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Report Entitled Payment Changes Are Needed for
First Assistants-at-Surgery (GAO-04-97)(To read the CMS response to this letter, click here.
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March 23, 2004
Marjorie Kanoff, Director
Health Care-Clinical Health Care Issues
United States General Accounting Office
441 G Street, NW
Washington , DC 20548
RE: Report Entitled Payment Changes Are Needed for First Assistants-at-Surgery
GAO-04-97
On behalf of the more than 51,000 clinically practicing physician assistants who are represented by the American Academy of Physician Assistants, we would like to take this opportunity to submit comments regarding the January 13, 2004 , report issued by the General Accounting Office (GAO) entitled Payment Changes Are Needed for First Assistants-at-Surgery (GAO-04-97).
The American Academy of Physician Assistants (AAPA) is the only national professional organization representing physician assistants (PAs) in all medical and surgical specialties. According to the AAPA's annual census report, more than 20 percent of the 51,000 clinically practicing PAs work in a surgical specialty or subspecialty and may provide first assisting at surgery services to Medicare patients.
The AAPA has serious concerns about many aspects of the report, but our most severe criticism revolves around the recommendation which would fundamentally alter Medicare's existing payment methodology for first assisting at surgery. While working to assure that Medicare funds are utilized in a cost-effective manner is a goal that we all share, we fear that implementing the report's recommendations may, in fact, compromise both the quality and the availability of surgical first assist services for Medicare patients.
The report recommends that current payment policy for first assisting under Medicare undergo a dramatic change. A shift in policy that eliminates fee-for-service first assist payments and proposes payment of these fees to hospitals in a prospective payment mechanism is suggested in the report. This change is supposed to lower Medicare's first assist costs by providing an incentive for hospitals to use a first assistant only when appropriate. We take issue with the implication that the hospital should decide when an assistant should be used. It is the surgeon who should determine if a first assistant is needed for a particular surgery. That decision should be based solely upon what is best for the patient, and not on the financial incentives of a particular payment methodology.
The report correctly points out that 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. The report fails to indicate that this shift actually saves the Medicare program money since nonphysician health professionals eligible for payment, such as PAs, are paid at 85 percent of the physician fee schedule for providing the same first assist services.
On another note, the report states that hospital employees likely serve as assistants-at-surgery for the majority of surgeries performed on Medicare patients. In fact, many PAs who perform first assist duties are not employees of the hospital. These PAs may be employees of the surgeon's private practice or self-employed independent contractors who work with surgeons. Since the hospital does not pay the salaries or benefits for these non-hospital employed PAs it would be highly inappropriate (and against Medicare regulations) to allow the hospital to collect Medicare payment for their services.
The report also suggests that there is insufficient information about the quality of care provided by assistants-at-surgery to assess the adequacy of the requirements for members of a particular profession to perform the role. The report ignores the demonstrated history of the PA profession in caring for Medicare patients. For more than 18 years PAs have had Medicare coverage for first assisting at surgery. Accredited PA education programs, clinical training that includes at least one rotation in surgery, national certification standards and state licensure all serve to assure that PAs deliver the highest quality care to Medicare beneficiaries.
We have pointed out many of the flaws contained in the report that, in our opinion, make the report's recommendations unworkable. The AAPA urges the General Accounting Office to rethink its position on this matter and to be receptive to the concerns coming from the health care professionals who provide first assist services to Medicare patients.
We appreciate the opportunity to comment on the report and hope that our comments are useful. If we can be helpful in supplying additional information or details regarding our comments, please do not hesitate to contact us.
Sincerely,
Stephen C. Crane, PhD, MPH
Executive Vice President/Chief Executive Officer
cc: The Honorable Charles E. Grassley The Honorable John D. Dingell
The Honorable Joe Barton The Honorable Charles B. Rangel
The Honorable Bill Thomas Mark McClellan, M.D.
The Honorable Max Baucus Glenn M. Hackbarth, J.D.
(To read the CMS response to this letter, click here.
Last Revised: 6/15/04
