CMS also establishes regulatory requirements for the health professions  eligible to receive payment under the Medicare physician fee schedule. 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). 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. 1). 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. 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. 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. Paying for  assistants under the physician fee schedule provides no such incentive.
Why GAO Did This Study

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.

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.