoming 2008 physician
fee schedule notice of proposed rulemaking.
While we appreciate the analysis conducted for this report, we do have
some concerns about the limitations of the analysis. The GAO report
limits its payment analysis to seven high volume anesthesia services
listed in its appendix. These services were chosen because they were
most prevalent and well represented across the Medicare payment
localities included in the claims data from the two anesthesia billing
companies that provided data. One of the shortcomings of the selected
procedures is that this list does not account for four of the top five
Medicare anesthesia services (i.e. Current Procedural Terminology codes
00142, 00562, 00810, and 01402), which account for almost 25 percent of
Medicare payments.
Private payer rates are not a criterion under the law to determine
whether Medicare physician payments are reasonable. The Medicare
physician payment system is a resource-based payment system based on
physician work, physician practice costs, and malpractice costs. These
are the criteria used to determine whether a service is fairly valued.
The differential in payments does not necessarily indicate a deficiency
in Medicare payment rates.
CMS also suggests that the report be revised to mention the fact that
the services of CRNAs in most rural hospitals and critical access
hospitals are paid on a reasonable cost basis, not a fee schedule
basis. Since these payments are made on a cost basis, it is more likely
that Medicare and private payers are paying the same fees in these
areas.
CMS thanks the GAO for reviewing this issue and providing information
that may be useful towards ensuring that Medicare payments for
anesthesia services do not result in an imbalance in the distribution
of anesthesia providers. This information is helpful to further the
discussion on appropriate Medicare payment for anesthesia services.
[End of section]
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Kathleen M. King, (202) 512-7114 or kingk@gao.gov:
Acknowledgments:
In addition to the contact named above, Christine Brudevold, Assistant
Director; Stella Chiang; Krister Friday; Jawaria Gilani; and Ba Lin
made key contributions to this report.
[End of section]
Related GAO Products:
Medicare Physician Services: Use of Services Increasing Nationwide and
Relatively Few Beneficiaries Report Major Access Problems. GAO-06-704.
Washington, D.C.: July 21, 2006.
Federal Employees Health Benefits Program: Competition and Other
Factors Linked to Wide Variation in Health Care Prices. GAO-05-856.
Washington, D.C.: August 15, 2005.
Medicare Physician Fees: Geographic Adjustment Indices Are Valid in
Design, but Data and Methods Need Refinement. GAO-05-119. Washington,
D.C.: March 11, 2005.
Physician Workforce: Physician Supply Increased in Metropolitan and
Nonmetropolitan Areas but Geographic Disparities Persisted. GAO-04-
124. Washington, D.C.: October 31, 2003.
FOOTNOTES
[1] Centers for Medicare & Medicaid Services (CMS), Medicare Part B
physician/supplier data, 2005. CMS is the agency that administers the
Medicare program. The $1.4 billion represents payments made under
Medicare Part B, which helps pay for physician and other
noninstitutional health care services provided to Medicare
beneficiaries.
[2] CMS established Medicare payment localities to reflect geographic
variations in the relative costs required to provide physician
services. For the purposes of this report, we refer to "Medicare
payment localities" as "payment localities" or "localities." There are
89 payment localities. Localities can encompass large geographic areas,
from cities to entire states. Many localities contain several cities,
towns, and rural areas with distinct characteristics and populations.
[3] According to CMS, the first-year impact of the physician fee
schedule on anesthesia service payments was not calculated.
[4] Medicare payments for physician services, including anesthesia
services, are updated by CMS on an annual basis, and except in 2002
when the update was negative and in 2006 and 2007 when the updates were
zero, the annual payment updates have resulted in annual increases in
payments for physician services. In addition to these annual updates,
payments for physician services can also be adjusted to reflect reviews
of the valuation of individual services. As a result of these reviews,
payments for anesthesia services were increased in 1997 and again in
2003.
[5] The differences between Medicare and private payments for
anesthesia services are not a legal criterion for determining Medicare
payment reasonableness.
[6] MedPAC is an independent federal body that advises the U.S.
Congress on issues affecting the Medicare program.
[7] For the purposes of this report, we also refer to "private
insurance payments" as "private payments."
[8] Dyckman & Associates, Survey of Health Plans Concerning Physician
Fees and Payment Methodology: A Study Conducted by Dyckman & Associates
for the Medicare Payment Advisory Commission, No. 03-7 (Washington,
D.C.: MedPAC, August 2003).
[9] MedPAC, Report to the Congress, Medicare Payment Policy
(Washington, D.C.: March 2006).
[10] GAO, Medicare Physician Fees: Geographic Adjustment Indices Are
Valid in Design, but Data and Methods Need Refinement, GAO-05-119
(Washington, D.C.: Mar. 11, 2005).
[11] GAO, Medicare Physician Services: Use of Services Increasing
Nationwide and Relatively Few Beneficiaries Report Major Access
Problems, GAO-06-704 (Washington, D.C.: July 21, 2006). We found that
two indicators of access to physician services--the proportion of
beneficiaries who received services and the number of services provided
to beneficiaries--suggest that Medicare beneficiaries' access to
physician services increased from April 2000 to April 2005.
[12] Due to the proprietary nature of the data and concerns about
identification of providers or beneficiaries, billing companies could
not provide payment information at a smaller geographic level--for
example, the county or zip code level.
[13] We did not have a sufficient volume of claims for anesthesia
services provided by CRNAs alone to include data from CRNA-performed
services in our analysis. We also did not include data for anesthesia
services provided by anesthesiologists with the involvement of other
anesthesia practitioners because the billing information for these
services from the two billing companies was not consistent and we
therefore determined it to be not reliable.
[14] In 2004, there were 270 different codes for anesthesia services,
which are generally classified according to the general area of
surgical intervention receiving anesthesia. Because we did not have
claims information for each of these 270 anesthesia services in each
Medicare payment locality, we focused our analysis on a set of
anesthesia services that were the most prevalent and well represented
in our claims file.
[15] A correlation coefficient measures the strength and direction of
linear association between two variables without controlling for the
effects of other characteristics as in a multivariate analysis.
[16] Because we did not have anesthesiology assistant supply data,
these providers were excluded from our supply analysis.
[17] The concentration of Medicare beneficiaries is the percentage of
Medicare beneficiaries in the general population.
[18] This correlation analysis included data from the payment
localities representing the 50 states and the District of Columbia. We
did not consider data from Puerto Rico, the Virgin Islands, and Guam.
The analysis was therefore based on data from 87 of Medicare's 89
payment localities.
[19] The NRMP places medical school graduates in residencies.
Residencies are 3-to 7-year graduate medical programs that physicians
in the United States must complete in order to provide direct patient
care. NRMP administrators estimate that the program fills approximately
80 to 90 percent of residencies nationwide each year.
[20] GAO, Physician Workforce: Physician Supply Increased in
Metropolitan and Nonmetropolitan Areas but Geographic Disparities
Persisted, GAO-04-124 (Washington, D.C.: Oct. 31, 2003).
[21] Metropolitan areas are metropolitan statistical areas, primary
metropolitan statistical areas, or New England county metropolitan
areas as of 2001.
[22] Other practitioners who can be involved in the provision of
anesthesia services include anesthesiologist assistants (AAs) and
medical residents. AAs are nonphysician anesthesia practitioners who
complete a 2-year graduate anesthesia training program and who work
only under the direction of anesthesiologists. Medical residents,
physicians in graduate medical training, can also be involved in the
provision of anesthesia services, but do not receive Medicare Part B
reimbursement for their role in providing anesthesia services.
[23] GAO analysis of 2004 Medicare Part B Extract Summary System (BESS)
data.
[24] Anesthesia services furnished by hospital-employed or contracted
CRNAs or AAs at qualified rural hospitals (including critical access
hospitals) can be paid on a reasonable cost basis and not under the
physician fee schedule.
[25] Facilities must comply with Medicare Conditions of Participation
in order to participate in the Medicare program. Beginning in 2001, CMS
provided an exemption allowing CRNAs to practice without physician
supervision in hospitals, critical access hospitals, and ambulatory
surgical centers, and still receive reimbursement for the anesthesia
services they deliver to Medicare beneficiaries. In order for a state
to qualify for this exemption, the governor of the state must submit a
letter to CMS, attesting that this exemption is in the best interest of
the state's citizens and that the exemption is consistent with state
law. See 42 C.F.R. §§ 416.42(d); 482.52(c); 485.639(e).
[26] The 14 states that have taken this exemption are Alaska, Idaho,
Iowa, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico,
North Dakota, Oregon, South Dakota, Washington, and Wisconsin. However,
in these states, hospitals, critical access hospitals, and ambulatory
surgical centers may independently require physician supervision for
CRNAs.
[27] J.D.Wassenaar and S.L. Thran, eds. American Medical Association,
Physician Socioeconomic Statistics: 2000 - 2002 Edition (Chicago:
2001).
[28] The CRNA estimate of percent of patient mix from Medicare is based
on informal surveys of AANA members.
[29] See Pub. L. No. 101-239, §6102(a), 103 Stat. 2106, 2169-84 (1989)
(adding §1848 to the Social Security Act) (codified, as amended, at 42
U.S.C. §1395w-4).
[30] CMS determines its base units largely on the base units formulated
by the American Society of Anesthesiologists in its 1988 Relative Value
Guide. Medicare's anesthesia service base units range from 1 to 30 and
are uniform nationwide. With the exception of the base units assigned
to cataract or iridectomy surgery, all of Medicare's base units are
taken from the Relative Value Guide.
[31] A conversion factor is a dollar amount that translates a service's
relative value into an actual payment amount. CMS established a
separate conversion factor for anesthesia services, apart from the
general conversion factor for medical and surgical services.
[32] Currently, Medicare payments for anesthesia services provided by
anesthesiologists alone, by anesthesiologists working with CRNAs, and
by CRNAs alone are equivalent. Medicare payments for anesthesiologists
and CRNAs involved in the same service may not be equivalent when the
anesthesiologist is supervising more than four anesthesia services
concurrently.
[33] Physicians who sign Medicare participation agreements--referred to
as participating physicians--must accept assignment for all the covered
services they provide to Medicare beneficiaries. See 42 U.S.C.
§1395u(h)(l). Those who do not sign participation agreements--referred
to as nonparticipating physicians--can either opt to accept assignment
on a service-by-service basis or not at all. Only nonparticipating
providers have the option to balance bill. Physicians who balance bill
currently cannot charge Medicare beneficiaries more than 115 percent of
95 percent of the Medicare approved amount, or 109.25 percent of the
allowed Medicare payment--an amount known as the limiting charge. See
42 U.S.C. §1395u(j). Physicians may decide their participation status
on an annual basis.
[34] GAO analysis of CMS data, April 2004.
[35] GAO analysis of Medicare BESS data, 2004.
[36] Direct Research, LLC, Medicare Physician Payment Rates Compared to
Rates Paid by the Average Private Insurer, 1999 - 2001: A Study
Conducted by Direct Research, LLC for the Medicare Payment Advisory
Commission, No. 03-6 (Washington, D.C.: MedPAC, August 2003).
[37] GAO, Federal Employees Health Benefits Program: Competition and
Other Factors Linked to Wide Variation in Health Care Prices, GAO-05-
856 (Washington, D.C.: Aug. 15, 2005).
[38] GAO, Medicare Physician Fees: Geographic Adjustment Indices Are
Valid in Design, but Data and Methods Need Refinement, GAO-05-119
(Washington, D.C.: Mar. 11, 2005).
[39] The difference between Medicare and private payments for
anesthesia services is based on seven anesthesia services provided by
anesthesiologists alone in 41 Medicare payment localities in 2004. See
app. I for more details.
[40] MGMA, Physician Compensation and Production Survey: 2006 Report
Based on 2005 Data. The compensation information collected by MGMA is
self-reported by practitioners and includes information for employed
and contracted physician and nonphysician practitioners. To collect
compensation data, MGMA mailed surveys to over 12,000 of its member
organizations, which include medical group practices and other types of
organizations involved in physician practice management. The response
rate was approximately 16 percent. MGMA defines compensation to include
the amounts reported on a W-2, 1099, or K1 (for partnerships) plus all
voluntary salary reductions. MGMA instructs respondents to include the
following sources of compensation: salary, bonus and/or incentive
payments, research stipends, honoraria, and distribution of profits.
[41] In the 2006 MGMA Physician Compensation and Production Survey,
"general anesthesiology" referred to anesthesiologists who did not
subspecialize. The "all generalist" specialty category included family
practice (without obstetrics), internal medicine, and pediatric/
adolescent medicine. The "all specialist" category included
anesthesiology, cardiology, dermatology, emergency medicine,
gastroenterology, hematology/oncology, neurology, obstetrics/
gynecology, ophthalmology, orthopedic surgery, otorhinolaryngology,
psychiatry, pulmonary medicine, diagnostic radiology, general surgery,
and urology.
[42] MGMA reported compensation for three categories each of
anesthesiologists (general, pain management, and pediatric),
pathologists (anatomic & clinical, anatomic, and clinical), and
radiologists (diagnostic invasive, diagnostic noninvasive, and nuclear
medicine). MGMA did not report compensation information for general
pathologists or general radiologists.
[43] Medicare payments for anesthesia services are paid using a system
of "base" and "time" units. The relative complexity of an anesthesia
service is measured by base units; the more activities that are
involved, the more base units assigned by Medicare. The time spent
performing an anesthesia service is measured continuously from when the
anesthesia practitioner begins preparing the patient for services and
ends when the patient may be safely placed in postoperative care and is
measured by 15-minute units of time with portions of time units rounded
to one decimal place. The sum of the base and time units are converted
into a dollar payment amount by multiplying the sum by an anesthesia
service-specific conversion factor, which also accounts for regional
differences in the cost of providing services.
[44] Anesthesia practitioners are likely to use billing companies
because they usually provide services in hospital settings and may not
have their own private offices or staff to perform billing functions,
such as submitting claims to insurers and collecting receivables from
patients.
[45] The 27 highest Medicare expenditure anesthesia services were
identified from our analysis of the 2003 Medicare Part B Extract
Summary System (BESS) file.
[46] The receivable was the difference between the insurer-specific
allowable and the received payment.
[47] A receivable less than 10 percent of the Medicare allowable for
the locality or greater than $50 would indicate that the claim had not
been fully paid by the insurer or the patient.
[48] The 41 payment localities included in the payment difference
analysis include 13 localities which are whole states, 18 urban and/or
suburban areas, and 10 additional statewide areas (not including
already specified urban and/or suburban areas). Nine of the localities
are located in the U.S. Census region of the West, while 8 are
represented in the Midwest region. The South and Northeast regions each
had 12 localities.
[49] Because time units vary depending on the length of anesthesia time
associated with a surgical procedure, Medicare payment for the same
anesthesia service provided in two different surgeries will be
different if the associated anesthesia time is different. The
conversion factor for an anesthesia service, unlike the payment for an
anesthesia service, is not influenced by variation in the time required
to provide the service.
[50] Anesthesiologists were considered active if they were currently
practicing, not employed by the federal government, and involved in
direct patient care.
[51] Anesthesiologists were identified in the AMA database if they
listed their major specialty as anesthesiology, pain management,
critical care anesthesiology, or pediatric anesthesiology.
[52] Only 87 of CMS's 89 payment localities were included because our
analysis was restricted to the 50 states and the District of Columbia.
Therefore, the localities of Puerto Rico and the Virgin Islands were
excluded. Though Hawaii and Guam share a locality, Guam was also
excluded separately.
[53] Only resident population data from the 50 states and the District
of Columbia were used in our analysis.
[54] Observations without a reliable geographic locator were excluded.
[55] Correlation coefficients may be negative (as one variable
increases, the other decreases) or positive (as one variable increases,
the other variable also increases). They range from -1.0, indicating a
perfectly negative association, to +1.0, indicating a perfectly
positive association. A correlation coefficient of 0 indicates no
association.
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