Medicare: Payment Changes Are Needed for Assistants-at-Surgery
Published: 2004-01-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicare pays for assistant-atsurgery services under both the hospital inpatient prospective payment system and the physician fee schedule. Payments under the physician fee schedule are limited to a few health professions. In 2001, Congress directed GAO to report on the potential impact on the Medicare program of allowing physician fee schedule payments to Certified Registered Nurse First Assistants for assistant-at-surgery services. This report examines: (1) who serves as an assistant-atsurgery, (2) whether health professionals who perform the role must meet a uniform set of professional requirements, and (3) whether Medicare's payment policies for assistants-at-surgery are consistent with the goals of the program and, if not, whether there are alternatives that would help attain those goals. GAO analyzed information provided by physician and other health professional associations and Medicare payment data.
section_title: What GAO Found
paragraphs: Members of a wide range of health professions serve as assistants-at-surgery, including physicians, residents in training for licensure or board certification in a physician specialty, several different kinds of nurses, and members of several other health professions. Hospitals employ all the types of nonphysician health professionals who perform the role. Hospital employees likely serve as assistants-at-surgery for a majority of the procedures for which the American College of Surgeons says an assistant is "almost always" necessary. The number of assistant-at-surgery services performed by physicians and paid under the Medicare physician fee schedule has declined, while the number of such services performed by nonphysician health professionals eligible to receive payment under the physician fee schedule has increased. There is no widely accepted set of uniform requirements for experience and education that the health professionals who serve as assistants-at-surgery are required to meet. The health professions whose members provide assistant-at-surgery services have varying educational requirements. No state licenses all the health professionals who serve as assistants-at-surgery. Furthermore, the certification programs developed by the various nonphysician health professional groups whose members assist at surgery differ. GAO found that there was insufficient information about the quality of care provided by assistants-at-surgery generally, or by a specific type of health professional, to assess the adequacy of the requirements for members of a particular profession to perform the role. There are three flaws in Medicare's policies for paying assistants-at-surgery that prevent the payment system from meeting the program's goals of making appropriate payment for medically necessary services by qualified providers. First, because Medicare pays for assistant-at-surgery services under both the hospital inpatient prospective payment system and the physician fee schedule, and hospital payments for surgical care are not adjusted when an assistant receives payment under the physician fee schedule, Medicare may be paying too much for some hospital surgical care. Second, paying a health professional under the physician fee schedule to be an assistant-at-surgery, instead of including this payment in an all-inclusive payment, gives neither the hospital nor surgeon an incentive to use an assistant only when one is medically necessary. Third, the distinctions between those health professionals eligible for payment as an assistant-at-surgery under the physician fee schedule and those who are not eligible are not based on surgical education or experience as an assistant. Criteria for determining who should be paid as assistants-at-surgery under the physician fee schedule do not exist. However, hospitals are responsible under health and safety rules to provide quality care for their patients.

section_title: Letter
paragraphs: Ensuring that Medicare beneficiaries receive care from qualified providers  and that payments to providers are for the appropriate amount and only  for medically necessary services are recognized goals of Medicare.  Achieving these goals when paying for assistants-at-surgery, who perform  tasks as members of surgical teams under the direction of surgeons, poses  a particular challenge because of the range of considerations affecting  whether hospitals or surgeons decide an assistant is necessary for a given  beneficiary’s surgical procedure and the variation in education and  experience of individuals who serve as assistants.
Medicare pays hospitals, physicians, and certain nonphysician health  professionals for assistant-at-surgery services through the hospital  inpatient prospective payment system (PPS) and the Medicare physician  fee schedule. Medicare makes a single payment to hospitals for all the  services, including assistant-at-surgery services, that a hospital provides to  a beneficiary while an inpatient. The inpatient PPS pays predetermined  fixed amounts for groups, or bundles, of services, designed to provide  incentives to control spending by rewarding efficiency. Medicare also pays  teaching hospitals under the inpatient PPS for providing graduate medical  education (GME) to the residents employed by the hospital, some of  whom assist at surgery.
Medicare also makes payments under the Medicare physician fee schedule  for assistant-at-surgery services performed by physicians and members of  certain nonphysician health professions whose members assist. These  nonphysician health professionals—primarily physician assistants, nurse  practitioners, and clinical nurse specialists—are allowed to bill Medicare  under the physician fee schedule. Congress has been asked to authorize  Certified Registered Nurse First Assistants (CRNFA) and other  nonphysician health professional groups whose members provide  assistant-at-surgery services to bill Medicare under the physician fee  schedule for these services.
In 2001, Congress directed us to report on the potential impact on the  Medicare program of allowing physician fee schedule payments to  CRNFAs for assistant-at-surgery services. Congress required that we give  special consideration to quality of care, appropriate education  requirements, and appropriate rates of Medicare payment for assistants-at- surgery. This report examines: (1) who serves as an assistant-at-surgery,  (2) whether health professionals who perform the role must meet a  uniform set of professional requirements, and (3) whether Medicare’s  payment policies for assistants-at-surgery are consistent with the goals of  the program and, if not, whether there are alternatives that would help  attain those goals.
To determine who serves as an assistant-at-surgery, we analyzed Medicare  data for 1997 through 2002 from the Part B Extract and Summary System  maintained by the Centers for Medicare & Medicaid Services (CMS),  which oversees Medicare. These summary data are derived from the  Medicare Physician/Supplier Procedure Summary Master Files, which  contain procedure-specific billing data for all physician and supplier  services provided to Medicare beneficiaries each year. CMS contractors  edit these data, and data limitations are published annually. We used our  analysis of these data to determine the number, variety, and location of  surgical procedures for which physician and nonphysician health  professional assistants-at-surgery sought Medicare payment under the  physician fee schedule. We also analyzed these data by the categories in  the American College of Surgeons’ (ACS) study that classifies each  surgical procedure by the likelihood that it will require an assistant-at- surgery. We could not determine the number of assistants-at-surgery who  were paid under the inpatient PPS because CMS does not collect those  data. We interviewed staff from CMS; representatives of nine large  academic teaching hospitals distributed across the country; and  representatives of state licensing boards, assistant-at-surgery education  programs, and associations of hospitals, physicians, nurses, and other  health professions, including those whose members assist at surgery (see  app. I). We used these interviews to determine whether nonphysician  health professionals who perform the role of assistant-at-surgery must  meet a uniform set of professional requirements. In making this  determination, we also reviewed literature about the licensure and  certification of health professionals who serve as assistants-at-surgery and  Medicare laws and regulations affecting assistants.
We conducted our work from July 2001 through December 2003 in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: Assistants-at-surgery, who serve as members of surgical teams, perform  tasks under the direction of surgeons and aid them in conducting  operations. These tasks may include making initial incisions (“opening”),  exposing the surgical site (“retracting”), stemming blood flow  (“hemostasis”), surgically removing veins and arteries to be used as bypass  grafts (“harvesting”), reconnecting tissue (“suturing”), and completing the  operation and reconnecting external tissue (“closing”). Some of these  tasks, like retraction, are relatively simple, while others, such as  harvesting, are more complex. An assistant-at-surgery may perform one or  more simple or complex tasks during an operation.
Tasks performed by others on the surgical team differ from those  performed by assistants-at-surgery. Scrub staff work within the sterile  field—the area within the operating room that is kept free from harmful  microorganisms—passing instruments, sponges, and other items directly  to the surgeon and assistant-at-surgery who work within the sterile field.  Circulators work outside the sterile field, responding to the needs of team  members within the sterile field. Anesthesiologists, or anesthetists, who  administer and monitor anesthesia, painkillers, and other drugs, are also  present during an operation.
subsections: section_title: Need for Assistants-at- Surgery Depends on Complexity of Operation, Condition of Patient
paragraphs: Decisions by a hospital or surgeon to use an assistant-at-surgery depend  on the complexity of the operation and medical condition of the patient.  Physician associations, such as the ACS and the American Society of  General Surgeons, maintain that the surgeon should be responsible for  determining if an assistant-at-surgery is needed, although some hospitals  require the use of an assistant for certain surgical procedures. Hospitals  that employ assistants-at-surgery may assign them to a procedure without  consulting the surgeon performing the procedure.
Since 1994, the ACS, with other surgical specialty organizations, has  conducted studies to determine which surgical procedures require  physicians as assistants-at-surgery. These studies classify surgical  procedures as “almost always,” “sometimes,” or “almost never” requiring   an assistant-at-surgery. The 2002 study classifies approximately 5,000  surgical procedures, about 1,750 of which are designated as “almost  always” requiring a physician to serve as an assistant-at-surgery.
A small number of surgical procedures have accounted for the majority of  the assistant-at-surgery services paid for under the Medicare physician fee  schedule: In 2002, 100 procedures accounted for almost 75 percent of the  assistant-at-surgery services that Medicare paid under the physician fee  schedule. ACS designated 81 of these procedures as “almost always”  requiring a physician as an assistant-at-surgery, and the remaining 19  procedures were designated as “sometimes” requiring a physician as an  assistant.
section_title: Medicare Pays for Assistants-at-Surgery as Part of PPS Payments to Hospitals and under the Physician Fee Schedule
paragraphs: Medicare pays for medically necessary services, including those  performed by assistants-at-surgery, for eligible elderly and disabled  patients provided by health professionals and institutions meeting certain  requirements. Part A, or Hospital Insurance, pays for inpatient hospital  care, care provided by certain other health care facilities, and some home  health care. Part B, or Supplementary Medical Insurance, includes  payment for the services and items provided by physicians, certain other  nonphysician health professionals, suppliers, outpatient hospital  departments, and home health care agencies.
Medicare makes payments to hospitals under part A through the hospital  inpatient PPS for assistants-at-surgery. A fixed payment is made for all  the inpatient hospital services, including assistant-at-surgery services, that  a hospital provides to a beneficiary with a given diagnosis or receiving a  particular type of surgery. Payments under the hospital inpatient PPS  reflect the average bundle of services that beneficiaries with a particular   diagnosis receive as inpatients in similar hospitals. The hospital’s payment  for a bundle of services is the same regardless of whether an assistant-at- surgery is used or who provides the assistant-at-surgery services.
Prospective payment systems, such as the hospital inpatient PPS, are  designed to promote efficiency: because the payment for a particular  bundle of services is almost always the same, regardless of the services a  particular patient receives, hospitals are discouraged from providing  unnecessary services. Providing additional services would not increase  their payments. Consequently, PPS payments to the hospital are  sometimes less and sometimes more than the cost of providing care.
Payments are also made under the hospital inpatient PPS to teaching  hospitals for providing GME to the residents employed by the hospital. In  2001, about 20 percent of the approximately 5,800 U.S. hospitals were  considered teaching hospitals. In 2003, surgical residents comprised about  20 percent of all residents at these hospitals. There were about 7,500  residents in general surgery and about 13,000 more surgical residents  training for specialties, such as orthopedics, all of whom were required to  serve as assistants-at-surgery as part of their training. In addition to these  surgical residents, some nonsurgical residents have surgical rotations  during which they serve as assistants-at-surgery.
Medicare makes part B payments to assistants-at-surgery under the  physician fee schedule when assistant services are performed by a  physician or by a nonphysician health professional authorized to receive  such payment. In 2002, these payments totaled about $158 million, less  than 2 percent of the $10.5 billion Medicare paid to surgeons for surgical  procedures that year. Medicare also makes global payments to surgeons  under the physician fee schedule that cover the surgery and some pre- and  postoperative services that the surgeons and their employees perform.  Assistant-at-surgery services are not included in this bundle of services.  Generally, the amount Medicare pays under the physician fee schedule is  based on the resources needed to perform a service: the physician’s time  and skill, practice expenses that include the costs of staff, equipment, and  supplies, and the cost of liability insurance. While a surgeon’s global fee  for a surgical procedure is set to reflect the resources required to perform  the service, payments under the physician fee schedule for assistant-at- surgery services are not; they are calculated as a fixed percentage of the  surgeon’s global fee. The percentage varies depending on the profession of  the assistant-at-surgery. The Medicare physician fee schedule pays  physicians more than nonphysician health professionals for assistant-at- surgery services (see table 1).
Medicare sets requirements that various health care institutions, suppliers,  and professionals must meet to be paid by the program. Institutions, such  as hospitals, must meet conditions of participation (CoP)—health and  safety rules used to ensure quality of care. Until 1986, HCFA specified  some requirements for assistant-at-surgery services in its hospital CoP.  Hospitals were required to have physicians serve as assistants-at-surgery  for procedures “with unusual hazard to life,” while “nurses, aides, or  technicians having sufficient training to properly and adequately assist’’  could assist at “lesser operations.” In a broad revision of the hospital CoP  in 1986, the agency eliminated these requirements: it said the purpose of  the revisions to the surgical services section, which had included the  assistant-at-surgery requirements, was to “delete the overly prescriptive   details” about the operation of surgical services. CMS retains  requirements for other surgical team members, including scrub and  circulating staff.
CMS also establishes regulatory requirements for the health professions  eligible to receive payment under the Medicare physician fee schedule.  Members of that profession can be paid for providing covered services,  including assistant-at-surgery services. Although CMS’s rules include the  minimum requirements that these professionals must meet to receive  payment for services, there are no specific requirements to receive  assistant-at-surgery payments in Medicare regulations. General  requirements include education, licensure, and certification; no surgical  education or experience is mandated. For example, physician assistants  must graduate from an accredited physician assistant education program,  pass the National Commission on Certification of Physician Assistants  certification examination, and be licensed to practice as a physician  assistant, but do not have to have experience as an assistant-at-surgery.
section_title: Various Health Professionals Provide Assistant-at-Surgery Services, and Hospital Employees Provide Most of These Services
paragraphs: Members of a wide range of health professions serve as assistants-at- surgery. Hospitals employ residents, international medical graduates, and  all the types of nonphysician health professionals who perform the role.  Hospital employees likely serve as assistants-at-surgery for a majority of  the procedures for which the ACS says an assistant is “almost always”  necessary. The number of assistant-at-surgery services performed by  physicians and paid for under the physician fee schedule has declined,  while the number of such services performed by nonphysician health  professionals eligible to receive payment under the physician fee schedule  has increased.
subsections: section_title: Members of a Variety of Health Professions Serve as Assistants-at-Surgery
paragraphs: Physicians, residents in training for licensure or board certification in a  physician specialty, several different kinds of nurses, and members of  several other health professions serve as assistants-at-surgery (see table  2). Surgical associations state that surgeons or residents are preferred as  assistants-at-surgery, but surgeons are often not available to assist at  surgery.
section_title: Hospitals Employ the Full Range of Health Professions Whose Members Serve as Assistants-at-Surgery
paragraphs: Hospitals employ the gamut of health professionals who serve as  assistants-at-surgery to perform the role. Some hospitals tend to hire  assistants-at-surgery from a particular health profession, sometimes  offering training courses in assistant services for that profession, to ensure  that the hospital has a sufficient number of assistants. To encourage  surgeons to use their operating rooms, hospitals may (1) employ  assistants-at-surgery, eliminating the need for the surgeons to hire their  own assistants, or (2) arrange for health professionals in independent  practice to serve as assistants.
While teaching hospitals use residents as assistants-at-surgery, these  hospitals may also hire nonphysician health professionals to perform the  role. In a recent survey of neurosurgery residency program directors,  nearly all cited the need to hire nonphysician health professional staff,  such as physician assistants, in response to the weekly 80-hour work limit  for residents. Teaching hospitals with other surgical specialty programs  may also need to hire nonphysician health professionals as assistants-at- surgery because of the limit on resident hours.
section_title: Hospital Employees Likely Perform More than Half of All Assistant-at-Surgery Services
paragraphs: Because hospitals are not required to keep records on the use of  assistants-at-surgery to receive Medicare payment under the inpatient PPS,  the number and cost of such services provided by all hospital employees  are unknown. Still, hospital employees likely serve as assistants-at-surgery  for the majority of the surgeries performed on Medicare patients. In 2002,  Medicare made payments under the physician fee schedule to assistants- at-surgery about 36 percent of the time that the program made payments  to surgeons for the surgical procedures that ACS designated in its most  recent study as “almost always” requiring an assistant-at-surgery. Since  the remaining 64 percent of those surgical procedures were likely to have  had assistants-at-surgery, hospital employees would likely have performed  this role. In its final regulation revising the physician fee schedule for 2000,  HCFA relied upon the results of the American Hospital Association’s  (AHA) National Hospital Panel Survey that found that only 11 percent of  responding hospitals said it was a regular practice for physicians to bring  their own staff to the hospital to serve as assistants-at-surgery or to  perform other functions. A representative of the AHA told us that most  assistants-at-surgery, including residents and nonphysician staff, are  hospital employees.
section_title: Nonphysicians Are Performing an Increased Share of Assistant-at- Surgery Services Paid under the Physician Fee Schedule
paragraphs: The percentage of assistant-at-surgery services paid to physicians under  the physician fee schedule has declined, and the percentage of these  services paid to nonphysician health professionals has increased,  particularly since enactment of the Balanced Budget Act of 1997 (BBA).  The act raised the amount paid for assistant-at-surgery services to these  nonphysician health professionals under the physician fee schedule,  extended billing by clinical nurse specialists and nurse practitioners to  urban areas (such billing had been limited to rural areas), and allowed  physician assistants to contract with surgeons to be an assistant without  having to be employees of the surgeon. The number of assistant-at- surgery services paid for under the physician fee schedule and provided by  nonphysician health professionals increased more than 200 percent from  1997 through 2002, while the number of services provided by physicians  serving as assistants declined about 23 percent. During this period, the  percentage of Medicare-paid assistant-at-surgery services performed by  nonphysician health professionals increased by 25 percentage points (see  fig. 1).
The amount paid to nonphysicians for these services has also increased.  Prior to 1987, nonphysicians could not be paid as assistants-at-surgery. In  1997, nonphysicians were paid only $16 million for assistant-at-surgery  services; in 2002, they were paid about $54 million. In comparison,  physicians were paid $295 million for assistant-at-surgery services in 1986;  $166 million in 1997; and $104 million in 2002.
section_title: Widely Accepted Professional Requirements for Assistants-at-Surgery Do Not Exist
paragraphs: There is no widely accepted set of standards for the education and  experience required to serve as an assistant-at-surgery. The health care  professions whose members provide assistant-at-surgery services have  varying educational requirements. No state licenses all the types of health  professionals who serve as assistants-at-surgery. And the licenses they  issue typically attest to the completion of broad-based health care  education, making them of limited value in determining which health  professionals have the education and experience to serve as an assistant- at-surgery. Furthermore, the certification programs developed by the  various nonphysician health professional groups whose members assist at  surgery differ. We found that there was insufficient information about the  quality of care provided by assistants-at-surgery—either generally or by  members of specific health professions—to assess the adequacy of the  requirements for a particular profession.
subsections: section_title: Health Professions Whose Members Assist at Surgery Have Varying Educational Requirements
paragraphs: The health professions whose members serve as assistants-at-surgery have  varying educational requirements (see table 3). For example, a licensed  practical nurse typically completes a 1-year educational program, while a  clinical nurse specialist must have a master’s of science degree in nursing.  In some cases, experience can substitute for education: orthopedic  physician assistants may have associate degrees or certificates from  military or nondegree programs or 5 years of experience working for an  orthopedic surgeon.
section_title: State Licenses Typically Do Not Require Education and Experience as Assistants-at-Surgery
paragraphs: While state licenses for health professionals, including those eligible for  payment as assistants-at-surgery under the physician fee schedule,  typically have “scopes of practice” that include assistant-at-surgery  services, education and experience as an assistant are not necessarily  required to obtain a license: the licenses for these health professions attest  to the completion of broad-based health care education, which may not  include courses in surgery.
No state licenses all the health professions whose members assist at  surgery in its jurisdiction. For example, orthopedic physician assistants  and surgical assistants are licensed in only a few states. Only one state,  Texas, has a specific assistant-at-surgery license. Members of different  health professions may qualify for this license, which requires surgical  education and experience. Nevertheless, a license is not required to serve  as an assistant-at-surgery in Texas.
section_title: Nonphysician Health Professions’ Certification Programs for Assistants-at- Surgery Vary
paragraphs: Certification programs for assistants-at-surgery generally require  completion of a certain level of education or experience and passage of an  examination. Each certification program created by a group of  nonphysician health professionals for its members who serve as  assistants-at-surgery has different requirements (see table 4). Certification  programs for some nonphysician health professions not eligible for  payment under the physician fee schedule are for a wide range of surgical  services; others are specific to a particular type of surgery. For example, a  CRNFA, in addition to being licensed as a registered nurse and earning a  bachelor’s degree in nursing, must obtain certification as an operating  room nurse, complete an approved program, have 2,000 hours of  experience as an assistant-at-surgery, and pass an examination. For a  surgical technologist to receive certification as an assistant-at-surgery,  he/she must have a surgical technologist certification, complete an  approved program or have 2 years of experience as an assistant, and pass  the examination.
Certifications for those who are eligible for payment under the physician  fee schedule as an assistant-at-surgery are typically for a broad range of  services and are not specifically surgery-related. For example, the  American Nurses Credentialing Center awards certifications to nurse  practitioners for acute, adult, family, gerontological, pediatric, adult  psychiatric and mental health, and family psychiatric and mental health  care.
section_title: No National Consensus on Requirements for Assistants-at-Surgery Exists
paragraphs: While some national physician and accreditation organizations say  assistants-at-surgery should have to meet some requirements, there is no  consensus about what those requirements should be. For example, ACS  has stated that when surgeons or residents are unavailable to serve as  assistants-at-surgery, nonphysician health professionals should be allowed  to perform the role if they meet the “national standards” for their health  profession or have “additional specialized training.” Similarly, the Joint  Commission on Accreditation of Healthcare Organizations (JCAHO), a  private organization that accredits health care organizations, including  hospitals, requires hospitals to credential their staff (i.e., establish  requirements, such as licensure, certification, and experience for  physicians and certain nonphysician health professionals) and ensure that  those requirements are used when personnel decisions are made. But  JCAHO does not suggest the type or length of education or experience to  be used in credentialing hospital staff who serve as assistants-at-surgery.
section_title: Literature on Assistants-at- Surgery Is Insufficient to Evaluate Quality of Care
paragraphs: We found little evidence about the quality of care provided by assistants- at-surgery. Our February 2003 search of relevant literature maintained by  the National Library of Medicine found only six articles dealing with the  quality of care provided by assistants-at-surgery. None of the articles  compares the quality of assistant-at-surgery services provided by one  nonphysician health profession with that provided by another  nonphysician health profession or physicians, and only one deals  specifically with the influence of assistants on surgical outcomes.
section_title: While Medicare Payments for Assistant-at-Surgery Services Have Flaws, Paying Hospitals for All These Services Would Correct Them
paragraphs: There are three flaws in Medicare’s policies for paying assistants-at- surgery that prevent the payment system from meeting the program’s goals  of making appropriate payment for medically necessary services by  qualified providers. First, because Medicare pays for assistant-at-surgery  services under both the hospital inpatient PPS and the physician fee  schedule, and hospital payments for surgical care are not adjusted when  an assistant receives payment under the physician fee schedule, Medicare  may be paying too much for some hospital surgical care. Second, paying a  health professional under the Medicare physician fee schedule to be an  assistant-at-surgery, instead of including this payment in an all-inclusive  payment, gives neither the hospital nor the surgeon an incentive to use an  assistant only when one is medically necessary. Third, the distinctions  between those health professionals eligible for payment as an assistant-at- surgery under the physician fee schedule and those who are not eligible   are not based on surgical education or experience as an assistant. Criteria  for determining who should be paid as assistants-at-surgery under the  physician fee schedule do not exist. However, hospitals are responsible  under health and safety rules to provide quality care for their patients.
subsections: section_title: Medicare Payments for Assistants-at-Surgery Are Flawed
paragraphs: Medicare’s policy of paying hospitals for the services associated with  inpatient surgical care that may include assistant-at-surgery services and  also paying physicians and certain nonphysician health professionals for  those services is flawed. When Medicare pays under the hospital inpatient  PPS and under the physician fee schedule for assistant-at-surgery services  delivered to a particular patient, Medicare may pay too much for the  assistant services because the hospital is not paid less when the assistant  receives payment under the physician fee schedule. In addition, a hospital  that uses an assistant-at-surgery who is eligible for payment under the  physician fee schedule has a financial advantage in the form of lower labor  costs over a hospital that uses assistants who cannot be paid under the  physician fee schedule.
Given the discretion that hospitals and surgeons have in determining when  and how an assistant-at-surgery is used, it is especially important that  Medicare’s payment policy create incentives to help ensure that assistant  services are provided for Medicare patients only when medically  necessary. Allowing physician fee schedule payments to certain  assistants-at-surgery, however, creates an incentive for hospitals to use  them, rather than those who cannot be paid under the fee schedule.  Because neither the hospital nor the surgeon incurs a cost when an  assistant-at-surgery is paid under the physician fee schedule, neither has a  financial incentive to use an assistant only when one is necessary. The  lack of this incentive is of concern because assistant-at-surgery services  receive little review to determine the medical necessity of the services. A  2001 report by the Department of Health and Human Services Office of  Inspector General found that most contractors used by Medicare to pay  for part B services do not have any mechanism to ensure that assistant-at- surgery requests for payment for nonphysician health professionals are  reviewed for medical necessity before they are paid. Medicare routinely  requires submission of documentation of medical necessity for medical  review for only 1 percent of assistant-at-surgery services paid under the  physician fee schedule.
Because the requirements for those authorized to be paid as assistants-at- surgery under the Medicare physician fee schedule do not include  assistant-at-surgery education or experience, payments can be made to  assistants with no such education or experience. For example, about 23  percent of physician assistants work in surgical specialties. Other  physician assistants working in nonsurgical specialties, however, may be  paid as assistants-at-surgery under the Medicare physician fee schedule,  and their only surgical experience may be a 6-week surgical rotation. On  the other hand, nonphysician health professionals, such as surgical  technologists, CRNFAs, and orthopedic physician assistants, all of whom  have certification programs requiring education and experience as an  assistant-at-surgery, cannot be paid by Medicare for their services under  the physician fee schedule.
One way to address a concern associated with the physician fee schedule  payments for assistants-at-surgery is to expand the number of  nonphysician health professions eligible for payment. But this would not  ensure that only those with the appropriate education and experience  serve as assistants-at-surgery unless CMS also sets standards for all those  who serve as assistants. There is no consensus, however, on what such  standards should include.
section_title: Bundling Payments for Assistant-at-Surgery Services into Hospital Payments Would Be Preferable to Bundling into Surgeons’ Fees
paragraphs: Bundling all payments for assistants-at-surgery into either the inpatient  hospital PPS or the surgeon’s global fee would address the flaws of the  current payment system. The possibility of paying too much for assistant- at-surgery services would be eliminated because Medicare would make  only one payment—to either the hospital or the surgeon—for the service.  The hospital or surgeon would have a financial incentive to use the most  appropriate assistant-at-surgery—and to use one only when necessary— because the payment would be the same regardless of whether an  assistant was used. The lack of a relationship between the nonphysician  health professionals eligible for assistant-at-surgery payments under the  physician fee schedule and their education and experience would be moot  because payments would no longer be made to individuals performing the   role; payments would be made, as part of a larger payment for a bundle of  services, to hospitals or surgeons, who would have the responsibility to  determine the education and experience that an assistant-at-surgery needs  and when an assistant is needed.
Folding payments for assistant-at-surgery services into inpatient PPS  payments has some advantages that would not accrue if payments were  folded into the surgeon’s global fee. Hospitals would continue to have  incentives to use assistants-at-surgery when they are necessary, and to use  the most appropriate assistant. Hospitals are already responsible—under  the hospital CoP—for ensuring the health and safety of their patients and  that necessary services are provided, including assistant-at-surgery  services. Most hospitals already have credentialing processes for their  employees. Also, since hospitals likely employ most assistants-at-surgery,  limiting payments for assistant services to those made under the inpatient  PPS would disrupt the employment relationships for far fewer assistants  than would be the case if payment was made to surgeons.
There is precedent for Congress approving legislation that no longer  allows a service to be paid for separately under part B, but instead  requires that the service be included in a bundle of services under part A.  In 1997, Congress passed legislation that requires virtually all kinds of  services or items furnished to beneficiaries residing in skilled nursing  facilities (SNF) that had been paid for separately under part B, instead be  included in a bundle of services paid for under part A. Prior to  implementation of the provision, SNFs could permit a nonphysician health  professional or supplier to seek payment under part B for ancillary  services or items furnished directly to SNF residents, as long as the SNF  did not include the service or item in its part A bill. The legislation,  however, prevents this “unbundling” by including in Medicare SNF PPS  payments ancillary services or items a SNF resident may require that  previously had been paid under part B.
Bundling assistant-at-surgery services into the package of services covered  by the surgeon’s global payment based on the Medicare physician fee  schedule has significant drawbacks. First, because the amount paid under  the inpatient hospital PPS for assistants-at-surgery is unknown, the total  amount to be added to the physician fee schedule for providing assistants  is unknown. Second, a payment amount for assistant-at-surgery services  would have to be determined for each surgical procedure. Since data are  not collected on how often each surgeon uses assistants-at-surgery for  each surgical procedure, the bundled payment would presumably include  an allotment for the expected average cost of assistants for all surgeons  performing the procedure. Using this approach, surgeons with an  unusually high number of procedures requiring assistants would be paid  too little, while those with an unusually low number of procedures  requiring assistants would be paid too much. In addition, a surgeon would  have a financial incentive to use an assistant-at-surgery less frequently for  surgical procedures for which ACS says that an assistant may be needed,  even when the condition of the beneficiary indicates that an assistant  would be desirable. Because there is a difference in costs to a surgeon  depending on whether an assistant-at-surgery is used, a surgeon’s bundled  payment amount could be adjusted when an assistant is used. Doing so,  however, would provide no financial incentive for surgeons to use an  assistant-at-surgery only when one is medically necessary.
section_title: Conclusions
paragraphs: Decisions to use an assistant-at-surgery should not be influenced by  payment; they should be based on medical necessity. The majority of  assistants-at-surgery are likely employed by hospitals, where the inpatient  hospital PPS pays for their services. If Congress were to consolidate  Medicare physician fee schedule payments for assistant-at-surgery  services into the inpatient hospital PPS, this would give hospitals an  incentive to use assistants only when they are necessary. Meanwhile, the  hospital CoP would continue to give hospitals an incentive to assure that  the most appropriate assistants-at-surgery are used as part of their  responsibility to provide quality care for their patients. Paying for  assistants under the physician fee schedule provides no such incentive.
section_title: Matter for Congressional Consideration
paragraphs: We suggest that Congress may wish to consider consolidating all Medicare  payments for assistant-at-surgery services under the hospital inpatient  prospective payment system.
section_title: Agency Comments
paragraphs: We received comments on a draft of this report from CMS, which agreed  that payment policy for assistants-at-surgery could be improved. CMS  noted that it would be helpful to describe the ongoing review process that  CMS uses to assign relative values to physician fee schedule services.  However, as we state in this report assistants-at-surgery are not paid on  the basis of the resources they use to perform their work, but are instead  paid a percentage of the amount paid the surgeon. CMS also discussed  several details related to implementing payment changes for assistants-at- surgery. Addressing these points was beyond the scope of this report.  CMS’s comments appear in appendix II. In addition, we obtained oral  comments on a draft of this report from representatives of the American  Medical Association, the American College of Surgeons, the American  Society of General Surgeons, the American Association of Orthopaedic  Surgeons, the Society of Thoracic Surgeons, the American Academy of  Nurse Practitioners, the American Academy of Physician Assistants, the  Association of periOperative Registered Nurses, and the American  Hospital Association. We have modified the report, as appropriate, in  response to their comments.
We are sending copies of this report to the Acting Administrator of CMS,  appropriate congressional committees, and other interested parties. We  will also make copies available to others upon request. This report will be  available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please call me at  (202) 512-7101. Lisanne Bradley and Michael Rose were major  contributors to this report.
section_title: Appendix I: Professional Associations, Schools, and Hospitals
section_title: Appendix II: Comments from the Centers for Medicare & Medicaid Services