Medicare: Payment Changes Are Needed for Assistants-at-Surgery	 
(13-JAN-04, GAO-04-97). 					 
                                                                 
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.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-97						        
    ACCNO:   A09120						        
  TITLE:     Medicare: Payment Changes Are Needed for		      
Assistants-at-Surgery						 
     DATE:   01/13/2004 
  SUBJECT:   Health care services				 
	     Health insurance					 
	     Hospitals						 
	     Payments						 
	     Surgery						 
	     Managed health care				 
	     Policy evaluation					 
	     Health care personnel				 
	     Standards (health care)				 
	     Medicare Program					 

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GAO-04-97

United States General Accounting Office

GAO

                       Report to Congressional Committees

January 2004

MEDICARE

              Payment Changes Are Needed for Assistants-at-Surgery

                                       a

GAO-04-97

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

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.

GAO suggests that Congress may wish to consider consolidating all Medicare
payments for assistant-atsurgery 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.

January 2004

MEDICARE

Payment Changes Are Needed for Assistants-at-Surgery

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-atsurgery 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.

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

                                       1

                                      3 5

                                       9

13

18 22 22 22

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

8 10

14

17

Figure

Figure 1: Percentage of Assistant-at-Surgery Services Paid under the
Physician Fee Schedule for Physicians and Nonphysician Health
Professionals, 1997-2002 13

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

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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,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.2 Congress has been asked to authorize

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

2Members 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.

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.3 Congress required that we give special
consideration to quality of care, appropriate education requirements, and
appropriate rates of Medicare payment for assistants-atsurgery. 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),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.5 We also analyzed these data by the categories in the American
College of Surgeons' (ACS) study that classifies each

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

4On 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.

5Of 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-atsurgery services occurred in a nonfacility setting, such as a
physician's office.

  Results in Brief

surgical procedure by the likelihood that it will require an
assistant-atsurgery.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.

Members of a wide range of health professions serve as
assistants-atsurgery, 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,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.

6American 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.

7International 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.

There is no widely accepted set of uniform requirements for experience and
education that the health professionals who serve as assistants-atsurgery
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-atsurgery 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-atsurgery 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.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 PPS9 for assistants-at-surgery.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

8Approximately 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.

942 U.S.C. S: 1395ww (2000).

10The 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. S: 1395x(b)(4), (s)(2)(K) (2000).

diagnosis receive as inpatients in similar hospitals. The hospital's
payment for a bundle of services is the same regardless of whether an
assistant-atsurgery 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.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.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.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 schedule14 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

11Additional 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.

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

13For 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.

1442 U.S.C. S: 1395w-4(a) (2000).

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-atsurgery 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-atsurgery services (see table 1).

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

                           Health profession Payment

                      Physician 16.0% of surgeon's payment

              Clinical nurse specialist 13.6% of surgeon's payment

                 Nurse practitioner 13.6% of surgeon's payment

                 Physician assistant 13.6% of surgeon's payment

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

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."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

1520 C.F.R. S: 405.1031(a) (1967), redesignated as 42 C.F.R. S:
405.1031(a) in 1977.

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

details" about the operation of surgical services.16 CMS retains
requirements for other surgical team members, including scrub and
circulating staff.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.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.

Members of a wide range of health professions serve as
assistants-atsurgery. 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.

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

1742 C.F.R. S: 482.51(a)(2), (3) (2002).

1842 C.F.R. S:S: 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.

Members of a Variety of Physicians, residents in training for licensure or
board certification in a Health Professions Serve physician specialty,
several different kinds of nurses, and members of as Assistants-at-Surgery
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 Total number of membersa

                                   Physician

                       Physician (postresidency) 850,000

                                Resident 100,000

                                     Nurse

Registered nurse, including those in surgical specialties, such as
orthopedics or plastic surgical

b

nurses 3.1 million

                  Licensed practical/vocational nurse 900,000

                          Nurse practitioner 130,000c

                       Clinical nurse specialist 69,000c

                Certified registered nurse first assistant 1,700

                            Other health professions

                          Surgical technologist 71,000

                           Physician assistant 46,000

       Ophthalmic assistant/technician/medical technologist 30,000-40,000

                         Surgical assistant 5,000-6,000

                         Orthopedic technologist 3,000

                      Orthopedic physician assistant 2,500

International medical graduate Unknown

Source: Health professional associations.

aNumbers are the most recent data available, typically for 2000.

bIncludes nurse practitioners, clinical nurse specialists, and CRNFAs. The
table also includes separate counts for each of these groups.

cThe numbers for nurse practitioners and clinical nurse specialists
include some nurses who have qualified as both.

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.19 Teaching hospitals with other surgical specialty programs
may also need to hire nonphysician health professionals as
assistants-atsurgery 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 assistantsat-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.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,

19Dongwoo 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).

20In 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.

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.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.22 The number of assistant-atsurgery
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.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.

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

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

23In 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.

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

Percentage 100

80

60

40

20

0 1997 1998 1999 2000 2001 2002

                                   Physicians

                                 Nonphysicians

Source: GAO.

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
assistantat-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.

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

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

Licensure requirements Health profession General education requirements in
all states

Physician

         Physician (postresidency) Doctor of medicine or osteopathy Yes

                 Resident Doctor of medicine or osteopathy Yesa

Nurse

Registered nurse, including those in Associate's or bachelor's degree in
nursing or nondegree Yes
surgical specialties, such as orthopedics hospital diploma
and plastic surgical nurses

Licensed practical/vocational nurse  1-year program                    Yes 
Nurse practitioner                   Master's of science in nursing   Yesb 
                                        or nondegree certificate         
Clinical nurse specialist            Master's of science in nursing   Yesb 
Certified registered nurse first     Bachelor's degree and             Yes 
assistant                            certification program            

                            Other health professions

Surgical technologist Associate's degree, military or nondegree certificate Noc

 Physician assistant Associate's or bachelor's degree or nondegree certificate
                                      Yes

Ophthalmic assistant/technician/medical Certificate programs or work
experience No technologist

Surgical assistant             Bachelor's degree or nondegree          Noe 
                                  certificated                            
                                  1-year certificate program, 2 years of   No 
Orthopedic technologist        experience, or                          
                                  combination                             
                                  Associate's degree, military or         Nof 
Orthopedic physician assistant nondegree certificate, or               
                                  5 years of experience                   

International medical graduate Non-U.S. degree in medicine No

Source: Health professional associations. aResidents typically become
licensed during their residency training. bSome states require an
additional license as an advanced practice nurse.

cOnly 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).

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

eOnly 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).

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

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.24 Nevertheless, a license is not required to
serve as an assistant-at-surgery in Texas.

Nonphysician Health Certification programs for assistants-at-surgery
generally require Professions' Certification completion of a certain level
of education or experience and passage of an Programs for
Assistants-at-examination. Each certification program created by a group
of

nonphysician health professionals for its members who serve asSurgery Vary
assistants-at-surgery has different requirements (see table 4).
Certification programs for some nonphysician health professions not
eligible for

24Effective 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.

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,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.

25As 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.

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

Surgical experience requirements for Health profession Surgical education
requirements for certification certification

Nurse

Registered nurse, surgery-related Requirements vary by certification
program, but Requirements vary by certification certificationa surgical
education is not required for certain surgical-program, but surgical
experience is not related certifications required for certain
surgical-related certifications

Certified registered nurse first Two to three surgical classes 2,400 hours
of operating room

assistant 	experience in the scrub or circulating role and 2,000 hours as
assistant-at-surgery

                            Other health professions

Surgical assistantb   Completion of an approved   2 to 3 years of surgical 
                            surgical assistant       assistant                
                       education program or an       experience, depending on 
                       international medical                    certification 
                           education program, unless                          
                              surgical experience is         program
                                substituted          

Orthopedic physician assistantc	Three permissible educational paths for
certification: 5 years of experience that includes completion of an
orthopedic physician assistant surgical assisting 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 technologistd Completion of an approved       2 years of surgical 
                          surgical education                       experience 
                          program that includes           
                          instruction and supervised      
                              surgical experience, unless 
                                   surgical experience is 
                                    substituted           

Orthopedic technologiste	Completion of an approved surgical education 1
year of surgical experience program that includes an operating room
rotation, unless surgical experience is substituted

Ophthalmic assistant/ Completion of an approved education program that 18
months of surgical experience technician/medical technologistf includes
instruction and supervised surgical

             experience, unless surgical experience is substituted

Source: Health professional associations.

aA 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.

bCertified Surgical Assistant (CSA), Surgical Assistant-Certified (SA-C).

cOrthopedic Physician's Assistant, Certified (OPA-C).

dCertified Surgical Assistant/Certified First Assistant (CST/CFA).

eOrthopedic Technologist-Surgery Certified (OT-SC).

fCertified Ophthalmic Assistant (COA), Technician (COT), or Medical
Technologist (COMT)-Ophthalmic Surgical Assisting.

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

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

We found little evidence about the quality of care provided by
assistantsat-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.

There are three flaws in Medicare's policies for paying
assistants-atsurgery 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-atsurgery 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.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 General27 found that most contractors used by Medicare to pay
for part B services do not have any mechanism to ensure that
assistant-atsurgery requests for payment for nonphysician health
professionals are

26No 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. S: 1395y(a)(1)(A) (2000).

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

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-atsurgery 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
assistantat-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.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

28BBA, S: 4432, 111 Stat. 414.

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

Matter for Congressional Consideration

  Agency Comments

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.

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 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-atsurgery. 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

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

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

Appendix I: Professional Associations, Schools, and Hospitals

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

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

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

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