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Review and Evaluation of Proposed LD 32
MANDATED HEALTH INSURANCE
BENEFIT FOR REIMBURSEMENT OF
REGISTERED NURSE FIRST ASSISTANTS
FOR SURGICAL PROCEDURES
 
A Report to the
Joint Standing Committee on
Banking and Insurance
of the
119th Maine Legislature

 

Prepared by the
Bureau of Insurance
May 1999

TABLE OF CONTENTS
Executive Summary ............................................ i
Background ................................................... 1
EVALUATION BASED ON 24-A M.R.S.A. § 2752
Social Impact ................................................ 4
Financial Impact ............................................ 10
Medical Efficacy ............................................ 14
Balancing the Effects ....................................... 16
Appendices .................................................. 19

• Appendix A: Letter from the Committee on Banking and Insurance with Proposed Legislative Amendment
• Appendix B: History of the Nurse’s Role as Surgical Assistant
• Appendix C: Florida and Minnesota Mandates
• Appendix D: Cost Comparisons from Florida & Mississippi RNFAs
• Appendix E: RNFAs in Maine
• Appendix F: Current Insurance Coverage
• Appendix G: Maine Health Information Center Analysis
• Appendix H: St. Joseph Hospital’s RNFA Policy
• Appendix I: Maine Cumulative Data on Mandates
• Appendix J: References

EXECUTIVE SUMMARY
The Joint Standing Committee on Banking and Insurance of the 119th Maine Legislature on March 19, 1999, directed the Bureau of Insurance to review LD 32, "An Act to Allow Reimbursement of Registered Nurse First Assistants for Surgical Procedures", as amended by the Committee. The review was conducted using the criteria outlined in 24-A M.R.S.A. § 2752 regarding the social and financial impact of the proposed mandate, and the medical efficacy of the providers covered under the proposal.
LD 32 and the draft proposed amendment require all group and individual health insurance and Health Maintenance Organization (HMO) contracts that provide for the payment of surgical assistants to reimburse for the services of registered nurse first assistants (RNFAs). The reimbursement is only required if an assisting physician would be covered and the RNFA performs such services as a substitute. The bill defines a RNFA and allows institutions to continue to credential these providers.
To assess the implications of LD 32, it was assumed that health plans would be permitted to issue reimbursement directed through the surgeon’s practice or facility. Although the wording of the legislation does not specifically stipulate this, it appears consistent with the intent of LD 32.
At least two states (Florida and Minnesota) have passed similar legislation requiring health insurance policies to provide payment to a registered nurse first assistant when the policy provides reimbursement for surgical assistance benefits. After enactment of this legislation, Florida and Minnesota Insurance Departments did not track the effects but reported they were minimal and did not receive any specific reports of cost increases resulting from the requirement. Ten other states (Georgia, Maine, Massachusetts, Missouri, North Dakota, Alabama, Hawaii, Louisiana, Rhode Island and Texas) have introduced or are considering similar legislation.
Although some national commercial carriers already recognize and reimburse RNFAs, coverage is inconsistent and variable. Of the 15 carriers responding to our request for coverage information, only three did not reimburse non-physician assistants. Most did not believe there would be an increase in premiums due to the proposed mandate or there would be a slight increase due to the additional credentialing of such providers.
The registered nurse first assistant (RNFA) is a technically skilled and highly educated nursing professional with a minimum of five years clinical/didactic education, certification and experience. The RNFA collaborates with the surgeon from the preoperative assessment procedures, through recovery and discharge of the patient. While no definite number was available, there are at least 14 RNFAs in Maine.
Studies and testimony from a variety of reliable sources cite the contribution of RNFAs to the quality of medical care. They provide the surgeon with a qualified, available and flexible assistant to surgery. Proponents feel that without reimbursement, they are unable to attract or retain these providers. Opponents include some health plans, the Maine Chamber and Business Alliance and the NFIB and primarily object to mandates in general.
Opposing health plans stated that they do reimburse for RNFA services through the reimbursement of the surgeon or hospital charge but feel costs would increase if they were required to separately reimburse the RNFA. Some carriers would prefer to have the RNs continue on the physicians’ and hospitals’ payroll because the surgeon or hospital is already reimbursed for the surgery and related expenses. Normally a procedure in a hospital or freestanding surgical suite already includes the cost of the Operating Room staff. If they are paid separately, carriers feel they may receive payment twice for the same services. Allowing for the RNFA to bill and be separately reimbursed, they believe may simply add costs and cause unbundling.
Since LD 32 does not require additional benefits and does not require health plans to pay more for current benefits, there is no clear rationale for increased benefit cost. LD 32 only requires coverage of RNFAs if reimbursement for an assisting physician (MD) would be covered and the RNFA is acting as a substitute. If health plans are already being charged for this type of assisting service through the operating room fee or "room charge", this may be adjusted to reflect unbundling of services. With this latitude health plans can avoid increased benefit costs pertaining to coverage of RNFAs. System and administrative changes are necessary to identify the specific RNFA that provided care. The estimated cost of added administration is not significant enough to measure due to the low number of RNFAs in the state currently. No carrier was able to give any specific cost estimates.
From an analysis provided by the Maine Health Information Center (MHIC), surgical assistant costs represent less than 0.01% of the total hospital charges for surgical procedures in Maine. While there are limitations to this analysis, these limitations do not significantly impact the estimate.
The factors included in balancing the social, economic and medical efficacy consideration are:

• LD 32 is not projected to increase premiums by a measurable amount.
• The health care benefits provided by health plans are unchanged.
• Providers will have a greater variety of qualified first assistants to choose from and flexibility to schedule surgery.
• Health plans and employer organizations share the concern that this proposed legislative amendment might lead to subsequent mandates that will further increase costs.

As with any legislation, there is the risk of unintended and unfavorable consequences. Variations from the assumption pertaining to the latitude health plans have in contracting with providers would alter the financial implications of LD 32.

BACKGROUND
The Joint Standing Committee on Banking and Insurance of the 119th Maine Legislature on March 19, 1999, directed the Bureau of Insurance to review LD 32, "An Act to Allow Reimbursement of Registered Nurse First Assistants for Surgical Procedures." The review was conducted using the criteria outlined in 24-A M.R.S.A. § 2752 regarding the social and financial impact of the proposed mandate, and the medical efficacy of the providers covered under the proposal.
LD 32 and the draft proposed amendment require all group and individual health insurance and Health Maintenance Organization (HMO) contracts that provide for the payment of surgical assistants to reimburse for the services of registered nurse first assistants. The reimbursement is only required if an assisting physician (MD) would be covered and the RNFA (see Table A below for acronym descriptions) who performed such services as a substitute. The proposed legislation defines a RNFA and allows institutions to continue to credential these providers.

Table A: Acronyms
ACS	American College of Surgeons
AORN	Association for Operating Room Nurses Inc.
OR	Operating Room
PA	Physician Assistant
RN	Registered Nurse
RNFA	Registered Nurse First Assistant

A RNFA is a technically skilled and highly educated nursing professional with a minimum of five years clinical/didactic education, certification and experience including: 2 years secondary education for RN licensure, 2 years practicing professional nursing in the operating room, achievement of national certification in operating room nursing (CNOR), and one academic year of tertiary education. A RNFA assesses the patient pre-operatively for significant clinical considerations. In the operating room, the RNFA functions interdependently with the operating surgeon. The RNFA assists the surgeon intra-operatively with handling tissue, providing exposure, using instruments, suturing, and providing homeostasis. RNFAs continue patient care by following the patient in the post-operative period by reassessing the patient’s status and evaluating the effects of perioperative care.
The evolution of registered nurses as first assistants spans more than a century. See Appendix B for a detailed time table. During war time nurses were instrumental in promoting infection control and environmental sanitation in the operating room. During World War II, nurses functioned as first assistants in both civilian and military facilities due to the combination of personnel shortages and high casualty rates. The period following World War II saw major increases in hospital construction, increases in elective surgery and a continued nursing shortage.
In 1948, E.L. Brown, a long-term advocate that nursing services could be performed by a person with shorter preparation than the RN, developed a report that called for increasing use of practical nurses, technicians and paid aides. The Brown Report was readily accepted by hospitals, third-party payers and unemployed military corpsmen. Practical nurses, technicians and paid aides workers and later PAs quickly began replacing RNs at the operating table. With these assistants, the role of the professional nurse in the operating room was threatened.
In the 1970’s, RNs who first assisted were seen as implementing a delegated medical task. Many nurses believed that assisting at surgery was purely a technical skill and not considered within the scope of the professional nursing role. In 1977 AORN raised the issue with their membership because the Virginia State Board of Nursing and the Board of Medicine had issued a statement that said RNs with certain preparation and experience could first assist. In 1980, the Pennsylvania State Board of Nurse Examiners ruled that RNs could not function as first assistants and if they did would be liable for malpractice. This decision was then reversed in 1984. Experiences in perioperative nursing had almost vanished from nursing curriculum.
By 1980, the ACS and AORN had defined the duties of the first assistant and developed guidelines for the RN. States differed in their determination of whether the RN could function as a first assistant. By 1985 the role of the RNFA had come full circle. AORN began surveying state boards of nursing to learn their positions on RNFAs. By 1992, all 50 states recognized the RNFA role as being within the scope of nursing practice.
AORN has been trying to achieve federal reimbursement for RNFA services under Medicare since 1987 when it became a priority because reimbursement was granted to PAs. Progress for AORN towards reimbursement for any nursing services on the federal level has been slow and arduous due to American Medical Association (AMA) objections, questionable budget estimates and difficulty comparing nurses’ skills to physicians’ skills. Currently, Medicare pays MD assistants 16% of the primary surgeon’s fee and pays a PA 65% of the 16% a physician would receive. Except for PAs, Medicare does not pay for the services of non-physicians who assist at surgery. Medicare does not reimburse RNFAs unless they are also a Nurse Practitioner or a Clinical Nurse Specialist.
Medicaid is funded jointly by the federal and state government, but it is administered solely by the state government. In Maine, Medicaid does not cover RNFAs separately. They are covered as part of a hospital staffing cost if the nurse is employed by the hospital.

EVALUATION OF LD 32 BASED ON REQUIRED CRITERIA

SOCIAL IMPACT
A. The social impact of mandating the benefit which shall include:
1. The extent to which the treatment or service is utilized by a significant portion of the population;
While no statewide figures were available, a surgeon’s office estimated that of the 400 major surgeries performed annually, its RNFA assisted with 350 cases for each of the past two years or 87.5% of cases. She followed all cases from pre-op to post-op and completed follow-up care after the patient left the hospital.
As payment has declined for physicians who assist at surgery, operating rooms (ORs) are turning to others to help. A survey by the OR Manager Journal and the AORN Specialty Assembly, indicates that close to 70% of ORs use personnel other than physicians to first assist. Only about a third of managers rely exclusively on a single category of assistant; most use a combination. For those using a single category, RNFAs are used by 16% of ORs compared to 7% for PAs, and 5% for surgical technologists.
2. The extent to which the treatment or service is available to the population;
The Maine AORN has 200 members which include 10 to 12 RNFAs. See Appendix E for the list of 14 RNFAs in Maine developed by the RNFA Specialty Assembly. The majority of these RNFAs are employed by surgeons.
3. The extent to which insurance coverage for this treatment or service is already available;
According to an AORN Journal, initial data suggest that the majority of RNFAs do not receive additional compensation for performing first assistant functions beyond their regular RN duties but greatly contribute to patient satisfaction. Medicare pays MD assistants 16% of the primary surgeon’s fee and a PA receives 65% of the 16% fee a physician would receive. Except for PAs, Medicare does not pay for the services of non-physicians who assist at surgery. A few RNFAs who also are clinical nurse specialists may qualify for Medicare and Medicaid reimbursement if they meet the state’s definition of an advanced practice nurse and work in a "rural area" as defined by the federal government. Partly due to the precedent set by Medicare not reimbursing for RNFAs, hospitals often do not seek reimbursement.
Surgeon’s offices complain that the reimbursement is not consistent from carriers for major medical insurance. One mentioned they have the most difficulty obtaining reimbursement from HMOs. Until recently, Blue Cross did not reimburse RNFAs especially under their HMO coverage. Blue Cross has since entered into an agreement to reimburse RNFAs. Tufts, Harvard Pilgrim, Provident, United Healthcare and Cigna typically do not reimburse according to the providers. While, Healthsource and NYLCare do typically reimburse RNFAs. The reimbursement also varies due to the specifics involved with each claim and this results in some conflicting information from that received by our carrier survey.
15 carriers responded to our request for coverage information. Only three carriers did not reimburse for non-physician first assistants, one carrier had no claims submitted by RNFAs and one carrier only reimbursed when mandated by state law. All the other carriers had some type of reimbursement procedure for RNFAs. Of these, the level of reimbursement ranged from 10% to 25% of the surgeon’s fee. Three carriers felt the proposed mandate would increase surgical claims costs and two carriers felt there may be a decrease due to covering non-physicians as lower cost providers. Five carriers felt there would be some administrative cost due to credentialing. Several questioned whether additional staff would be needed to perform the credentialing depending on the number of RNFAs. See Appendix F for carriers responses to our survey.
4. If coverage is not generally available, the extent to which the lack of coverage results in persons being unable to obtain necessary health care treatment;
Surgeons state that they often have difficulty finding a physician willing to assist in surgery due to time commitments and the low reimbursement rates for first assisting. This leads to problems scheduling surgery for patients.
5. If the coverage is not generally available, the extent to which the lack of coverage results in unreasonable financial hardship on those persons needing treatment;
If an RNFA’s bill for services is denied and passed on to the patient it could run from $245 to $913 depending on the type of surgery performed (using a 1996 cost comparison from Mississippi RNFAs). Often the hospital or surgeon employing the RNFA that contracts with an HMO does not seek reimbursement if it is not a covered service and instead absorbs it in to its operating costs.
6. The level of public demand and the level of demand from providers for the treatment or service;
Public demand for RNFAs is difficult to gauge because typically individuals do not choose the surgical team that assists the surgeon.
The ACS in its Statement of Principles states that it is proper for a surgeon to delegate the performance of part of a given operation to assistants. Registered nurses with additional specialized training are mentioned as functioning as first assistants to the surgeon at the operating table in those situations or at hospitals where more completely trained assistants are not available.
Several surgeons testified at the public hearing on LD 32 that they seek services of RNFAs because of their skill and availability.
7. The level of public demand and the level of demand from the providers for individual and group insurance coverage of the treatment or service;
Support by surgeons for reimbursement was evident from testimony during the public hearing on LD 32. In addition, AORN issued a statement entitled "Support State Legislation for Reimbursement of RN First Assistants." Both advocate for equitable reimbursement for RNFA services and believe that it is in the best interests of the patient and the health care system to provide for such reimbursements. Until RNFAs can receive direct reimbursement, there is less incentive to use these high quality, cost-effective providers.
8. The level of interest in and the extent to which collective bargaining organizations are negotiating privately for inclusion of this coverage in group contracts;
No information available. This is not a benefit typically requested by employees because the reimbursement methods are often not apparent to the insured and therefore not apt to be considered during collective bargaining.
9. The likelihood of achieving the objectives of meeting the consumer need as evidenced by the experience of other states;
At least two states (Florida and Minnesota) have passed similar legislation requiring health insurance policies to provide payment to a registered nurse first assistant or to employers of registered nurse first assistants for services within their scope of licensure when the policy provides reimbursement for surgical assistance benefits. See Appendix C. Ten other states (Georgia, Maine, Massachusetts, Missouri, North Dakota, Alabama, Hawaii, Louisiana, Rhode Island and Texas) have introduced or are considering similar legislation.
In a Florida bill analysis and economic impact statement, the Department of Insurance did not expect that there would be any rate impact because coverage of the RNFAs was only required when surgical assistant benefits were provided. After enactment of the bill, the Department did not track the impact of the mandate but felt it was minimal and did not receive any specific reports of cost increases resulting from the requirement. Minnesota also had no experience to report but felt there was no or minimal impact due to the requirement.
Florida Blue Cross established creditialing criteria and reimburses RNFAs similar to PAs at 20% of the surgical allowance and did not determine any cost impact due to the mandate in that state. Their primary concern was that the provider be qualified. Minnesota Blue Cross provided similar information.
10. The relevant findings of the state health planning agency or the appropriate health system agency relating to the social impact of the mandated benefit;
No information was available from various agencies including the Bureau of Health, the Office of Data, Research, and Vital Statistics and Medicaid.
11. The alternatives to meeting the identified need;
Some carriers would prefer to have the RNs continue on the physicians’ and hospitals’ payroll because the surgeon or hospital is already reimbursed for the surgery and related expenses. Normally a procedure in a hospital or freestanding surgical suite already includes the cost of the Operating Room staff. If they are paid separately, carriers feel they may pay twice for the same services. Allowing for the RNFA to bill and be separately reimbursed may simply add costs and cause unbundling.
12. Whether the benefit is a medical or a broader social need and whether it is consistent with the role of health insurance and the concept of managed care;
In 1994, the Washington, DC-based Health Care Advisory Board noted a growing national trend to utilize RNFAs, citing such benefits as increased case load for the institution and improved surgeon and nurse satisfaction. They proposed establishment of RNFA services as a definitive, reimbursable nursing service as part of the solution to providing assistants at surgery.
An asset of RNFAs is their flexibility. At various times, a RN on staff could perform the duties of scrub nurse, circulating nurse or RNFA for their employer. With the additional education and experience they are available to serve as a low cost, highly skilled and available alternative to MD first assistants.
13. The impact of any social stigma attached to the benefit upon the market;
There is no apparent social stigma for these benefits.
14. The impact of this benefit upon the availability of other benefits currently being offered; and
LD 32 should not impact other benefits currently offered.
15. The impact of the benefit as it relates to employers shifting to self-insurance plans and the extent to which the benefit is currently being offered by employers with self-insured plans; and
Information from a surgeon’s office indicates that several self-insured plans do currently reimburse for RNFAs including Bangor Hydro and Dexter Shoe.
The Maine Health Information Center (MHIC), a leading non-profit health care data organization surveyed several plan third party administrators (TPAs) for self-funded employers within the Maine Health Management Coalition (the "Coalition"). The Coalition is a non-profit organization comprised of 31 employers that collectively provide health care benefits to over 125,000 Maine citizens. The plans that responded represent 70% of the coalition’s self-insured covered lives. Coverage of RNFAs varied with each plan. One TPA did not cover RNFAs but was in the process of evaluating coverage. The other TPA did offer coverage but it varied by employer with the majority not covering RNFAs. One plan that offers a self-insured point of service product does provide coverage for RNFAs but does not credential RNFAs and requires bills to be submitted by the surgeon. See Appendix G.
A Texas Department of Insurance report to its legislature in December of 1998 found that numerous studies of self-funded health plans show that most of the benefits mandated by state law are voluntarily included in self-funded plans. While there are a number of advantages and disadvantages to self-insuring, employers report they self-fund to save money, to have more control of plan benefits, and because it enables them to offer a single plan to employees in multiple states. A survey of self-funded Texas employers shows that about 15 percent self-fund specifically to avoid certain mandated benefits. However, the vast majority of employers reported they include all the Texas mandates in their benefit plans.
16. The impact of making the benefit applicable to the state employee health insurance program;
Healthsource provides reimbursement at a set fee for all First Assistants regardless of whether the First Assistant is a nurse, physician or other appropriate health care provider. The State Employee Health Commission Office did not determine an exact cost estimate but felt there would be an expected increase if negotiations of a new fee schedule and direct reimbursement of RNFAs were to occur under LD 32.

FINANCIAL IMPACT
B. The financial impact of mandating the benefit which shall include:
1. The extent to which the proposed insurance coverage would increase or decrease the cost of the treatment or service over the next five years;
Proponents argue that payment for RNFA services rendered would encourage institutions to employ these practitioners. Costs would then decrease because the percentage of payment to a MD who assists at surgery who is currently being covered is greater than the percentage paid to an RNFA.
Opponents believe costs would increase due to increased frequency of billing for surgical assisting and the fact that hospitals would be unlikely to lower their operating room charges as a result of RNFAs billing separately.
2. The extent to which the proposed coverage might increase the appropriate or inappropriate use of the treatment or service over the next five years;
Hospitals currently determine which surgeries need a first assistant and when the RNFA is qualified to assist through credentialing. Two guides that have been used are:

• The American College of Surgeons’ "Use of Physicians as Assistants at Surgery", which lists CPT-4 codes for surgical services and tells whether each requires an assistant almost always, sometimes or never. Ratings are provided by panels of surgeons. The guide is no longer in print and not available from the American College of Surgeons. It was provided to the Bureau by the Maine Medical Association. One carrier mentioned using the guide with modifications as required based on input from internal and external consultants from surgical subspecialties.
• Milliman & Robertson’s, the consultants and actuaries, publish assistant guidelines in "Healthcare Management Guidelines, Vol 1", which deals with inpatient and surgical care. The guidelines list CPT-4 codes, with a yes or no to indicate whether an assistant is used.

The decision to request an assist at surgery remains the responsibility of the primary surgeon. Carriers determine medical necessity when a claim is filed or when a preauthorization for surgery is submitted.
3. The extent to which the mandated treatment or service might serve as an alternative for more expensive or less expensive treatment or service;
Proponents state that payment to a MD who assists at surgery is greater than the percentage paid to a RNFA. The RNFAs are qualified to assist as a replacement for a physician in most cases. See Appendix D for a cost comparison of RNFA assist fees versus other first assistant fees. See Appendix F for the current reimbursement practices of carriers in Maine.
4. The methods which will be instituted to manage the utilization and costs of the proposed mandate;
Carriers would still determine the reimbursement levels and necessity of a first assist for the type of surgery. Tufts Health Plan provides reimbursement for surgical assisting only for those cases of sufficient complexity to require the services of a MD surgical assistant. They are concerned that LD 32 would require reimbursement for the services of a RNFA for all surgical procedures for which it currently provides reimbursement for surgical assisting. It could potentially result in utilization of a RNFA for a procedure in which the patient would be better served by using a MD assistant.
Tufts is also concerned with the additional cost that could result from RNFAs assisting on relatively low-complexity surgical procedures for which there is generally no reimbursement for MD assistants. However, LD 32 as amended would not require this. From the list of common procedures that RNFAs seek reimbursement for reported by AORN, all but three are listed in The American College of Surgeons’ "Use of Physicians as Assistants at Surgery" as "almost always" requiring the use of a physician as an assistant at surgery. The remaining three procedures are listed as "sometimes" requiring the assistant.
According to Tufts, currently charges for the RNFA are built into the operating room fee and average approximately $800 per case. They stated that while several operating room services are included in this room charge, nursing support is undoubtedly one of the services constituting this charge.
5. The extent to which the insurance coverage may affect the number and types of providers over the next five years;
The mandate is expected to encourage more RNFAs to enter the field if reimbursement is required.
6. The extent to which insurance coverage of the health care service or provider may be reasonably expected to increase or decrease the insurance premium and administrative expenses of policyholders;
In response to legislation in 1994, AORN members in Florida prepared a table illustrating the cost savings for cardiovascular, orthopedic, neurosurgical, obstetric and gynecologic, and general surgery procedures. RNFAs in Mississippi prepared similar tables in their legislative effort, showing the cost-effectiveness of using RNFAs when assisting physicians are reimbursed. See Appendix D.
Of the 15 insurers responding to our request for coverage information, most did not believe there would be an increase or significant increase to premiums due to the mandate because they already provide similar coverage. Three HMOs that provide no coverage for non-physician assistants anticipated that costs would increase for claims and administrative costs. For those HMOs, the mandate would require the plans to cover a category of providers whose services have been included within the payment made to either the hospital or the surgeon. Dividing the payment into two portions is a form of unbundling which historically has increased the cost of medical care. These costs could then drive premiums up.
7. The impact of indirect costs, which are costs other than premiums and administrative costs, on the question of the costs and benefits of coverage;
Some literature suggests that research on patient outcomes has demonstrated that physician behavior alone cannot account for the quality of patient care in hospitals: quality outcomes are more closely linked to teamwork, and specifically to nurse-physician interactions.
8. The impact of this coverage on the total cost of health care; and
Opponents of the legislation state that mandating payment to specific provider types has been shown to increase costs over time both in absolute cost for the services and administrative costs.
The MHIC provided an analysis of the total cost of surgical first assistant costs in Maine. The impact of RNFA coverage is considered within the context of these costs. Total volume of surgical procedures was determined using the list of common procedures using an RNFA provided by AORN and the hospital discharge database and ambulatory surgery database for Maine. The Coalition claims database was used to estimate the cost of surgical assistants. They determined from this data that surgical assistants are a small portion of health care costs in Maine. As a relative comparison, surgical assistants represent less than 0.01% of the total hospital charges for surgical procedures. There may be additional costs that are not reflected in this figure such as training and accrediting assistants. While there are other limitations to this analysis, these limitations do not significantly impact the estimate. See Appendix G for the entire MHIC report.
9. The effects on the cost of health care to employers and employees, including the financial impact on small employers, medium-sized employers, and large employers.
Small business representatives contend that government health care mandates are discriminatory because they do not apply to large companies that self-insure, or to Medicaid and Medicare. They feel that the burden of cost-sharing for this mandate would fall squarely on the shoulders of small businesses and their employees. For this particular mandate, Medicare and Medicaid do not presently cover the RNFAs.
The estimated premium impact of LD 32 for employers is minimal and not a measurable increase in premium.
MEDICAL EFFICACY
C. The medical efficacy of mandating the benefit which shall include:
1. The contribution of the benefit to the quality of patient care and the health status of the population, including the results of any research demonstrating the medical efficacy of the treatment or service compared to alternatives or not providing the treatment or service; and
In a 1996 article on RNFA in Cardiac Surgery, a sample of 37 RNFAs who work in acute care settings (hospitals) identified the ways they contribute to improving the practice of perioperative patient care. Contributions included the following: decreased turnover time, increased consistency of service to surgeons, increased level of patient assessment and satisfaction, increased patient scheduling, decreased lost time, increased surgeon productivity, decreased operating time and increased internurse communication about patient and procedural requirements.
2. If the legislation seeks to mandate coverage of an additional class of practitioners:
a. The results of any professionally acceptable research demonstrating the medical results achieved by the additional class of practitioners relative to those already covered; and
A 1992 article published in the Texas Heart Institute Journal concluded from a clinical research study that the choice of either a MD-surgeon or experienced RN as first assistant does not influence the course or outcome of abdominal aortic aneurysm surgery. The morbidity and mortality rates were independent of the type of assistant, as were the operative time, blood loss, and adjusted blood transfusion volume.
A study at the Cleveland Clinic Foundation (CCF) published in the March 1998 AORN Journal examined the use of RNFAs for a procedure routinely performed to harvest the radial artery (RA) for coronary artery bypass graft surgery (CABG). Using the RNFA allows surgeons to focus on other surgical tasks which saves an estimated $1,300 per hour in operating room time. In one study at another institution, 26% of 156 patients who had RA harvested for CABG procedures experienced postoperative complications. At CCF, 100% of the RAs are removed by the RNFA. As of January 22, 1998, 1,000 patients had RAs harvested at CCF and only 2 experienced true complications.
According to a May 1998 AORN Journal, research is currently in progress to explore RNFA quality of care, patient satisfaction, cost-effectiveness, compensation and reimbursement.
b. The methods of the appropriate professional organization that assure clinical proficiency.
The Maine State Board of Nursing licenses and regulates RNs. No certification has been required by the Board for a RN to perform as a RNFA. RNs have been able to perform as RNFAs in Maine since 1984 in accordance with AORN standards.
Hospitals determine practice privileges of individuals acting as first assistants based on verified credentials, reviewed and approved by the hospital credentialing committee. Core requirements established by Hospital licensure regulations and National Accreditation Programs but be met. Hospital privileges are determined based on experience and may be restricted to specific categories of surgery. As an example, a copy of St. Joseph Hospital’s RNFA policy provided by the Hospital Association can be found in Appendix H. St. Joseph Hospital does not allow the RNFA to function as a scrub nurse. It also contains a form to specify which surgical privileges are approved for a particular individual.
The RNFA role is recognized by boards of nursing in all 50 states as being within the scope of nursing practice. RNFAs are also recognized by the American College of Surgeons (ACS), the American Nurses Association (ANA), National League of Nursing (NLN) and the Nation Association of Orthopedic Nurses (NAON).
National certification (CRNFA) for the RNFA is voluntary. The certification process provides a means for the individual RNFA to be recognized for having achieved excellence, but the RNFA must meet rigid requirements before applying.
Association of Operating Room Nurses, Inc. (AORN) is a professional organization with 43,000 operating room nurse members nationally. It publishes recommendations for education standards for RNFA programs. They have also advocated for reimbursement of RNFAs.

BALANCING THE EFFECTS
D. The effects of balancing the social, economic, and medical efficacy considerations which shall include:
1. The extent to which the need for coverage outweighs the cost of mandating the benefit for all policyholders; and
Based on the hearing testimony of the proponents, surgeons need to be free to choose to employ individuals without fear of economic loss. However, health plans feel that the medical care is currently covered by reimbursing for operating room staff in general. Until RNFAs can receive reimbursement, however, there is no incentive to use these high quality, cost-effective providers for first assisting.
2. The extent to which the problem of coverage may be solved by mandating the availability of the coverage as an option for policyholders.
Traditionally, group policyholders do not view mandated offerings as desirable unless they are requested by their certificate holders. This is not a benefit typically requested by employees or individuals because the reimbursement methods are often not apparent to the insured and therefore not apt to be considered when purchasing a policy.
Since the estimated administrative cost associated with LD 32 would not be reduced by making the mandated coverage optional and the benefit cost is negligible, there would be no cost advantage in requiring health plans to offer the mandated coverage as an option.
3. The cumulative impact of mandating this benefit in combination with existing mandates on the costs and availability of coverage.
It is not possible to precisely measure the impact of mandated benefits. However, it is possible to estimate an outside limit, the maximum possible increase in health insurance premiums resulting from mandates. Because various mandates apply to different categories of coverage, this maximum likewise varies. The Bureau’s estimates of the maximum premium increases due to existing mandates and the proposed mandate are displayed in Table B. These estimates are based on the estimated potion of claim costs that mandated benefits represent, as detailed in Appendix I. The true cost impact is less that this for two reasons:
1. Some of these services would likely be provided even in the absence of a mandate.
2. It has been asserted (and some studies confirm) that covering certain services or providers will reduce claims in other areas. For instance, covering mental health and substance abuse may reduce claims for physical conditions. Covering social workers may reduce claims for more expensive providers such as psychiatrists and psychologists. Covering chiropractic services may reduce claims for back surgery. Covering screening mammograms may reduce claims for breast cancer treatment.
While both of these factors reduce the cost impact of the mandates, we are not able to estimate the extent of the reduction at this time.

TABLE B – MAXIMUM PREMIUM INCREASES
CURRENT MANDATES
	GROUPS WITH MORE THAN 20 EMPLOYEES		SMALLER GROUPS	INDIVIDUALS
FEE-FOR-SERVICE PLANS	6.74%		2.08%	2.07%
MANAGED CARE PLANS	6.16%		2.0%	1.9%
LD 32
FEE-FOR-SERVICE PLANS	0%		0%	0%
MANAGED CARE PLANS	0%		0%	0%
CUMULATIVE IMPACT
FEE-FOR-SERVICE PLANS	6.74%	2.08%		2.07%
MANAGED CARE PLANS	6.16%	2.0%		1.9%

While some studies have estimated much higher costs for mandated benefits, these studies were not based on the specific mandates applicable in Maine and therefore are not relevant.
There is no indication that mandated benefits have impacted the availability of health insurance.

APPENDIX A
Letter from the Committee on Banking and Insurance with
Proposed Legislative Amendment

APPENDIX D
Cost Comparisons
from Florida and Mississippi RNFAs

APPENDIX C
RNFAs in Maine
Current Insurance Coverage
St. Joseph Hospital’s RNFA Policy
Maine Cumulative Data on Mandates

APPENDIX B
History of the Nurse’s Role as Assistant During Surgery
1854 – 1856 Crimean War The role of nurse as first assistant was initially conceived during Nightingale’s tenure.
1861 – 1865 Civil War Lucy Wilhelmina Otey organized a corps of women to serve as nurses and established the Ladies Relief Hospital. By the end of the war, her hospital had the lowest death rate of any military hospitals in Lynchburg.
World War II Nurses functioned as first assistants in both civilian and military facilities. The combination of personnel shortages and high casualty rates gave impetus to the continued need for the RN to act as first assistant.
1945 following World War II Major increases in hospital construction, increases in elective surgery procedures and a continued nursing shortage. The solution was to free nurses to nurse and to use others to first assist.
1948 E.L. Brown Report Suggested no institution should pay for nursing services that could be performed as effectively by a person with shorter preparation than the RN. The report called for increasing use of practical nurses, technicians and paid aides. These workers quickly began replacing RNs at the operating table.
1965 Use of operating room technicians had become accepted practice and there was a return of large numbers of independent corpsmen trained as assistants.
1970 The PA was functioning as first assistant during surgery. With these assistants, the roles of the professional nurse in the operating room were seriously threatened.
1980 Pennsylvania State Board of Nurse Examiners ruled that RNs could not function as first assistants and if they did would be liable for malpractice.
1980 The ACS and AORN had defined the duties of the first assistant and developed guidelines for the RN. States differed in their determination of whether the RN could function as a first assistant.
1984 Pennsylvania State Board of Nurse Examiners previous ruling was withdrawn.
1985 Efforts and events to confirm the importance of the role of the RN first assistant.
1992 Surveys of boards of nursing indicated that no states ruled that assisting at surgery by the RN was outside the scope of nursing practice. The RN First Assistant Specialty Assembly as formed with a mission of providing a coalition dedicated to the advancement of the RNFA.

APPENDIX F: Maine Carrier’s Survey Response

 

 

APPENDIX E: List of Registered Nurse First Assistants in Maine
Developed by the RN First Assistant Specialty Assembly

Blodgett, Shirley - Portland
O’Donnell, Beth - Portland
Tharpe, Nell – Boothbay Harbor
Tarr, Nancy - Augusta
Gervais, Tanna - Waterville
Thomas, Jane - Belfast
Burgess-Zamzow, Carol -Bangor
Dingle, Sara - Bangor
Farley, Kim - Bangor
Schwartz, Rebecca - Bangor
Madsen, Sally - Calais
Doody-Chabre, Kris - Caribou
Walton, Scott – Caribou
Carpenter, Alice – Ft. Kent

Appendix I: Maine Cumulative Data on Mandate Experience and Estimates

Following are the estimated claim costs for the existing mandates without the reductions:

• Mental Health - The mandate applies only to groups of more than 20. The amount of claims paid has been tracked since 1984 and has historically been in the range of 3% to 4% of total group health claims. Mental health parity for listed conditions was effective 7/1/96. The 1997 data showed a small increase to 4.16% of total group health claims. This figure represents our best estimate for future years.

• Substance Abuse - The mandate applies only to groups of more than 20 and does not apply to HMOs. The amount of claims paid has been tracked since 1984. Until 1991, it was in the range of 1% to 2% of total group health claims. This percentage has shown a downward trend beginning in 1989 and continuing through the most recent data which was 0.5% for 1997. This is probably due to utilization review, which has sharply reduced the incidence of inpatient care. Inpatient claims have decreased from about 90% of the total to about 70%. We estimate the percentage to remain at the 0.5% level, although further decreases are possible.

• Chiropractic - The amount of claims paid have been tracked since 1986 and has been approximately 1% of total health claims each year. We therefore estimate 1% going forward.

• Screening Mammography - The amount of claims paid has been tracked since 1992 and have generally been in the range of 0.2% to 0.3%. We estimate 0.3% going forward.

• Dentists - This mandate requires coverage to the extent that the same services would be covered if performed by a physician. It does not apply to HMOs. A 1992 study done by Milliman and Robertson for the Mandated Benefits Advisory Commission estimated that these claims represent 0.5% of total health claims and that the actual impact on premiums is "slight." It is unlikely that this coverage would be excluded in the absence of a mandate. We include 0.1% as an estimate.

• Breast Reconstruction - At the time this mandate was being considered in 1995, Blue Cross estimated the cost at $0.20 per month per individual. We have no more recent estimate. We include 0.02% in our estimate of the maximum cumulative impact of mandates.

• Errors of Metabolism - At the time this mandate was being considered in 1995, Blue Cross estimated the cost at $0.10 per month per individual. We have no more recent estimate. We include 0.01% in our estimate.

• Diabetic supplies - Our report on this mandate indicated that most of the 15 carriers surveyed said there would be no cost or an insignificant cost because they already provide coverage. One carrier said it would cost $.08 per month for an individual. Another said .5% of premium ($.50/Member/Month) and a third said 2%. We include 0.2% in our estimate.

• Minimum maternity stay - Our report stated that Blue Cross did not believe there would be any cost for them. No other carriers stated that they required shorter stays than required by the bill. We therefore estimate no impact.

• Pap tests - No cost estimate is available. HMOs would typically cover these anyway. For indemnity plans, the relatively small cost of this test would not in itself satisfy the deductible, so there would be no cost unless other services were also received. We estimate a negligible impact of 0.01%.

• Annual GYN exam without referral (managed care plans) - This only affects HMO plans and similar plans. No cost estimate is available. To the extent the PCP would, in absence of this law, have performed the exam personally rather than referring to an OB/GYN, the cost may be somewhat higher. We include 0.1%.

• Breast cancer length of stay - The report estimated a cost of 0.07% of premium.

• Off-label use prescription drugs - The HMOs claimed to already cover off-label drugs, in which case there would be no additional cost. However, providers testified that claims have been denied on this basis. The report does not resolve this conflict but states a "high-end cost estimate" of about $1 per member per month (0.6% of premium) if it is assumed there is currently no coverage for off-label drugs. We include half this amount, or 0.3%.

• Prostate Cancer - No increase in premiums should be expected for the HMOs that provide the screening benefits currently as part of their routine physical exam benefits. The report estimated additional claims cost for indemnity plans would approximate $0.10 per member per month. With the inclusion of administrative expenses, we would expect a total cost of approximately $0.11 per member per month, or about 0.07% of total premiums.

These costs are summarized on the following table.

COST OF EXISTING MANDATED HEALTH INSURANCE BENEFITS

 

APPENDIX J: REFERENCES
"A summary of AORN’s efforts toward achieving recognition and reimbursement for RN first assistants," AORN Journal, February 1995, Vol 61, No. 2, pg 431-438.
"AORN Recommended Education Standards for RN First Assistant Programs," Association of Operating Room Nurses, Inc, 1999 Standards, Recommended Practices, and Guidelines.
"Future Solutions Now: Creating a Hospital-Based RN First Assistant Program," Surgical Services Management, October 1998, Vol 4, No. 4, pg 34-40.
Groah, Linda K. (1983), Operating Room Nursing: The Perioperative Role, Reston Publishing.
"Influence of the First Assistant on Abdominal Aortic Aneurysm Surgery," Texas Heart Institute Journal, Volume 19, Number 1, 1992.
Keane, Claire B. (1986). Essentials of Medical-Surgical Nursing, 2nd ed., W.B. Sauders Company.
"Managers seek creative solutions to assisting," OR Manager March 1999.
"RN first assistants deserve third-party reimbursement, whether it be direct or indirect," AORN Journal, March 1987, Vol 45, No. 3, pg 662-664.
"Statements on Principles," The American College of Surgeons, Chicago, IL, 1996-98.
"RN First Assistants Expand Their Perioperative Role," AORN Journal, March 1998, Vol 67, No. 3, pg 560-565.
"RN First Assisting – 1997 Canadian Update," Canadian Operating Room Nursing Journal, May/June 1997.
Rothrock, Jane C. (1999). RN First Assistant: The Perioperative Role of the Future, 3rd ed. Philadelphia: J.B. Lippincott Company.
Rothrock, Jane C. and Meeker, Margaret H.(1999). Alexanders’s care of the patient in surgery, 11th ed. Mosby.
"The Evolving Role of Advanced Practice Nurses in Surgery," AORN Journal, May 1998, Vol 67, NO. 5.
"The Impact of Mandated Health Benefits," Texas Department of Insurance Report to the Texas Legislature, Dec. 1998.
"The R.N. First Assistant in Cardiac Surgery: Reflections and Prespectives of the Role," Capsules & Comments in Perioperative Nursing, Volume 2, Issue 1, 1996.
"Where Is The ‘Nursing’ In The RNFA/PNS Role?," Canadian Operating Room Nursing Journal, May/June 1997.
"Who’s First Assisting: ORs turn to non-MDs but reimbursement lags," OR Manager, September 1997.

Websites
Association of Operating Room Nurses: http://www.aorn.org
American Academy of Nurse Practitioners: http://www.aanp.org
American College of Nurse Practitioners: http://www.nurse.org/acnp
American College of Surgeons: http://www.facs.org
American Nurses Association: http://www.nursingworld.org
National Council of State Boards of Nursing: http://www.ncsbn.org
Agency for Health Care Policy Research: http://www.ahcpr.gov
Nursing Informatics: http://www.cini.com/cin
National Institute of Nursing Research: http://www.nih.gov/ninr
RN First Assistants: http://www.rnfa-firsthand.com
Internet Grateful Med V2.6.2: http://igm.nlm.nih.gov

 

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