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entitled 'Medicare: Payment Changes Are Needed for Assistants-at-
Surgery' which was released on January 13, 2004.

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Report to Congressional Committees:

United States General Accounting Office:

GAO:

January 2004:

Medicare:

Payment Changes Are Needed for Assistants-at-Surgery:

GAO-04-97:

GAO Highlights:

Highlights of GAO-04-97, a report to congressional committees 

Why GAO Did This Study:

Medicare pays for assistant-at-surgery services under both the 
hospital inpatient prospective payment system and the physician fee 
schedule. Payments under the physician fee schedule are limited to a 
few health professions. In 2001, Congress directed GAO to report on 
the potential impact on the Medicare program of allowing physician fee 
schedule payments to Certified Registered Nurse First Assistants for 
assistant-at-surgery services. This report examines: (1) who serves 
as an assistant-at-surgery, (2) whether health professionals who 
perform the role must meet a uniform set of professional requirements, 
and (3) whether Medicare’s payment policies for assistants-at-surgery 
are consistent with the goals of the program and, if not, whether 
there are alternatives that would help attain those goals. GAO 
analyzed information provided by physician and other health 
professional associations and Medicare payment data.

What GAO Found:

Members of a wide range of health professions serve as assistants-at-
surgery, including physicians, residents in training for licensure or 
board certification in a physician specialty, several different kinds 
of nurses, and members of several other health professions. Hospitals 
employ all the types of nonphysician health professionals who perform 
the role. Hospital employees likely serve as assistants-at-surgery for 
a majority of the procedures for which the American College of 
Surgeons says an assistant is “almost always” necessary. The number of 
assistant-at-surgery services performed by physicians and paid under 
the Medicare physician fee schedule has declined, while the number of 
such services performed by nonphysician health professionals eligible 
to receive payment under the physician fee schedule has increased.

There is no widely accepted set of uniform requirements for experience 
and education that the health professionals who serve as assistants-at-
surgery are required to meet. The health professions whose members 
provide assistant-at-surgery services have varying educational 
requirements. No state licenses all the health professionals who serve 
as assistants-at-surgery. Furthermore, the certification programs 
developed by the various nonphysician health professional groups whose 
members assist at surgery differ. GAO found that there was 
insufficient information about the quality of care provided by 
assistants-at-surgery generally, or by a specific type of health 
professional, to assess the adequacy of the requirements for members 
of a particular profession to perform the role.

There are three flaws in Medicare’s policies for paying assistants-at-
surgery that prevent the payment system from meeting the program’s 
goals of making appropriate payment for medically necessary services 
by qualified providers. First, because Medicare pays for assistant-at-
surgery services under both the hospital inpatient prospective payment 
system and the physician fee schedule, and hospital payments for 
surgical care are not adjusted when an assistant receives payment 
under the physician fee schedule, Medicare may be paying too much for 
some hospital surgical care. Second, paying a health professional 
under the physician fee schedule to be an assistant-at-surgery, 
instead of including this payment in an all-inclusive payment, gives 
neither the hospital nor surgeon an incentive to use an assistant only 
when one is medically necessary. Third, the distinctions between those 
health professionals eligible for payment as an assistant-at-surgery 
under the physician fee schedule and those who are not eligible are 
not based on surgical education or experience as an assistant. 
Criteria for determining who should be paid as assistants-at-surgery 
under the physician fee schedule do not exist. However, hospitals are 
responsible under health and safety rules to provide quality care for 
their patients.

What GAO Recommends:

GAO suggests that Congress may wish to consider consolidating all 
Medicare payments for assistant-at-surgery services under the hospital 
inpatient prospective payment system. CMS agreed that payment policy 
for assistants-at-surgery could be improved.

www.gao.gov/cgi-bin/getrpt?GAO-04-97.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Majorie Kanof (202) 
512-7101.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Various Health Professionals Provide Assistant-at-Surgery Services, 
and Hospital Employees Provide Most of These Services:

Widely Accepted Professional Requirements for Assistants-at-Surgery Do 
Not Exist:

While Medicare Payments for Assistant-at-Surgery Services Have Flaws, 
Paying Hospitals for All These Services Would Correct Them:

Conclusions:

Matter for Congressional Consideration:

Agency Comments:

Appendix I: Professional Associations, Schools, and Hospitals:

Appendix II: Comments from the Centers for Medicare & Medicaid 
Services:

Tables:

Table 1: Physician Fee Schedule Payments for Health Professionals for 
Assistant-at-Surgery Services:

Table 2: Health Professions Whose Members Can Assist at Surgery:

Table 3: Education and State Licensure Requirements for Those Who May 
Assist at Surgery:

Table 4: Surgical Education and Experience Requirements for 
Certification as an Assistant-at-Surgery:

Figure:

Figure 1: Percentage of Assistant-at-Surgery Services Paid under the 
Physician Fee Schedule for Physicians and Nonphysician Health 
Professionals, 1997-2002:

Abbreviations:

ACS: American College of Surgeons: 
AHA: American Hospital Association: 
BBA: Balanced Budget Act of 1997: 
CMS: Centers for Medicare & Medicaid Services: 
CoP: condition of participation: 
CRNFA:Certified Registered Nurse First Assistant: 
GME: graduate medical education: 
HCFA Health Care Financing Administration: 
PPS prospective payment system:

United States General Accounting Office:

Washington, DC 20548:

January 13, 2004:

Congressional Committees:

Ensuring that Medicare beneficiaries receive care from qualified 
providers and that payments to providers are for the appropriate amount 
and only for medically necessary services are recognized goals of 
Medicare. Achieving these goals when paying for assistants-at-
surgery,[Footnote 1] who perform tasks as members of surgical teams 
under the direction of surgeons, poses a particular challenge because 
of the range of considerations affecting whether hospitals or surgeons 
decide an assistant is necessary for a given beneficiary's surgical 
procedure and the variation in education and experience of individuals 
who serve as assistants.

Medicare pays hospitals, physicians, and certain nonphysician health 
professionals for assistant-at-surgery services through the hospital 
inpatient prospective payment system (PPS) and the Medicare physician 
fee schedule. Medicare makes a single payment to hospitals for all the 
services, including assistant-at-surgery services, that a hospital 
provides to a beneficiary while an inpatient. The inpatient PPS pays 
predetermined fixed amounts for groups, or bundles, of services, 
designed to provide incentives to control spending by rewarding 
efficiency. Medicare also pays teaching hospitals under the inpatient 
PPS for providing graduate medical education (GME) to the residents 
employed by the hospital, some of whom assist at surgery.

Medicare also makes payments under the Medicare physician fee schedule 
for assistant-at-surgery services performed by physicians and members 
of certain nonphysician health professions whose members assist. These 
nonphysician health professionals--primarily physician assistants, 
nurse practitioners, and clinical nurse specialists--are allowed to 
bill Medicare under the physician fee schedule.[Footnote 2] Congress 
has been asked to authorize Certified Registered Nurse First Assistants 
(CRNFA) and other nonphysician health professional groups whose members 
provide assistant-at-surgery services to bill Medicare under the 
physician fee schedule for these services.

In 2001, Congress directed us to report on the potential impact on the 
Medicare program of allowing physician fee schedule payments to CRNFAs 
for assistant-at-surgery services.[Footnote 3] Congress required that 
we give special consideration to quality of care, appropriate education 
requirements, and appropriate rates of Medicare payment for assistants-
at-surgery. This report examines: (1) who serves as an assistant-at-
surgery, (2) whether health professionals who perform the role must 
meet a uniform set of professional requirements, and (3) whether 
Medicare's payment policies for assistants-at-surgery are consistent 
with the goals of the program and, if not, whether there are 
alternatives that would help attain those goals.

To determine who serves as an assistant-at-surgery, we analyzed 
Medicare data for 1997 through 2002 from the Part B Extract and Summary 
System maintained by the Centers for Medicare & Medicaid Services 
(CMS),[Footnote 4] which oversees Medicare. These summary data are 
derived from the Medicare Physician/Supplier Procedure Summary Master 
Files, which contain procedure-specific billing data for all physician 
and supplier services provided to Medicare beneficiaries each year. CMS 
contractors edit these data, and data limitations are published 
annually. We used our analysis of these data to determine the number, 
variety, and location of surgical procedures for which physician and 
nonphysician health professional assistants-at-surgery sought Medicare 
payment under the physician fee schedule.[Footnote 5] We also analyzed 
these data by the categories in the American College of Surgeons' (ACS) 
study that classifies each surgical procedure by the likelihood that it 
will require an assistant-at-surgery.[Footnote 6] We could not 
determine the number of assistants-at-surgery who were paid under the 
inpatient PPS because CMS does not collect those data. We interviewed 
staff from CMS; representatives of nine large academic teaching 
hospitals distributed across the country; and representatives of state 
licensing boards, assistant-at-surgery education programs, and 
associations of hospitals, physicians, nurses, and other health 
professions, including those whose members assist at surgery (see app. 
I). We used these interviews to determine whether nonphysician health 
professionals who perform the role of assistant-at-surgery must meet a 
uniform set of professional requirements. In making this determination, 
we also reviewed literature about the licensure and certification of 
health professionals who serve as assistants-at-surgery and Medicare 
laws and regulations affecting assistants.

We conducted our work from July 2001 through December 2003 in 
accordance with generally accepted government auditing standards.

Results in Brief:

Members of a wide range of health professions serve as assistants-at-
surgery, including physicians, residents in training for licensure or 
board certification in a physician specialty, several different kinds 
of nurses, and members of several other health professions. Hospitals 
employ residents, international medical graduates,[Footnote 7] and all 
the types of nonphysician health professionals who perform the role. 
Hospital employees likely serve as assistants-at-surgery for a majority 
of the procedures for which the ACS says an assistant is "almost 
always" necessary. Since 1997, the number of assistant-at-surgery 
services performed by physicians and paid under the Medicare physician 
fee schedule has declined, while the number of such services performed 
by nonphysician health professionals eligible to receive payment under 
the physician fee schedule has increased.

There is no widely accepted set of uniform requirements for experience 
and education that the health professionals who serve as assistants-at-
surgery are required to meet. The health professions whose members 
provide assistant-at-surgery services have varying educational 
requirements. No state licenses all the health professionals who serve 
as assistants-at-surgery, and the health professional licenses that 
states do issue typically attest to the completion of broad-based 
health care education, rather than education or experience as an 
assistant. Furthermore, the certification programs developed by the 
various nonphysician health professional groups whose members assist at 
surgery differ. We found that there was insufficient information about 
the quality of care provided by assistants-at-surgery generally, or by 
a specific type of health professional, to assess the adequacy of the 
requirements for members of a particular profession to perform the 
role.

There are three flaws in Medicare's policies for paying assistants-at-
surgery that prevent the payment system from meeting the program's 
goals of making appropriate payment for medically necessary services by 
qualified providers. First, because Medicare pays for assistant-at-
surgery services through both the hospital inpatient PPS and the 
physician fee schedule, and hospital payments for surgical care are not 
adjusted when an assistant receives payment under the physician fee 
schedule, Medicare may be paying too much for some hospital surgical 
care. Second, paying a health professional under the Medicare physician 
fee schedule to be an assistant-at-surgery, instead of including this 
payment in an all-inclusive payment, gives neither the hospital nor 
surgeon an incentive to use an assistant only when one is medically 
necessary. Third, the distinctions between those health professionals 
eligible for payment as an assistant-at-surgery under the physician fee 
schedule and those who are not eligible are not based on surgical 
education or experience as an assistant. Criteria for determining who 
should be paid as assistants-at-surgery under the physician fee 
schedule do not exist. However, hospitals are responsible under health 
and safety rules to provide quality care for their patients.

To help address these flaws and meet Medicare's goals, we suggest that 
Congress may wish to consider consolidating all Medicare payments for 
assistant-at-surgery services under the hospital inpatient prospective 
payment system. We received comments on a draft of this report from 
CMS, which agreed that payment policy for assistants-at-surgery could 
be improved. CMS also discussed several details related to implementing 
payment policy changes.

Background:

Assistants-at-surgery, who serve as members of surgical teams, perform 
tasks under the direction of surgeons and aid them in conducting 
operations. These tasks may include making initial incisions 
("opening"), exposing the surgical site ("retracting"), stemming blood 
flow ("hemostasis"), surgically removing veins and arteries to be used 
as bypass grafts ("harvesting"), reconnecting tissue ("suturing"), and 
completing the operation and reconnecting external tissue ("closing"). 
Some of these tasks, like retraction, are relatively simple, while 
others, such as harvesting, are more complex. An assistant-at-surgery 
may perform one or more simple or complex tasks during an operation.

Tasks performed by others on the surgical team differ from those 
performed by assistants-at-surgery. Scrub staff work within the sterile 
field--the area within the operating room that is kept free from 
harmful microorganisms--passing instruments, sponges, and other items 
directly to the surgeon and assistant-at-surgery who work within the 
sterile field. Circulators work outside the sterile field, responding 
to the needs of team members within the sterile field. 
Anesthesiologists, or anesthetists, who administer and monitor 
anesthesia, painkillers, and other drugs, are also present during an 
operation.

Need for Assistants-at-Surgery Depends on Complexity of Operation, 
Condition of Patient:

Decisions by a hospital or surgeon to use an assistant-at-surgery 
depend on the complexity of the operation and medical condition of the 
patient. Physician associations, such as the ACS and the American 
Society of General Surgeons, maintain that the surgeon should be 
responsible for determining if an assistant-at-surgery is needed, 
although some hospitals require the use of an assistant for certain 
surgical procedures. Hospitals that employ assistants-at-surgery may 
assign them to a procedure without consulting the surgeon performing 
the procedure.

Since 1994, the ACS, with other surgical specialty organizations, has 
conducted studies to determine which surgical procedures require 
physicians as assistants-at-surgery. These studies classify surgical 
procedures as "almost always," "sometimes," or "almost never" 
requiring an assistant-at-surgery. The 2002 study classifies 
approximately 5,000 surgical procedures, about 1,750 of which are 
designated as "almost always" requiring a physician to serve as an 
assistant-at-surgery.[Footnote 8]

A small number of surgical procedures have accounted for the majority 
of the assistant-at-surgery services paid for under the Medicare 
physician fee schedule: In 2002, 100 procedures accounted for almost 75 
percent of the assistant-at-surgery services that Medicare paid under 
the physician fee schedule. ACS designated 81 of these procedures as 
"almost always" requiring a physician as an assistant-at-surgery, and 
the remaining 19 procedures were designated as "sometimes" requiring a 
physician as an assistant.

Medicare Pays for Assistants-at-Surgery as Part of PPS Payments to 
Hospitals and under the Physician Fee Schedule:

Medicare pays for medically necessary services, including those 
performed by assistants-at-surgery, for eligible elderly and disabled 
patients provided by health professionals and institutions meeting 
certain requirements. Part A, or Hospital Insurance, pays for inpatient 
hospital care, care provided by certain other health care facilities, 
and some home health care. Part B, or Supplementary Medical Insurance, 
includes payment for the services and items provided by physicians, 
certain other nonphysician health professionals, suppliers, outpatient 
hospital departments, and home health care agencies.

Medicare makes payments to hospitals under part A through the hospital 
inpatient PPS[Footnote 9] for assistants-at-surgery.[Footnote 10] A 
fixed payment is made for all the inpatient hospital services, 
including assistant-at-surgery services, that a hospital provides to a 
beneficiary with a given diagnosis or receiving a particular type of 
surgery. Payments under the hospital inpatient PPS reflect the average 
bundle of services that beneficiaries with a particular diagnosis 
receive as inpatients in similar hospitals. The hospital's payment 
for a bundle of services is the same regardless of whether an 
assistant-at-surgery is used or who provides the assistant-at-surgery 
services.

Prospective payment systems, such as the hospital inpatient PPS, are 
designed to promote efficiency: because the payment for a particular 
bundle of services is almost always the same, regardless of the 
services a particular patient receives, hospitals are discouraged from 
providing unnecessary services.[Footnote 11] Providing additional 
services would not increase their payments. Consequently, PPS payments 
to the hospital are sometimes less and sometimes more than the cost of 
providing care.

Payments are also made under the hospital inpatient PPS to teaching 
hospitals for providing GME to the residents employed by the 
hospital.[Footnote 12] In 2001, about 20 percent of the approximately 
5,800 U.S. hospitals were considered teaching hospitals. In 2003, 
surgical residents comprised about 20 percent of all residents at these 
hospitals.[Footnote 13] There were about 7,500 residents in general 
surgery and about 13,000 more surgical residents training for 
specialties, such as orthopedics, all of whom were required to serve as 
assistants-at-surgery as part of their training. In addition to these 
surgical residents, some nonsurgical residents have surgical rotations 
during which they serve as assistants-at-surgery.

Medicare makes part B payments to assistants-at-surgery under the 
physician fee schedule[Footnote 14] when assistant services are 
performed by a physician or by a nonphysician health professional 
authorized to receive such payment. In 2002, these payments totaled 
about $158 million, less than 2 percent of the $10.5 billion Medicare 
paid to surgeons for surgical procedures that year. Medicare also makes 
global payments to surgeons under the physician fee schedule that cover 
the surgery and some pre-and postoperative services that the surgeons 
and their employees perform. Assistant-at-surgery services are not 
included in this bundle of services. Generally, the amount Medicare 
pays under the physician fee schedule is based on the resources needed 
to perform a service: the physician's time and skill, practice expenses 
that include the costs of staff, equipment, and supplies, and the cost 
of liability insurance. While a surgeon's global fee for a surgical 
procedure is set to reflect the resources required to perform the 
service, payments under the physician fee schedule for assistant-at-
surgery services are not; they are calculated as a fixed percentage of 
the surgeon's global fee. The percentage varies depending on the 
profession of the assistant-at-surgery. The Medicare physician fee 
schedule pays physicians more than nonphysician health professionals 
for assistant-at-surgery services (see table 1).

Table 1: Physician Fee Schedule Payments for Health Professionals for 
Assistant-at-Surgery Services:

Health profession: Physician; Payment: 16.0% of surgeon's payment.

Health profession: Clinical nurse specialist; Payment: 13.6% of 
surgeon's payment.

Health profession: Nurse practitioner; Payment: 13.6% of surgeon's 
payment.

Health profession: Physician assistant; Payment: 13.6% of surgeon's 
payment.

Source: 42 C.F.R. §§ 405.502(a)(9), 414.52, 414.56 (2002).

[End of table]

Medicare sets requirements that various health care institutions, 
suppliers, and professionals must meet to be paid by the program. 
Institutions, such as hospitals, must meet conditions of participation 
(CoP)--health and safety rules used to ensure quality of care. Until 
1986, HCFA specified some requirements for assistant-at-surgery 
services in its hospital CoP. Hospitals were required to have 
physicians serve as assistants-at-surgery for procedures "with unusual 
hazard to life," while "nurses, aides, or technicians having sufficient 
training to properly and adequately assist'' could assist at "lesser 
operations."[Footnote 15] In a broad revision of the hospital CoP in 
1986, the agency eliminated these requirements: it said the purpose of 
the revisions to the surgical services section, which had included the 
assistant-at-surgery requirements, was to "delete the overly 
prescriptive details" about the operation of surgical services.
[Footnote 16] CMS retains requirements for other surgical team 
members, including scrub and circulating staff.[Footnote 17]

CMS also establishes regulatory requirements for the health professions 
eligible to receive payment under the Medicare physician fee schedule. 
Members of that profession can be paid for providing covered services, 
including assistant-at-surgery services.[Footnote 18] Although CMS's 
rules include the minimum requirements that these professionals must 
meet to receive payment for services, there are no specific 
requirements to receive assistant-at-surgery payments in Medicare 
regulations. General requirements include education, licensure, and 
certification; no surgical education or experience is mandated. For 
example, physician assistants must graduate from an accredited 
physician assistant education program, pass the National Commission on 
Certification of Physician Assistants certification examination, and be 
licensed to practice as a physician assistant, but do not have to have 
experience as an assistant-at-surgery.

Various Health Professionals Provide Assistant-at-Surgery Services, 
and Hospital Employees Provide Most of These Services:

Members of a wide range of health professions serve as assistants-at-
surgery. Hospitals employ residents, international medical graduates, 
and all the types of nonphysician health professionals who perform the 
role. Hospital employees likely serve as assistants-at-surgery for a 
majority of the procedures for which the ACS says an assistant is 
"almost always" necessary. The number of assistant-at-surgery services 
performed by physicians and paid for under the physician fee schedule 
has declined, while the number of such services performed by 
nonphysician health professionals eligible to receive payment under the 
physician fee schedule has increased.

Members of a Variety of Health Professions Serve as Assistants-at-
Surgery:

Physicians, residents in training for licensure or board certification 
in a physician specialty, several different kinds of nurses, and 
members of several other health professions serve as assistants-at-
surgery (see table 2). Surgical associations state that surgeons or 
residents are preferred as assistants-at-surgery, but surgeons are 
often not available to assist at surgery.

Table 2: Health Professions Whose Members Can Assist at Surgery:

Health profession: Physician: 

Health profession: Physician (postresidency); Total number of 
members[A]: 850,000.

Health profession: Resident; Total number of members[A]: 100,000.

Health profession: Nurse: 

Health profession: Registered nurse, including those in surgical 
specialties, such as orthopedics or plastic surgical nurses; Total 
number of members[A]: 3.1 million[B].

Health profession: Licensed practical/vocational nurse; Total number of 
members[A]: 900,000.

Health profession: Nurse practitioner; Total number of members[A]: 
130,000[C].

Health profession: Clinical nurse specialist; Total number of 
members[A]: 69,000[C].

Health profession: Certified registered nurse first assistant; Total 
number of members[A]: 1,700.

Health profession: Other health professions: 

Health profession: Surgical technologist; Total number of members[A]: 
71,000.

Health profession: Physician assistant; Total number of members[A]: 
46,000.

Health profession: Ophthalmic assistant/technician/medical 
technologist; Total number of members[A]: 30,000-40,000.

Health profession: Surgical assistant; Total number of members[A]: 
5,000-6,000.

Health profession: Orthopedic technologist; Total number of members[A]: 
3,000.

Health profession: Orthopedic physician assistant; Total number of 
members[A]: 2,500.

Health profession: International medical graduate; Total number of 
members[A]: Unknown.

Source: Health professional associations.

[A] Numbers are the most recent data available, typically for 2000.

[B] Includes nurse practitioners, clinical nurse specialists, and 
CRNFAs. The table also includes separate counts for each of these 
groups.

[C] The numbers for nurse practitioners and clinical nurse specialists 
include some nurses who have qualified as both.

[End of table]

Hospitals Employ the Full Range of Health Professions Whose Members 
Serve as Assistants-at-Surgery:

Hospitals employ the gamut of health professionals who serve as 
assistants-at-surgery to perform the role. Some hospitals tend to hire 
assistants-at-surgery from a particular health profession, sometimes 
offering training courses in assistant services for that profession, to 
ensure that the hospital has a sufficient number of assistants. To 
encourage surgeons to use their operating rooms, hospitals may (1) 
employ assistants-at-surgery, eliminating the need for the surgeons to 
hire their own assistants, or (2) arrange for health professionals in 
independent practice to serve as assistants.

While teaching hospitals use residents as assistants-at-surgery, these 
hospitals may also hire nonphysician health professionals to perform 
the role. In a recent survey of neurosurgery residency program 
directors, nearly all cited the need to hire nonphysician health 
professional staff, such as physician assistants, in response to the 
weekly 80-hour work limit for residents.[Footnote 19] Teaching 
hospitals with other surgical specialty programs may also need to hire 
nonphysician health professionals as assistants-at-surgery because of 
the limit on resident hours.

Hospital Employees Likely Perform More than Half of All Assistant-at-
Surgery Services:

Because hospitals are not required to keep records on the use of 
assistants-at-surgery to receive Medicare payment under the inpatient 
PPS, the number and cost of such services provided by all hospital 
employees are unknown. Still, hospital employees likely serve as 
assistants-at-surgery for the majority of the surgeries performed on 
Medicare patients. In 2002, Medicare made payments under the physician 
fee schedule to assistants-at-surgery about 36 percent of the time that 
the program made payments to surgeons for the surgical procedures that 
ACS designated in its most recent study as "almost always" requiring an 
assistant-at-surgery.[Footnote 20] Since the remaining 64 percent of 
those surgical procedures were likely to have had assistants-at-
surgery, hospital employees would likely have performed this role. In 
its final regulation revising the physician fee schedule for 2000, HCFA 
relied upon the results of the American Hospital Association's (AHA) 
National Hospital Panel Survey that found that only 11 percent of 
responding hospitals said it was a regular practice for physicians to 
bring their own staff to the hospital to serve as assistants-at-surgery 
or to perform other functions.[Footnote 21] A representative of the AHA 
told us that most assistants-at-surgery, including residents and 
nonphysician staff, are hospital employees.

Nonphysicians Are Performing an Increased Share of Assistant-at-Surgery 
Services Paid under the Physician Fee Schedule:

The percentage of assistant-at-surgery services paid to physicians 
under the physician fee schedule has declined, and the percentage of 
these services paid to nonphysician health professionals has increased, 
particularly since enactment of the Balanced Budget Act of 1997 (BBA). 
The act raised the amount paid for assistant-at-surgery services to 
these nonphysician health professionals under the physician fee 
schedule, extended billing by clinical nurse specialists and nurse 
practitioners to urban areas (such billing had been limited to rural 
areas), and allowed physician assistants to contract with surgeons to 
be an assistant without having to be employees of the surgeon.[Footnote 
22] The number of assistant-at-surgery services paid for under the 
physician fee schedule and provided by nonphysician health 
professionals increased more than 200 percent from 1997 through 2002, 
while the number of services provided by physicians serving as 
assistants declined about 23 percent.[Footnote 23] During this period, 
the percentage of Medicare-paid assistant-at-surgery services 
performed by nonphysician health professionals increased by 25 
percentage points (see fig. 1).

The amount paid to nonphysicians for these services has also increased. 
Prior to 1987, nonphysicians could not be paid as assistants-at-
surgery. In 1997, nonphysicians were paid only $16 million for 
assistant-at-surgery services; in 2002, they were paid about $54 
million. In comparison, physicians were paid $295 million for 
assistant-at-surgery services in 1986; $166 million in 1997; and $104 
million in 2002.

Figure 1: Percentage of Assistant-at-Surgery Services Paid under the 
Physician Fee Schedule for Physicians and Nonphysician Health 
Professionals, 1997-2002:

[See PDF for image]

[End of figure]

Widely Accepted Professional Requirements for Assistants-at-Surgery Do 
Not Exist:

There is no widely accepted set of standards for the education and 
experience required to serve as an assistant-at-surgery. The health 
care professions whose members provide assistant-at-surgery services 
have varying educational requirements. No state licenses all the types 
of health professionals who serve as assistants-at-surgery. And the 
licenses they issue typically attest to the completion of broad-based 
health care education, making them of limited value in determining 
which health professionals have the education and experience to serve 
as an assistant-at-surgery. Furthermore, the certification programs 
developed by the various nonphysician health professional groups whose 
members assist at surgery differ. We found that there was insufficient 
information about the quality of care provided by assistants-at-
surgery--either generally or by members of specific health professions-
-to assess the adequacy of the requirements for a particular 
profession.

Health Professions Whose Members Assist at Surgery Have Varying 
Educational Requirements:

The health professions whose members serve as assistants-at-surgery 
have varying educational requirements (see table 3). For example, a 
licensed practical nurse typically completes a 1-year educational 
program, while a clinical nurse specialist must have a master's of 
science degree in nursing. In some cases, experience can substitute for 
education: orthopedic physician assistants may have associate degrees 
or certificates from military or nondegree programs or 5 years of 
experience working for an orthopedic surgeon.

Table 3: Education and State Licensure Requirements for Those Who May 
Assist at Surgery:

Health profession: Physician: 

Health profession: Physician (postresidency); General education 
requirements: Doctor of medicine or osteopathy; Licensure requirements 
in all states: Yes.

Health profession: Resident; General education requirements: Doctor of 
medicine or osteopathy; Licensure requirements in all states: Yes[A].

Health profession: Nurse: 

Health profession: Registered nurse, including those in surgical 
specialties, such as orthopedics and plastic surgical nurses; General 
education requirements: Associate's or bachelor's degree in nursing or 
nondegree hospital diploma; Licensure requirements in all states: Yes.

Health profession: Licensed practical/vocational nurse; General 
education requirements: 1-year program; Licensure requirements in all 
states: Yes.

Health profession: Nurse practitioner; General education requirements: 
Master's of science in nursing or nondegree certificate; Licensure 
requirements in all states: Yes[B].

Health profession: Clinical nurse specialist; General education 
requirements: Master's of science in nursing; Licensure requirements in 
all states: Yes[B].

Health profession: Certified registered nurse first assistant; General 
education requirements: Bachelor's degree and certification program; 
Licensure requirements in all states: Yes.

Health profession: Other health professions: 

Health profession: Surgical technologist; General education 
requirements: Associate's degree, military or nondegree certificate; 
Licensure requirements in all states: No[C].

Health profession: Physician assistant; General education 
requirements: Associate's or bachelor's degree or nondegree 
certificate; Licensure requirements in all states: Yes.

Health profession: Ophthalmic assistant/technician/medical 
technologist; General education requirements: Certificate programs or 
work experience; Licensure requirements in all states: No.

Health profession: Surgical assistant; General education requirements: 
Bachelor's degree or nondegree certificate[D]; Licensure requirements 
in all states: No[E].

Health profession: Orthopedic technologist; General education 
requirements: 1-year certificate program, 2 years of experience, or 
combination; Licensure requirements in all states: No.

Health profession: Orthopedic physician assistant; General education 
requirements: Associate's degree, military or nondegree certificate, or 
5 years of experience; Licensure requirements in all states: No[F].

Health profession: International medical graduate; General education 
requirements: Non-U.S. degree in medicine; Licensure requirements in 
all states: No.

Source: Health professional associations.

[A] Residents typically become licensed during their residency 
training.

[B] Some states require an additional license as an advanced practice 
nurse.

[C] Only two states have laws that regulate this profession: Texas 
established a licensure program in 2001 for "licensed surgical 
assistants," and beginning July 1, 2004, surgical technologists are 
required to meet registration requirements to practice in Illinois 
(2003 Ill. Laws 93-0280, adding 225 Ill. Stat. 130/1 - 130/170).

[D] Some international medical graduates who have not obtained a 
residency or qualified for a license choose to become certified as 
surgical assistants.

[E] Only two states have laws that regulate this profession: Texas 
established a licensure program in 2001 for "licensed surgical 
assistants," and beginning July 1, 2004, surgical assistants are 
required to meet registration requirements to practice in Illinois 
(2003 Ill. Laws 93-0280, adding 225 Ill. Stat. 130/1 - 130/170).

[F] Licensure is required in Tennessee (Tenn. Code Ann. § 63-19-202 
(2003)) and New York (N.Y. Educ. §§ 6540 - 6548 (2001)). In California, 
some orthopedic physician assistants who were licensed as physician 
assistants have been grandfathered in as physician assistants.

[End of table]

State Licenses Typically Do Not Require Education and Experience as 
Assistants-at-Surgery:

While state licenses for health professionals, including those eligible 
for payment as assistants-at-surgery under the physician fee schedule, 
typically have "scopes of practice" that include assistant-at-surgery 
services, education and experience as an assistant are not necessarily 
required to obtain a license: the licenses for these health professions 
attest to the completion of broad-based health care education, which 
may not include courses in surgery.

No state licenses all the health professions whose members assist at 
surgery in its jurisdiction. For example, orthopedic physician 
assistants and surgical assistants are licensed in only a few states. 
Only one state, Texas, has a specific assistant-at-surgery license. 
Members of different health professions may qualify for this license, 
which requires surgical education and experience.[Footnote 24] 
Nevertheless, a license is not required to serve as an assistant-at-
surgery in Texas.

Nonphysician Health Professions' Certification Programs for 
Assistants-at-Surgery Vary:

Certification programs for assistants-at-surgery generally require 
completion of a certain level of education or experience and passage of 
an examination. Each certification program created by a group of 
nonphysician health professionals for its members who serve as 
assistants-at-surgery has different requirements (see table 4). 
Certification programs for some nonphysician health professions not 
eligible for payment under the physician fee schedule are for a wide 
range of surgical services; others are specific to a particular type of 
surgery. For example, a CRNFA, in addition to being licensed as a 
registered nurse and earning a bachelor's degree in nursing,[Footnote 
25] must obtain certification as an operating room nurse, complete an 
approved program, have 2,000 hours of experience as an assistant-at-
surgery, and pass an examination. For a surgical technologist to 
receive certification as an assistant-at-surgery, he/she must have a 
surgical technologist certification, complete an approved program or 
have 2 years of experience as an assistant, and pass the examination.

Certifications for those who are eligible for payment under the 
physician fee schedule as an assistant-at-surgery are typically for a 
broad range of services and are not specifically surgery-related. For 
example, the American Nurses Credentialing Center awards certifications 
to nurse practitioners for acute, adult, family, gerontological, 
pediatric, adult psychiatric and mental health, and family psychiatric 
and mental health care.

Table 4: Surgical Education and Experience Requirements for 
Certification as an Assistant-at-Surgery:

Health profession: Nurse: 

Health profession: Registered nurse, surgery-related certification[A]; 
Surgical education requirements for certification: Requirements vary by 
certification program, but surgical education is not required for 
certain surgical-related certifications; Surgical experience 
requirements for certification: Requirements vary by certification 
program, but surgical experience is not required for certain surgical-
related certifications.

Health profession: Certified registered nurse first assistant; Surgical 
education requirements for certification: Two to three surgical 
classes; Surgical experience requirements for certification: 2,400 
hours of operating room experience in the scrub or circulating role and 
2,000 hours as assistant-at-surgery.

Health profession: Other health professions: 

Health profession: Surgical assistant[B]; Surgical education 
requirements for certification: Completion of an approved surgical 
assistant education program or an international medical education 
program, unless surgical experience is substituted; Surgical experience 
requirements for certification: 2 to 3 years of surgical assistant 
experience, depending on certification program.

Health profession: Orthopedic physician assistant[C]; Surgical 
education requirements for certification: Three permissible 
educational paths for certification: completion of an orthopedic 
physician assistant program that includes surgical education; a primary 
care physician assistant program that may have minimal surgical 
education; and a nurse practitioner program that may or may not include 
surgical education, unless surgical experience is substituted; Surgical 
experience requirements for certification: 5 years of experience that 
includes surgical assisting.

Health profession: Surgical technologist[D]; Surgical education 
requirements for certification: Completion of an approved surgical 
education program that includes instruction and supervised surgical 
experience, unless surgical experience is substituted; Surgical 
experience requirements for certification: 2 years of surgical 
experience.

Health profession: Orthopedic technologist[E]; Surgical education 
requirements for certification: Completion of an approved surgical 
education program that includes an operating room rotation, unless 
surgical experience is substituted; Surgical experience requirements 
for certification: 1 year of surgical experience.

Health profession: Ophthalmic assistant/ technician/medical 
technologist[F]; Surgical education requirements for certification: 
Completion of an approved education program that includes instruction 
and supervised surgical experience, unless surgical experience is 
substituted; Surgical experience requirements for certification: 18 
months of surgical experience.

Source: Health professional associations.

[A] A variety of surgery-related certifications are available to 
registered nurses. Some of these are for surgical specialties, such as 
orthopedic nurse certified (ONC) or certified plastic surgical nursing 
(CPSN). While the ONC requires 1,000 hours of experience as an 
orthopedic nurse and the CPSN requires 2 years' experience of plastic 
surgical nursing, both of which may include operating room experience, 
neither program requires operating room experience.

[B] Certified Surgical Assistant (CSA), Surgical Assistant-Certified 
(SA-C).

[C] Orthopedic Physician's Assistant, Certified (OPA-C).

[D] Certified Surgical Assistant/Certified First Assistant (CST/CFA).

[E] Orthopedic Technologist-Surgery Certified (OT-SC).

[F] Certified Ophthalmic Assistant (COA), Technician (COT), or Medical 
Technologist (COMT)-Ophthalmic Surgical Assisting.

[End of table]

No National Consensus on Requirements for Assistants-at-Surgery Exists:

While some national physician and accreditation organizations say 
assistants-at-surgery should have to meet some requirements, there is 
no consensus about what those requirements should be. For example, ACS 
has stated that when surgeons or residents are unavailable to serve as 
assistants-at-surgery, nonphysician health professionals should be 
allowed to perform the role if they meet the "national standards" for 
their health profession or have "additional specialized training." 
Similarly, the Joint Commission on Accreditation of Healthcare 
Organizations (JCAHO), a private organization that accredits health 
care organizations, including hospitals, requires hospitals to 
credential their staff (i.e., establish requirements, such as 
licensure, certification, and experience for physicians and certain 
nonphysician health professionals) and ensure that those requirements 
are used when personnel decisions are made. But JCAHO does not suggest 
the type or length of education or experience to be used in 
credentialing hospital staff who serve as assistants-at-surgery.

Literature on Assistants-at-Surgery Is Insufficient to Evaluate Quality 
of Care:

We found little evidence about the quality of care provided by 
assistants-at-surgery. Our February 2003 search of relevant literature 
maintained by the National Library of Medicine found only six articles 
dealing with the quality of care provided by assistants-at-surgery. 
None of the articles compares the quality of assistant-at-surgery 
services provided by one nonphysician health profession with that 
provided by another nonphysician health profession or physicians, and 
only one deals specifically with the influence of assistants on 
surgical outcomes.

While Medicare Payments for Assistant-at-Surgery Services Have Flaws, 
Paying Hospitals for All These Services Would Correct Them:

There are three flaws in Medicare's policies for paying assistants-at-
surgery that prevent the payment system from meeting the program's 
goals of making appropriate payment for medically necessary services by 
qualified providers. First, because Medicare pays for assistant-at-
surgery services under both the hospital inpatient PPS and the 
physician fee schedule, and hospital payments for surgical care are not 
adjusted when an assistant receives payment under the physician fee 
schedule, Medicare may be paying too much for some hospital surgical 
care. Second, paying a health professional under the Medicare physician 
fee schedule to be an assistant-at-surgery, instead of including this 
payment in an all-inclusive payment, gives neither the hospital nor the 
surgeon an incentive to use an assistant only when one is medically 
necessary. Third, the distinctions between those health professionals 
eligible for payment as an assistant-at-surgery under the physician fee 
schedule and those who are not eligible 
are not based on surgical education or experience as an assistant. 
Criteria for determining who should be paid as assistants-at-surgery 
under the physician fee schedule do not exist. However, hospitals are 
responsible under health and safety rules to provide quality care for 
their patients.

Medicare Payments for Assistants-at-Surgery Are Flawed:

Medicare's policy of paying hospitals for the services associated with 
inpatient surgical care that may include assistant-at-surgery services 
and also paying physicians and certain nonphysician health 
professionals for those services is flawed. When Medicare pays under 
the hospital inpatient PPS and under the physician fee schedule for 
assistant-at-surgery services delivered to a particular patient, 
Medicare may pay too much for the assistant services because the 
hospital is not paid less when the assistant receives payment under the 
physician fee schedule. In addition, a hospital that uses an assistant-
at-surgery who is eligible for payment under the physician fee schedule 
has a financial advantage in the form of lower labor costs over a 
hospital that uses assistants who cannot be paid under the physician 
fee schedule.

Given the discretion that hospitals and surgeons have in determining 
when and how an assistant-at-surgery is used, it is especially 
important that Medicare's payment policy create incentives to help 
ensure that assistant services are provided for Medicare patients only 
when medically necessary.[Footnote 26] Allowing physician fee schedule 
payments to certain assistants-at-surgery, however, creates an 
incentive for hospitals to use them, rather than those who cannot be 
paid under the fee schedule. Because neither the hospital nor the 
surgeon incurs a cost when an assistant-at-surgery is paid under the 
physician fee schedule, neither has a financial incentive to use an 
assistant only when one is necessary. The lack of this incentive is of 
concern because assistant-at-surgery services receive little review to 
determine the medical necessity of the services. A 2001 report by the 
Department of Health and Human Services Office of Inspector 
General[Footnote 27] found that most contractors used by Medicare to 
pay for part B services do not have any mechanism to ensure that 
assistant-at-surgery requests for payment for nonphysician health 
professionals are reviewed for medical necessity before they are paid. 
Medicare routinely requires submission of documentation of medical 
necessity for medical review for only 1 percent of assistant-at-surgery 
services paid under the physician fee schedule.

Because the requirements for those authorized to be paid as assistants-
at-surgery under the Medicare physician fee schedule do not include 
assistant-at-surgery education or experience, payments can be made to 
assistants with no such education or experience. For example, about 23 
percent of physician assistants work in surgical specialties. Other 
physician assistants working in nonsurgical specialties, however, may 
be paid as assistants-at-surgery under the Medicare physician fee 
schedule, and their only surgical experience may be a 6-week surgical 
rotation. On the other hand, nonphysician health professionals, such as 
surgical technologists, CRNFAs, and orthopedic physician assistants, 
all of whom have certification programs requiring education and 
experience as an assistant-at-surgery, cannot be paid by Medicare for 
their services under the physician fee schedule.

One way to address a concern associated with the physician fee schedule 
payments for assistants-at-surgery is to expand the number of 
nonphysician health professions eligible for payment. But this would 
not ensure that only those with the appropriate education and 
experience serve as assistants-at-surgery unless CMS also sets 
standards for all those who serve as assistants. There is no consensus, 
however, on what such standards should include.

Bundling Payments for Assistant-at-Surgery Services into Hospital 
Payments Would Be Preferable to Bundling into Surgeons' Fees:

Bundling all payments for assistants-at-surgery into either the 
inpatient hospital PPS or the surgeon's global fee would address the 
flaws of the current payment system. The possibility of paying too much 
for assistant-at-surgery services would be eliminated because Medicare 
would make only one payment--to either the hospital or the surgeon--for 
the service. The hospital or surgeon would have a financial incentive 
to use the most appropriate assistant-at-surgery--and to use one only 
when necessary--because the payment would be the same regardless of 
whether an assistant was used. The lack of a relationship between the 
nonphysician health professionals eligible for assistant-at-surgery 
payments under the physician fee schedule and their education and 
experience would be moot because payments would no longer be made to 
individuals performing the role; payments would be made, as part of a 
larger payment for a bundle of services, to hospitals or surgeons, who 
would have the responsibility to determine the education and 
experience that an assistant-at-surgery needs and when an assistant is 
needed.

Folding payments for assistant-at-surgery services into inpatient PPS 
payments has some advantages that would not accrue if payments were 
folded into the surgeon's global fee. Hospitals would continue to have 
incentives to use assistants-at-surgery when they are necessary, and to 
use the most appropriate assistant. Hospitals are already responsible-
-under the hospital CoP--for ensuring the health and safety of their 
patients and that necessary services are provided, including assistant-
at-surgery services. Most hospitals already have credentialing 
processes for their employees. Also, since hospitals likely employ most 
assistants-at-surgery, limiting payments for assistant services to 
those made under the inpatient PPS would disrupt the employment 
relationships for far fewer assistants than would be the case if 
payment was made to surgeons.

There is precedent for Congress approving legislation that no longer 
allows a service to be paid for separately under part B, but instead 
requires that the service be included in a bundle of services under 
part A. In 1997, Congress passed legislation that requires virtually 
all kinds of services or items furnished to beneficiaries residing in 
skilled nursing facilities (SNF) that had been paid for separately 
under part B, instead be included in a bundle of services paid for 
under part A.[Footnote 28] Prior to implementation of the provision, 
SNFs could permit a nonphysician health professional or supplier to 
seek payment under part B for ancillary services or items furnished 
directly to SNF residents, as long as the SNF did not include the 
service or item in its part A bill. The legislation, however, prevents 
this "unbundling" by including in Medicare SNF PPS payments ancillary 
services or items a SNF resident may require that previously had been 
paid under part B.

Bundling assistant-at-surgery services into the package of services 
covered by the surgeon's global payment based on the Medicare physician 
fee schedule has significant drawbacks. First, because the amount paid 
under the inpatient hospital PPS for assistants-at-surgery is unknown, 
the total amount to be added to the physician fee schedule for 
providing assistants is unknown. Second, a payment amount for 
assistant-at-surgery services would have to be determined for each 
surgical procedure. Since data are not collected on how often each 
surgeon uses assistants-at-surgery for each surgical procedure, the 
bundled payment would presumably include an allotment for the expected 
average cost of assistants for all surgeons performing the procedure. 
Using this approach, surgeons with an unusually high number of 
procedures requiring assistants would be paid too little, while those 
with an unusually low number of procedures requiring assistants would 
be paid too much. In addition, a surgeon would have a financial 
incentive to use an assistant-at-surgery less frequently for surgical 
procedures for which ACS says that an assistant may be needed, even 
when the condition of the beneficiary indicates that an assistant would 
be desirable. Because there is a difference in costs to a surgeon 
depending on whether an assistant-at-surgery is used, a surgeon's 
bundled payment amount could be adjusted when an assistant is used. 
Doing so, however, would provide no financial incentive for surgeons to 
use an assistant-at-surgery only when one is medically necessary.

Conclusions:

Decisions to use an assistant-at-surgery should not be influenced by 
payment; they should be based on medical necessity. The majority of 
assistants-at-surgery are likely employed by hospitals, where the 
inpatient hospital PPS pays for their services. If Congress were to 
consolidate Medicare physician fee schedule payments for assistant-at-
surgery services into the inpatient hospital PPS, this would give 
hospitals an incentive to use assistants only when they are necessary. 
Meanwhile, the hospital CoP would continue to give hospitals an 
incentive to assure that the most appropriate assistants-at-surgery are 
used as part of their responsibility to provide quality care for their 
patients. Paying for assistants under the physician fee schedule 
provides no such incentive.

Matter for Congressional Consideration:

We suggest that Congress may wish to consider consolidating all 
Medicare payments for assistant-at-surgery services under the hospital 
inpatient prospective payment system.

Agency Comments:

We received comments on a draft of this report from CMS, which agreed 
that payment policy for assistants-at-surgery could be improved. CMS 
noted that it would be helpful to describe the ongoing review process 
that CMS uses to assign relative values to physician fee schedule 
services. However, as we state in this report assistants-at-surgery are 
not paid on the basis of the resources they use to perform their work, 
but are instead paid a percentage of the amount paid the surgeon. CMS 
also discussed several details related to implementing payment changes 
for assistants-at-surgery. Addressing these points was beyond the scope 
of this report. CMS's comments appear in appendix II. In addition, we 
obtained oral comments on a draft of this report from representatives 
of the American Medical Association, the American College of Surgeons, 
the American Society of General Surgeons, the American Association of 
Orthopaedic Surgeons, the Society of Thoracic Surgeons, the American 
Academy of Nurse Practitioners, the American Academy of Physician 
Assistants, the Association of periOperative Registered Nurses, and the 
American Hospital Association. We have modified the report, as 
appropriate, in response to their comments.

We are sending copies of this report to the Acting Administrator of 
CMS, appropriate congressional committees, and other interested 
parties. We will also make copies available to others upon request. 
This report will be available at no charge on GAO's Web site at http:/
/www.gao.gov.

If you or your staffs have any questions about this report, please call 
me at (202) 512-7101. Lisanne Bradley and Michael Rose were major 
contributors to this report.

Marjorie Kanof:  
Director, Health Care--Clinical Health Care Issues:

Signed by Marjorie Kanof: 

List of Committees:

The Honorable Charles E. Grassley: Chairman: The Honorable Max Baucus: 
Ranking Minority Member: Committee on Finance: United States Senate:

The Honorable W.J. "Billy" Tauzin: Chairman: The Honorable John D. 
Dingell: Ranking Minority Member: Committee on Energy and Commerce: House 
of Representatives:

The Honorable Bill Thomas: Chairman: The Honorable Charles B. Rangel 
Ranking Minority Member Committee on Ways and Means House of 
Representatives:

[End of section]

Appendix I: Professional Associations, Schools, and Hospitals:

To obtain information about assistants-at-surgery and their services we 
contacted subject matter experts. We interviewed representatives of:

American Academy of Nurse Practitioners; 
American Academy of Physician Assistants; 
American Association of Orthopaedic Surgeons; 
American Board of Surgical Assistants; 
American College of Surgeons; 
American Hospital Association; 
American Medical Association; 
American Nurses Association; 
American Nurses Credentialing Center; 
American Society of General Surgeons; 
American Society of Plastic Surgical Nurses; 
Anne Arundel Community College, Department of Nursing; 
Association of periOperative Registered Nurses; 
Association of Surgical Technologists; 
BJC HealthCare; 
Centers for Medicare & Medicaid Services; 
Certification Board Perioperative Nursing; 
Commission on Accreditation of Allied Health Education Programs; 
Duke University Hospital; 
Educational Commission for Foreign Medical Graduates; 
Ft. Sam Houston, Academy of Health Sciences, U.S. Army; 
Inova Fairfax Hospital; 
Johns Hopkins University, School of Medicine; 
Joint Commission on Allied Health Personnel in Ophthalmology; 
Massachusetts General Hospital; 
Mayo Clinic; 
Medical Group Management Association; 
Montgomery College Surgical Technology Program; 
National Association of Clinical Nurse Specialists; 
National Association of Orthopaedic Nurses; 
National Board for Certification of Orthopaedic Technologists; 
National Commission for Certifying Agencies/National Organization for 
Competency Assurance; 
National Rural Health Association; 
National Surgical Assistant Association; 
Naval School of Health Sciences New York State Board for Medicine; 
Office of the Surgeon General of the Air Force; 
Office of the Chief, Medical Corps, U.S. Navy; 
Stanford University Hospital; 
Texas State Board of Medical Examiners; 
The American Society of Orthopaedic Physician's Assistants; 
The Cleveland Clinic; 
The Society of Thoracic Surgeons; 
University of California at Los Angeles School of Nursing; 
University of Maryland School of Nursing; 
University of Michigan Hospital; 
University of Washington Medical Center. 

[End of section]

Appendix II: Comments from the Centers for Medicare & Medicaid 
Services:

DEPARTMENT OF HEALTH & HUMAN SERVICES	
Centers for Medicare & Medicaid Services:
Administrator 
Washington, DC 20201:

TO:	Marjorie Kanof:

Director, Health Care-Clinical Health Care Issues General Accounting 
Office:

FROM:	Dennis G. Smith; 
Acting Administrator Centers for Medicare & Medicaid Services:

Signed by Dennis G. Smith: 

SUBJECT: General Accounting Office Draft Report: "Medicare: Payment 
Changes Are Needed For Assistants-at-Surgery, "(GAO-04-97):

Thank you for the opportunity to comment on the General Accounting 
Office's (GAO) draft report entitled, Medicare: Payment Changes are 
Needed for Assistants-at-Surgery.

In this report, GAO examines: (1) who serves as an assistant-at-
surgery; (2) whether health professionals who perform the role must 
meet a uniform set of professional requirements; and (3) whether 
Medicare's payment policies for assistants-at-surgery are consistent 
with the goals of the program and, if not, whether there are 
alternatives that would help attain those goals.

The GAO suggests that the Congress may wish to consider consolidating 
all Medicare payment for assistant-at-surgery services under the 
hospital inpatient prospective payment system (IPPS).

The CMS has the following comments:

The CMS agrees that payment policy in this area could be improved. 
However, many of the policy changes envisioned, such as changing IPPS 
rates, would require Congressional action.

We understand GAO's concerns regarding the qualifications of 
assistants-at-surgery. In the report, GAO may want to balance this 
concern with the importance of a surgeon's medical judgment and 
practice preferences. For example, in some cases, shifting payment for 
these services to IPPS rates may be disruptive to surgeons that have 
built up relationships with their assistant-at-surgery staff. If a 
physician insists on using his or her own staff, it is not clear how 
this assistant-at-surgery would be reimbursed or whether the hospital 
would even permit the assistant to perform services. GAO may want to 
address this issue in their report.

It might be helpful if GAO further explained how the construction of 
the IPPS rates and physician fee schedule (PFS) rates creates the 
potential for duplicate payment.

* In GAO's discussion on why assistant-at-surgery cases should not be 
bundled into the PFS payment rates, it cites several drawbacks. It may 
be helpful to describe the ongoing review process CMS uses to assign 
relative values to PFS services, since this process addresses several 
of the concerns GAO raised in this section.

* The GAO may want to consider the effect of the Sustainable Growth Rate 
(SGR) system in their analysis of this issue. If Congress were to move 
assistant-at-surgery expenses into the bundled PPS rates or into the 
PFS rates, the SGR could play a role in determining total actual 
savings to the Government.

* It is important to note that total PFS payments, including assistant-
at-surgery payments under the PFS, grow at a predetermined amount based 
on a formula set in law. Whether or not these payments are made under 
the PFS, the total amount of money spent under the PFS remains the 
same.

* Any changes to the IPPS rates would require Congressional action.

[End of section]

FOOTNOTES

[1] An assistant-at-surgery is sometimes referred to as a first 
assistant or second assistant.

[2] Members of a few other health professions, such as nurse midwives, 
can also be paid as assistants-at-surgery under the physician fee 
schedule. Assistant-at-surgery services performed by these 
professionals accounted for less than 1 percent of such Medicare-paid 
assistant services in 2002. When discussing payments for assistants-at-
surgery under the physician fee schedule, this report focuses on 
physicians, physician assistants, nurse practitioners, and clinical 
nurse specialists.

[3] Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 
Act of 2000, Pub. L. No. 106-554, App. F, § 433, 114 Stat. 2763, 2763A-
526.

[4] On July 1, 2001, the agency that administers the Medicare program 
was renamed from the Health Care Financing Administration (HCFA) to 
CMS. This report refers to the agency as HCFA when discussing actions 
taken before the name change and as CMS when discussing actions taken 
after the name change.

[5] Of the assistant-at-surgery services paid under the physician fee 
schedule in 2002, almost 90 percent were for hospital inpatients, about 
10 percent were for surgeries on hospital outpatients, and about 1 
percent for surgeries in ambulatory surgical centers. Less than one-
half of 1 percent of services allowed under the physician fee schedule 
for assistant-at-surgery services occurred in a nonfacility setting, 
such as a physician's office.

[6] American College of Surgeons (ACS), Physicians as Assistants at 
Surgery: 2002 Study, 4th edition (Chicago, Ill.: 2002). ACS members and 
members of 14 other surgical specialty organizations reviewed 
procedures applicable to their specialties and determined how often 
each surgical procedure requires the use of a physician as an 
assistant-at-surgery.

[7] International medical graduates are physicians who have graduated 
from a medical school outside the United States, Puerto Rico, or 
Canada. For purposes of this report, international medical graduates do 
not include individuals who are in U.S. residency programs or who are 
physicians licensed in the United States, but may include some who are 
certified as surgical assistants.

[8] Approximately 1,550 surgical procedures are designated as 
"sometimes" requiring a physician as an assistant-at-surgery. In 
addition to procedures designated as "almost always" or "sometimes" 
requiring a physician to serve as an assistant-at-surgery, the 
remaining procedures are designated as "almost never" requiring a 
physician to serve as an assistant.

[9] 42 U.S.C. § 1395ww (2000).

[10] The bundle of services for which hospital inpatient payments are 
made generally does not include physician services provided by 
physicians, physician assistants, nurse practitioners, and clinical 
nurse specialists. 42 U.S.C. § 1395x(b)(4), (s)(2)(K) (2000).

[11] Additional payments are made for cases in which inpatient hospital 
care has been extraordinarily costly. About 7 percent of inpatient 
hospital PPS payments in fiscal year 2002 were for these cases.

[12] Teaching hospitals are paid an amount for each resident that 
covers the costs associated with providing services. 42 U.S.C. § 
1395ww(h) (2000).

[13] For purposes of this report, surgical residencies are defined as 
those in colon and rectal surgery, neurological surgery, obstetrics and 
gynecology, ophthalmology, orthopedic surgery, adult reconstructive 
orthopedics, foot and ankle orthopedics, hand surgery, musculoskeletal 
oncology, orthopedic sports medicine, orthopedic surgery of the spine, 
orthopedic trauma, pediatric orthopedics, otolaryngology, neurotology, 
pediatric otolaryngology, plastic surgery, craniofacial surgery, 
general surgery, pediatric surgery, surgical critical care, urology, 
pediatric urology, vascular surgery, and thoracic surgery.

[14] 42 U.S.C. § 1395w-4(a) (2000).

[15] 20 C.F.R. § 405.1031(a) (1967), redesignated as 42 C.F.R. § 
405.1031(a) in 1977.

[16] Medicare and Medicaid Programs; Conditions of Participation for 
Hospitals, 51 Fed. Reg. 22010, 22027, 22042 (1986) (codified at 42 
C.F.R. part 482).

[17] 42 C.F.R. § 482.51(a)(2), (3) (2002).

[18] 42 C.F.R. §§ 410.20(b), 410.74(c), 410.75(b), 410.76(b) (2002), 
rules for physicians, physician assistants, nurse practitioners, and 
clinical nurse specialists, respectively. Medicare may pay for any 
medically necessary service that an eligible health professional may 
perform under state law.

[19] Dongwoo John Chang, M.D., and Susan Bell, R.N., "Restricted: The 
Impact of Residents' 80-Hour Workweek on Neurosurgical Resident 
Training and Patient Care," American Association of Neurological 
Surgeons Bulletin: The Socioeconomic and Professional Quarterly for 
AANS Members, 12:2:7-10 (2003).

[20] In 2002, about 75 percent of these Medicare-paid services for 
assistants-at-surgery were for surgical procedures determined by ACS as 
"almost always" requiring a physician as an assistant, about 24 percent 
for procedures ACS determined to "sometimes" require an assistant, and 
the remaining payments were for procedures determined as "almost never" 
requiring an assistant or for surgical procedures with no designation.

[21] Medicare Program; Revisions to Payment Policies Under the 
Physician Fee Schedule for Calendar Year 2000, 64 Fed. Reg. 59401 
(1999).

[22] Pub.L.No. 105-33, §§ 4511-4512, 111 Stat. 251, 442-443. These 
provisions apply to services performed after 1997.

[23] In 1997, Medicare paid 1,246,817 assistant-at-surgery services, 
1,100,919 of which were provided by physicians. In 2002, Medicare paid 
1,356,244 assistant-at-surgery services, 848,314 of which were provided 
by physicians.

[24] Effective September 2001, Texas established a license category for 
"licensed surgical assistants." (Texas Acts 2001 Tex. Gen. Laws ch. 
1014, adding Tex. Occupations Code Ann., ch. 206.) Licensure 
requirements include 2,000 hours of experience, completion of a 
surgical training program with courses in specified areas such as 
anatomy and aseptic technique, an associate's degree, and certification 
by a national organization recognized by the Texas State Board of 
Medical Examiners.

[25] As of January 1, 2000, only registered nurses who have a 
bachelor's degree in nursing can be newly certified as CRNFAs. In 2002, 
less than 20 percent of CRNFAs had such a degree.

[26] No Medicare payment may be made for any expenses incurred for 
items or services that "are not reasonable and necessary for the 
diagnosis or treatment of illness or injury…." 42 U.S.C. § 
1395y(a)(1)(A) (2000).

[27] Department of Health and Human Services, Office of Inspector 
General, Medicare Coverage of Non-Physician Practitioner Services, OEI-
02-00-00290, June 2001.

[28] BBA, § 4432, 111 Stat. 414.

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