Introduction
The ASGS Committee on Health Policy has been studying the issues of payment for surgeons as assistants at surgery. This report summarizes the Committee’s findings and conclusions and includes recommendations to constitute ASGS policy on the issue.
Discussion
HCFA has often proposed a severe reduction in payments for surgeons as assistants. While this proposal has dropped out of the current Congressional budget process, it is likely to resurface. It is of such serious importance that ASGS should address the issue. The Committee believes that HCFA’s position does not reflect a concern for quality, but rather for cost. By refusing to pay for surgeons as assistants in procedures that the “1996 Study: Physicians as Assistants at Surgery,” published by the American College of Surgeons categorizes as “sometimes” or “almost never” requiring an assistant surgeon, HCFA is attempting to reduce Medicare payments by sacrificing quality. The Committee does not oppose eliminating the cost of an assistant surgeon in those cases that allow safe performance without one, but quality of care should always be the foremost issue.
Having a qualified surgeon as an assistant at surgery provides an instant second opinion consultation, not only in difficult, but in every assisted operation. While the primary surgeon may focus on completing the technical aspects of a portion of an operation, the assistant surgeon can look at the broader picture from a different vantage point and can often perform ancillary parts of the operation at the same time that the primary surgeon is performing a different portion of the procedure.
Execution of delicate procedures often requires technical expertise on the part of both surgeon and assistant. Problems that arise during a procedure are better solved when two surgeons are present to bring to bear their combined experience. Having a surgeon as an assistant at surgery usually makes the operation go faster and more smoothly. If something happens to the primary surgeon during a procedure, the assistant provides for continuity of the operation.
Both common sense and the combined experience of the Committee verify that having expert assistance can translate into shortening the time needed for anesthesia, increasing the safety of the procedure, reducing the surgical complication rates, and thus decreasing operating room costs. This potential reduction in mortality and morbidity may occur especially in cases involving frail, elderly patients. HCFA must realize that any policy that eliminates paying for surgeons as assistants directly affects quality of surgical care and could jeopardize the lives of surgical patients.
The Committee wishes to emphasize that the decision of whether or not to use a surgeon as an assistant is strictly a quality of care issue. Use of a surgeon as an assistant provides no monetary benefit to the surgeon. In fact, the surgeon assistant receives only relatively small amounts for providing the service. In a state where payment for a hernia is $284, the assistant earns $32 for an hour’s work in assisting with the operation. The prime beneficiary of this activity is the patient. The Committee also believes that HCFA and other third party payers should be made aware that if their payment policies, specifically their denials of payment, cause harm to patients, they will share the legal responsibility for the outcome of these decisions.
The Committee agreed that the “1996 Study: Physicians as Assistants at Surgery,” published by the American College of Surgeons, summarizes well the procedures that “almost always” require a surgeon as assistant, those that “almost never” require a surgeon as an assistant, and those that “sometimes” require a surgeon as an assistant. The Committee believes that HCFA and other health care third party payers should pay routinely without question for a physician as an assistant in those procedures that almost always require one. ASGS believes that this physician should be a qualified surgeon except in those rare instances in which a qualified surgeon is not available. For procedures that sometimes or almost never require an assistant surgeon, the primary surgeon should have the ability to make the decision as to the need for an assistant.
The Committee favors having HCFA and other third party payers rely upon the judgment of the primary surgeon using the services of a surgeon as an assistant as adequate evidence of the need to have one. The Committee believes that the principal surgeon is best able to determine the potential need for an assistant based on knowledge of the individual characteristics of the patient undergoing the procedure and the complexities of the procedure itself.
To assist in the documentation of the surgeon’s decision-making process, ASGS proposes a list of characteristics of the patient and the operation contemplated that should determine the need for an assistant:
Characteristics of the patient:
• Extremes of age
• Obesity
• Bleeding tendency
• Immune status
• Cardiovascular status
• Metabolic status
• Intercurrent illness
Characteristics of the operation
• Complexity
• Delicacy
• Danger
• Significant decision-making required
If HCFA and other payers wish to develop alterate or additional mechanisms for the surgeon to identify the need for an assistant, ASGS believes that its simplicity should be measured against the above system. Such mechanisms should not cause great expenditures of time for compliance by the surgeons or their staff and should never include automatic nonpayment for assistant surgeons in the “sometimes” or the “almost never” categories. The Committee recommends the incorporation of the proposed system into claims form that will be adaptable to electronic claims submission.
The Committee recommends that the ASGS join with other surgical specialty organizations to emphasize to HCFA the value of physicians as assistants. ASGS should establish a policy that reflects such recognition. If the need remains present, a coalition such as the Coalition for Access to Specialty Care could be helpful in this undertaking. Failure on HCFA’s part to negotiate a safe and satisfactory policy with surgical specialty organizations would prompt the coalition to seek legislative relief.
The pubic is a necessary element in influencing the federal government and Congress. The Committee suggests the following possible initiatives to gather and share concrete illustrations of compromised patient care resulting from the lack of a physician as assistant at surgery:
Use the ASGS newsletter to solicit instances where the refusal of a payor to pay for a surgeon as an assistant compromised patient care.
Seek related litigation data from physician-owned and operated professional liability insurance companies.
Encourage ASGS members to write articles or letters to the editor of local newspapers about the importance of surgeons as assistants.
Identify ASGS members who have special access to the news media.
ASGS could produce a patient education brochure for surgeons to distribute to their patient.
ASGS develop a liaison with consumer protection and advocacy organizations such as AARP to promote public influence in issues concerning quality of care.
The Committee has also considered the policy for the use of surgeons as assistants in military and Veterans Administration hospitals. HCFA should not require that Medicare recipients have a lower standard of care than that provided within governmental hospitals.
Finally, the Committee recognizes that HCFA is undergoing a change in leadership. Perhaps the new HCFA administrator will be willing to review and negotiate this issue.
Recommendations:
ASGS believes that the decision to use a surgeon as an assistant in surgery should be first and foremost a quality of care issue. ASGS recommends adoption of the following policies:
- HCFA and other health care third party payers should pay routinely without question for a surgeon as an assistant in those procedures that usually or sometimes require one.
- The ASGS proposes a list of characteristics of the patient and of the operation that should be accepted as validating the need for a surgeon as an assistant for those procedures that rarely need an assistant. These are presented in Appendix A.
- HCFA and other third party payers in considering whether to pay for a surgeon as an assistant in those procedures that rarely require an assistant should accept the existence of at lease one of these characteristics and/or the explanation furnished by the primary surgeon for the need of a surgeon as an assistant for a particular procedure.
- Payers should develop a readily acceptable mechanism that does not employ vast expenditures of time of the surgeon or staff for authorizing the use of a surgeon as an assistant.
- The ASGS should seek to join with other surgical specialty organizations to petition HCFA to recognize the value of surgeons as assistants in surgery.
- The ASGS should develop a liaison with consumer protection organizations such as AARP to promote public influence in issues concerning quality of care.
The ASGS should pursue a study of the potential use of the characteristics in Appendix A for documenting the need of a surgeon as an assistant, for identifying the appropriate site of service, and for a risk rating system to be used in evaluating surgical outcomes.
The ASGS should convene expert panels to further refine the methodology of determining which procedures need surgeons as assistants.
ADOPTED, ASGS Board of Trustees, March, 1998
Appendix A
Examples of conditions or characteristics that may increase the hazard of a surgical procedure. Documentation of any one of these should validate the need to use a surgeon as an assistant in surgery.
Characteristics of the patient:
• Extremes of age
• Obesity
• Bleeding tendency
• Immune status
• Cardiovascular status
• Metabolic status
• Intercurrent illness
Characteristics of the operation
• Complexity
• Delicacy
• Danger
• Significant decision-making required
Other factors may also enter into the decision, such as site of the procedure.