Anesthesia Services: Differences between Private and Medicare Payments Likely Due to Providers’ Strong Negotiating Position

What GAO Found

Literature GAO reviewed indicated that private insurance payments for anesthesia services on average were more than 3-1/2 times those of Medicare payments. This payment difference increased from what GAO reported in 2007—average private insurance payments for certain anesthesia services in 2004 were about 3 times those of Medicare. While Medicare rates for anesthesia services are set by the Centers for Medicare & Medicaid Services (CMS), private insurance rates are set through negotiations between providers and private insurers.

GAO identified three recent studies with analyses of private insurance and Medicare payments for anesthesia services:

Researchers from Yale University calculated that private insurance payments were 3.67 times Medicare payments, on average, for services provided by anesthesiologists for one large private insurer in 2015 operating across all 50 states and the District of Columbia.

The Health Care Cost Institute calculated that in 2017 private insurance payments ranged from 2 to 7 times Medicare payments, on average, across six common services provided by anesthesiologists in 33 states. Wide state-to-state variation within specific services was reported.

The American Society of Anesthesiologists reported that private insurance payments were 3.46 times Medicare payments, on average, based on a survey of its members in 2019.

According to studies GAO reviewed and stakeholders GAO interviewed, market factors likely enhanced anesthesia providers’ negotiating position and allowed them to secure higher private payments. For example, several studies and stakeholders cited market concentration as a key factor that increased private payments for anesthesia services. In a market with high provider concentration—or relatively few providers in a given market—there is little competition between providers, enabling the providers within that market to negotiate for higher payments from private insurers. Studies also indicated that specialists, including anesthesia providers, could negotiate higher in-network payment rates because they were able to leave an insurer’s network with little risk of losing patients or revenue. In addition, when anesthesia providers are not a part of a private insurer’s network, they are typically able to bill for a higher amount than the insurer would pay for an in-network provider, known as out-of-network billing. This dynamic decreases providers’ incentives to participate in insurer networks because it creates an attractive alternative to network participation.

GAO’s interviews with stakeholders, literature review, and review of agency data generally did not indicate that the supply of anesthesia providers was insufficient for Medicare beneficiaries. CMS data indicate that the number of active anesthesia providers per 100,000 Medicare beneficiaries increased from 2010 through 2018 and that a very small number of anesthesia providers opted out of the Medicare program. Furthermore, researchers and stakeholders GAO interviewed were not aware of any issues with access to anesthesia services for Medicare beneficiaries, including those in traditionally underserved rural areas.

Why GAO Did This Study

In 2018, Medicare paid over $2 billion for anesthesia services, such as general anesthesia administered to beneficiaries undergoing surgical or other invasive procedures. The joint explanatory statement for the Further Consolidated Appropriations Act, 2020 included a provision for GAO to update its 2007 report and examine how differences in payment rates for anesthesia services have changed since that time. In 2007, GAO reported that Medicare payments in 2004 for certain anesthesia services provided by anesthesiologists were on average 67 percent lower than private insurance payments in certain geographic areas—indicating that private payments were about 3 times more than Medicare payments at that time.

This report describes what is known about (1) recent trends in differences between Medicare and private payments for anesthesia services, and (2) the sufficiency of the supply of anesthesia providers for Medicare beneficiaries. GAO reviewed literature and available published data on payment differences for anesthesia services, published in the United States since 2010. GAO also reviewed data from CMS on the number of anesthesia providers from 2010, 2018, and 2020. GAO also interviewed a nongeneralizable selection of three research groups, two beneficiary advocacy groups, and five stakeholder groups, including those representing anesthesiologists, nurse anesthetists, and hospitals, to obtain their perspectives on these issues. The Department of Health and Human Services provided no comments on this report.

For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.

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    Move Over laws vary by state but generally require motorists to move over a lane or slow down, or both, when approaching emergency response vehicles with flashing lights stopped on the roadside. U.S. Department of Transportation's (DOT) National Highway Traffic Safety Administration (NHTSA) data provide limited information on whether crashes involved violations of these state laws, but the agency is taking steps to collect additional data. For instance, NHTSA's 2018 data show 112 fatalities from crashes involving emergency vehicles, representing 0.3 percent of all traffic fatalities that year, but these data cannot be used to definitively identify which crashes involved a violation of Move Over laws. NHTSA is proposing updates to the data that it encourages states to include on crash report forms to better identify crashes involving violations of Move Over laws, and plans to convene an expert panel and initiate a pilot project to study further data improvements. Selected state officials reported that they have taken actions to improve public education and enforcement of Move Over laws but still face challenges in both areas. Such actions include education through various forms of media and regional coordination among states to conduct targeted enforcement of Move Over laws within their respective borders during the same time period. State officials cited raising public awareness as the most prevalent challenge, as motorists may not know the law exists or its specific requirements. Variation in the requirements of some Move Over laws—such as for which emergency vehicles motorists are required to move over—may contribute to challenges in educating the public about these laws, according to state officials. DOT has taken actions and is planning others to help improve emergency responder roadside safety. NHTSA helps states promote public awareness of Move Over laws by developing and disseminating marketing materials states can use to develop their own traffic safety campaigns. NHTSA also administers funding that states can use for public awareness activities or enforcement initiatives related to emergency responder safety. FHWA has coordinated with a network of stakeholders across the country to train emergency responders on traffic incident management best practices. Finally, in response to congressional direction, NHTSA officials are planning several research efforts intended to enhance emergency responder safety, including studies on motorist behaviors that contribute to roadside incidents and technologies that protect law enforcement officials, first responders, roadside crews and other responders. General Requirements of Move Over Laws for Motorists on a Multiple Lane Roadway     Police, fire, medical, towing, and other responders risk being killed or injured by passing vehicles when responding to a roadside emergency. To protect these vulnerable workers and improve highway safety, all states and the District of Columbia have enacted Move Over laws. GAO was asked to review issues related to Move Over laws and emergency responder roadside safety. This report: (1) examines data NHTSA collects on crashes involving violations of Move Over laws, (2) describes selected states' actions and challenges related to Move Over laws, and (3) describes DOT efforts to improve emergency responder roadside safety. GAO analyzed NHTSA's 2018 crash data, which were the latest data available; reviewed federal and state laws and regulations, and DOT initiatives to improve emergency responder roadside safety; reviewed state reports to DOT; and interviewed NHTSA and FHWA officials, traffic safely and law enforcement officials in seven selected states, and stakeholders from traffic safety organizations and occupational groups, such as the Emergency Responder Safety Institute and the International Association of Chiefs of Police. GAO selected states based on a variety of factors, including traffic fatality rates per vehicle mile traveled and recommendations from stakeholders. DOT provided technical comments, which we incorporated as appropriate. For more information, contact Elizabeth Repko at (202) 512-2834 or RepkoE@gao.gov.
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  • Secretary Pompeo’s Meeting with Islamic Republic of Afghanistan’s Negotiating Team
    In Crime Control and Security News
    Office of the [Read More…]
  • Houston gang member charged for trafficking young teen for sex
    In Justice News
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  • Secretary Michael R. Pompeo with Israeli Prime Minister Benjamin Netanyahu and Bahraini Foreign Minister Abdullatif bin Rashid Al Zayani Before Their Meeting
    In Crime Control and Security News
    Michael R. Pompeo, [Read More…]
  • Submission to Congress of the Executive Summary of the Report on Adherence to and Compliance with Arms Control, Nonproliferation, and Disarmament Agreements and Commitments (Compliance Report)
    In Crime Control and Security News
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  • Assistant Attorney General Beth A. Williams Delivers Opening Remarks at the Federalist Society, Colorado Lawyers Chapter Panel Discussion: “Reviewing the Supreme Court’s 2019/20 Term”
    In Crime News
    Thank you for that kind introduction, Will, and for the invitation to join you today. Though I wish I could join you in person, even at this distance, it is a great pleasure to be here with you all.
    [Read More…]
  • Department of Justice Awards over $1 Million in Forensic Grants to Aid Wyoming Investigators
    In Crime News
    Attorney General William [Read More…]
  • Keynote Address of Deputy Attorney General Jeffrey A. Rosen on Combatting Fraud in the Age of COVID-19 at the BBB National Programs NAD 2020 Conference
    In Crime News
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  • Aruba Travel Advisory
    In Travel
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  • Justice Department Files Race Discrimination Lawsuit Against Housing Authority in Oklahoma
    In Crime News
    The Justice Department announced today that it has filed a lawsuit alleging that the Housing Authority of the Town of Lone Wolf, Oklahoma, along with its former employees, David Haynes and Myrna Hess, violated the Fair Housing Act and Title VI of the Civil Rights Act of 1964 when they denied housing to an African-American applicant and her young child because of their race. 
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  • Michigan Man Pleads Guilty to Using Threats to Obstruct Free Exercise of Religious Beliefs
    In Crime News
    The Justice Department today announced that Ronald Wyatt, 22, pleaded guilty today in U.S. District Court for the Eastern District of Michigan to intentionally threatening physical harm to a female victim, T.P., to obstruct T.P.’s free exercise of religion. As part of his plea agreement, Wyatt admitted that he targeted T.P., who is African-American, because of her race. 
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  • Secretary Pompeo’s Call with Singaporean Foreign Minister Balakrishnan
    In Crime Control and Security News
    Office of the [Read More…]
  • Judiciary Addresses Cybersecurity Breach: Extra Safeguards to Protect Sensitive Court Records
    In U.S Courts
    After the recent disclosure of widespread cybersecurity breaches of both private sector and government computer systems, federal courts are immediately adding new security procedures to protect highly sensitive confidential documents filed with the courts.
    [Read More…]
  • Elliott Broidy Pleads Guilty for Back-Channel Lobbying Campaign to Drop 1MDB Investigation and Remove a Chinese Foreign National
    In Crime News
    Elliott Broidy, 63, of Beverly Hills, California, pleaded guilty today before U.S. District Judge Colleen Kollar-Kotelly to one count of conspiracy to violate the Foreign Agents Registration Act.
    [Read More…]
  • Federal Court Permanently Bars Southern Florida Tax Preparer from Preparing Returns
    In Crime News
    A federal court in the Southern District of Florida has permanently enjoined a West Palm Beach tax return preparer and her business from preparing federal income tax returns for others, the Justice Department announced today. According to the court’s order, it issued the injunction in response to violations of a prior order in the case that had allowed the preparer and her business to prepare returns subject to certain restrictions. In April 2017, the United States filed a complaint against Lena D. Cotton and Professional Accounting LDC, LLC, that alleged the defendants prepared returns with improper education credits, manipulated filing statuses, and improper vehicle deductions, among other issues. In November 2017, the court permanently enjoined both defendants from this and other specific conduct and required defendants to engage a “neutral monitor” to “determin[e] and/or secur[e] compliance” with injunction.
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  • Hungary Travel Advisory
    In Travel
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  • Political Scientist Author Charged With Acting As An Unregistered Agent Of The Iranian Government
    In Crime News
    A criminal complaint was unsealed today in federal court in Brooklyn charging Kaveh Lotfolah Afrasiabi, also known as “Lotfolah Kaveh Afrasiabi,” with acting and conspiring to act as an unregistered agent of the Government of the Islamic Republic of Iran, in violation of the Foreign Agents Registration Act (FARA). Afrasiabi was arrested yesterday at his home in Watertown, Massachusetts, and will make his initial appearance this morning in federal court in Boston, Massachusetts, before United States Magistrate Judge Jennifer C. Boal.
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  • Congratulations to Bolivia’s President-Elect Luis Arce
    In Crime Control and Security News
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  • Secretary Blinken’s Calls with Israeli Foreign Minister Ashkenazi
    In Crime Control and Security News
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  • Tax Preparer Charged with COVID-19 Loan Fraud
    In Crime News
    A South Florida tax preparer was charged Tuesday by criminal information with wire fraud in connection with a scheme to obtain over 100 COVID-19-relief loans under the Paycheck Protection Program (PPP).
    [Read More…]
  • Condemning ISIS-K Attack on a Kabul Gathering
    In Crime News
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  • Doctor Sentenced for Role in Unlawful Distribution of Opioids
    In Crime News
    An Ohio physician was sentenced to two years in prison today for his role in illegally distributing opioids.
    [Read More…]
  • Justice Department Files Statement of Interest in Michigan Religious Schools’ Challenge to COVID-19 Closing Order
    In Crime News
    The Justice Department today filed a statement of interest in federal district court in Kalamazoo, Michigan, arguing that the Free Exercise Clause of the Constitution requires the state of Michigan to justify why it cannot provide exemptions to its school closing order for in-person instruction at religious high schools when it provides exemptions for trade and technical instruction in person, college sports teams, and other educational activities.
    [Read More…]
  • Secretary Blinken’s Call with Guatemalan Foreign Minister Brolo
    In Crime Control and Security News
    Office of the [Read More…]
  • Former Tennessee Correctional Officer Sentenced Following Staff Assault of Inmate
    In Crime News
    A former Tennessee correctional officer was sentenced Friday to two years in prison and two years of supervised release for his involvement in a staff assault of an inmate.
    [Read More…]
  • North Carolina Risk Consultant Sentenced to Prison for Tax Fraud and Illegally Possessing a Firearm
    In Crime News
    A North Carolina businessman was sentenced today to three years in prison for tax fraud and illegal possession of a firearm.
    [Read More…]
  • Secretary Blinken’s Call with Kenyan Cabinet Secretary for Foreign Affairs Omamo
    In Crime Control and Security News
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  • Mexican man sentenced for having meth welded to tires
    In Justice News
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  • Man Sentenced for Role in Investment-Fraud Scheme
    In Crime News
    A Virginia man was sentenced today to over eight years in prison for his role in an investment-fraud scheme in which he and his co-conspirators stole at least $5.7 million from victim investors.
    [Read More…]