ACS Views on Legislative, Regulatory, and Other Issues

Assistants at Surgery—

• Letter to Chairmen and Ranking Members, 3/17/04

Dear Chairmen and Ranking Members:

The undersigned organizations representing physicians and other non-physician professionals write to express our deep concern with the recent recommendation of the General Accounting Office (GAO) to revise Medicare payment policy regarding assistants-at-surgery. The recommendations included in this report reach far beyond the scope of the Congressional request and have serious implications for the quality and safety of surgical patient care.

The report's overall recommendation that Congress should consider consolidating all Medicare payments for assistants-at-surgery services under the hospital inpatient PPS is wholly inappropriate for the following reasons. First, the recommendation will lead to interference with a surgeon's professional judgment regarding medical necessity and patient safety. Second, there is no indication that current payment policies provide incentives for the improper use of assistants-at-surgery. Third, the report's recommendations raise serious concerns about creating new financial disincentives for hospitals to provide appropriately skilled assistants. Finally, expenditure data suggest that current policy has promoted efficient use of assistants with appropriate skill levels. Therefore, we strongly urge Congress to maintain current Medicare payment policies for assistant-at-surgery services.

First, the recommendation ignores the surgeon's professional judgment about the level of care required by his or her patient. In addition, the report fails to acknowledge that the various types of professionals who provide these services are not wholly interchangeable. There are significant differences in the training and experience among providers. Their services as assistants-at-surgery are not always limited just to providing a "second set of hands." At times, surgeons call upon assistants to utilize problem-solving skills that are only developed through medical and surgical training. As a result, the primary surgeon's decision about who is most appropriate to serve as an assistant at surgery may be based on factors such as the nature of a specific operation, the unique medical circumstances of an individual patient, the availability of appropriately trained physicians or non-physician staff, or ready access to other appropriately trained specialists elsewhere in the hospital. The arrangement proposed by GAO, however, would prevent the surgeon from seeking assistance from the most appropriate professional available and raises serious patient safety concerns.

Second, there is no indication that current payment policies provide incentives for the improper use of physicians or non-physicians as assistants at surgery. The report ignores the fact that current policies provide no incentive for physicians to choose one type of provider over another. The surgeon's payment remains the same, regardless of whether a surgical resident, a physician-employed or independently-employed physician assistant, or hospital staff provide these services. The only factor in this decision is a desire to provide safe, high-quality surgical care.

In addition, the report offers no assurances that current hospital payments are adequate to enable them to provide prompt access to the various types of professionals, including physicians, whose services may be needed—vague references to the hospital responsibilities under health and safety rules notwithstanding. Indeed, where the issue of financial incentives is concerned, GAO's recommendation actually acts contrary to its stated purpose by establishing entirely new financial incentives for hospitals to make available only the lowest cost—rather than most appropriate—type of provider.

Finally, current payment policies have not contributed to escalating Medicare program costs, nor are there any indications that assistants at surgery are being used unnecessarily. Each year, Medicare pays for more than 70 million surgical procedures, at a cost of $10.5 billion in 2002. Of those procedures, an assistant-at-surgery was paid under the fee schedule in less than 2 percent of cases, resulting in $158 million in Medicare Part B payments. Physicians assisted in many of these cases, but in many other circumstances non-physician professionals were used.

Since the enactment of the Balanced Budget Act of 1997 non-physician professionals have been eligible for reimbursement, and the percentage of assistant-at-surgery services paid to physicians under the fee schedule has declined. Conversely, the percentage of these services paid to non-physician professional has increased. Total Medicare payments for assistants-at-surgery services under physician fee schedule have actually declined by 46 percent since 1986. This amounted to a $137 million cost-savings to Medicare in 2002 alone.

Congress has rejected proposals to bundle assistant-at-surgery payments with those for other services in the past because the detriments far outweigh any potential benefits. Given the significant patient safety implications, the absence of any data demonstrating inappropriate behavior under current polices, and the relatively small amount of Medicare spending involved, we urge you once again to preserve current Medicare payment policies for these important services.

Sincerely,

Revised January 27, 2005

ACS Views on Legislative, Regulatory, and Other Issues

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