The more than 36 leaders featured in this article spoke at Becker’s 30th Annual Meeting: The Business and Operations of ASCs, Oct. 30 to Nov. 2, 2024, at the Hyatt Regency in Chicago.
If you would like to join the event as a speaker, please contact Patsy Newitt at pnewitt@beckershealthcare.com
As part of an ongoing series, Becker’s is connecting with healthcare leaders who will speak at the event to get their insight on thought-provoking questions within the industry.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is the biggest challenge ASCs face regarding anesthesia today, and if you could change one thing to address it, what would it be?
Alex Andrade. COO at Medical Associates (Dubuque, Iowa): Last year, we successfully insourced anesthesia into our independent medical group. Initially, this move was a defensive strategy to ensure we had greater control over our operations and resources. However, we are now shifting our focus and aiming to be more strategic in our approach. Our goal is to leverage our anesthesia team to drive operating efficiencies and increase throughput as part of one end-to-end process.
Brent Ashby. CEO and Administrator at Jankat Services (Pueblo, Colo.): I think one of the biggest challenges regarding anesthesia is determining how to cover that service. In many areas there are shortages of anesthesia providers, anesthesiologists and certified registered nurse anesthetists. Some surgery centers have gone the route of hiring their own anesthesia providers to work exclusively for their center. As smaller anesthesia groups across the country consolidate into large anesthesia groups such as U.S. Anesthesia Partners, many centers are struggling to find the appropriate level of coverage for their needs, particularly with these larger groups attempting to cover so many locations. Another challenge that ties to the availability of providers is having anesthesia providers who are efficient and understand the unique dynamics of the surgery center environment. When the large groups cover hospitals a surgery center may see an anesthesia provider who is not very conscious of anesthesia costs and the need to watch those closely in the surgery center setting.
Alejandro Badia, MD. Founder and Chief Medical Officer at Badia Hand to Shoulder Center (Miami): The biggest challenge currently facing anesthesia groups is cost of staffing. The current salaries being commanded by anesthesia [staff] is not commensurate with the continued decline of reimbursement for these vital services. Despite an experienced, board-certified anesthesiologist covering a three-room ASC with two well-trained CRNAs, the insurance payments with many payers simply do not cover costs for that anesthesia group. The irony is that the overall surgical care costs are much lower (40% to 60%) in an ASC environment as compared to hospital based surgery, yet the insurance ecosystem has not rewarded this which can then lead to further escalation in our overall healthcare costs — now near 20% of U.S. GDP. This is further testament to the need for real dialogue and finding solutions to our worsening U.S. healthcare debacle.
Ron Bullen. Executive Director, ProHealth Care Moreland Surgery Center (Waukesha, Wis.): Consider providing an equity opportunity for your anesthesia group. Nothing aligns strategic commitments better than a share of ownership. Your anesthesia group is critical to operational efficiency success, growth and cost containment. Nothing produces better results than skin in the game.
Jennilee Caffey. Regional Administrator of Baylor Scott & White Sports Surgery Center at The Star (Frisco, Texas): The biggest challenges facing us today is anesthesia shortages, and anesthesia groups contracting with local hospitals to guarantee coverage. Further incentivizing coverage in the hospital versus the ASC. Increased usage of anesthesia assistants and certified nurse anesthetists.
Janet Carlson. Vice President of ASC Operations at Commonwealth Pain & Spine (Louisville, Ky.): The one consistent thing for ASCs is that we are all dealing with the same challenges to find Anesthesia support for safe patient care. The anesthesiologists and CRNAs do not need to be confronted with the recent risk of diminished reimbursement because of unscrupulous payer interference — this looks and feels a lot like the “corporate practice of medicine”. If I could change one thing, it would be the ability to pay anesthesia a fair wage in my ASCs for their services. They are an integral part of our successes and outstanding patient outcomes. I cannot compete with the stipends that large health systems pay for anesthesia support. This is a direct result of the unfair reduced compensation for ASC services as compared to hospitals and hospital outpatient departments.
Rena Courtay, BSN, RN. Vice President of Ambulatory Surgery at Trinity Health (Livonia, Mich.): The biggest challenge facing ASCs regarding anesthesia is rising subsidies. One thing to change is standard care delivery models with one free MD.
Tina Driggers. Administrator of DSC Day Surgery Center (Winter Haven, Fla.): The biggest challenge we face with anesthesia is the nationwide shortage of anesthesia staff. This leads to room closure and cancelling of cases which in turns ends up with economic stresses to the surgery center.
Another issue is the hourly salary being paid by hospitals. This does not help our recruitment or maintain our economic viability since we now have to subsidize the department to be able to keep the rooms open.
In order to address the above long term, we will need to increase our MD/CRNA/AA graduates and training facilities. In the meantime we will need to address remuneration with commercial insurance carriers about the volume of care, higher acuity of the patients, patient outcomes and satisfaction.
The need for increasing compensation to the anesthesia departments to compete with the hospital subsidies is a necessity. It is unfortunate that our commercial insurance carriers have to bail out Medicare rates, but the system is broken. These cases are performed at a massive savings to the insurance companies and part of these savings should be passed down to the Anesthesia departments who are working at surgery centers and doing the majority of the surgical volume to keep the system alive.
Angela Durham. Vice President of Ancillary Services at US Heart and Vascular (Franklin, Tenn.): The root cause: supply and demand. The single, greatest challenge ASCs face today with anesthesia coverage is supply and demand. The diminishing supply of anesthesia providers that began in 2000 is compounded by the increased demand for providers in ASCs and the unsustainable, painfully low payer rates offered to ASCs. This trifecta of clashing variables elevates the supply and demand factor to “root cause” status. Layer into the equation the following three related drivers and quickly identify an even graver outlook for the ASCs’ ability to offer deep sedation by an airway trained professional.
The drivers: Hospitals, ASC Growth and commercial payers
Hospitals: Hospitals have the luxury of raising compensation to maintain coverage. Commercial payers award hospitals with rates 2 to 3 times that of an ASC due to place of service designation and higher acuity patients. This rate disparity between the hospital, HOPD and ASC settings enables hospitals to monopolize the anesthesia space by offering the highest possible compensation to anesthesia providers. Hospital compensation directly impacts the independent ASC, as anesthesia providers cannot achieve the same level of compensation in an ASC. Furthermore, hospitals are now getting savvy to the non-financial incentive an ASC offers the anesthesia provider. As the hospital began experiencing the competitive pressure of the ASC attracting anesthesia providers due to lower acuity patients and better working hours, they responded in kind, offering equally appealing schedules that allow providers to achieve their desired work/life balance plus high rates of compensation. The long-standing ASC value proposition to an anesthesia provider (work/life balance and a non-bureaucratic, family environment) is diminished as hospitals respond to supply and demand factors by leveraging their high payer rates to outprice anesthesia providers to levels ASCs cannot sustain.
Independent ASC growth: As partnerships with payers around value-based care become top of mind, independent physician practices are executing on lower cost solutions to the patient and system. An ASC offers the most significant cost-reduction opportunity to all stakeholders while also increasing timely access to surgical care and improved quality, safety and clinical outcomes. This well-known fact is driving private equity and independent medical practices alike to double down on the ASC space. However, anesthesia services present an unanticipated headwind for ASC owners. This increased ASC supply presents an automatic new level of demand for an already limited number of anesthesia providers. Hospital-driven anesthesia cost inflation inhibits ASCs from achieving the goal of low-cost alternatives to hospital-based surgical care, leaving ASCs no choice but to sedate with less desirable drugs or sacrifice margin to afford compensation demands.
Commercial payers: To add insult to injury, commercial payers are not valuing anesthesia care with reasonable rates of reimbursement and are slow to respond to private ASC requests to secure payer contracts. Ultimately, the patient’s experience suffers due to not being able to provide deep sedation with drugs such as propofol. Patients are forced to suffer [postoperative nausea and vomiting] and longer post-op recovery times due to sedation with drugs generating longer half-life and slower onset. These less-desirable drugs contribute to sluggishness, nausea and increased risk for falls.
An actionable solution to this growing problem is for an ASC to assume full control of its fate by owning and operating its own anesthesia business. Direct ownership of this critical ancillary service in an ASC allows cost containment, coverage stability and the highest possible [net promoter score] from patients. This model allows anesthesia providers to join the ASC family as a permanent member of the care team, which in turn boosts anesthesia providers, staff and physician NPS as well. This solution allows an ASC to absorb only the direct costs related to anesthesia coverage and avoid the mark-up generated by the third-party, external staffing agency. Agencies pay their providers high premiums and operate without scale, resulting in high, unsustainable, administrative, overhead and billing fees being passed through to the ASC by way of unaffordable subsidy charges. ASC owners should position themselves to sustain operations independently without the threat of unpredictable added cost resulting from the use of a third-party group.
Bruce Feldman, MS. Administrator at Eastern Orange Ambulatory Surgery Center (Cornwall, N.Y.): I believe the biggest challenge ASCs face regarding anesthesia today is the provision of anesthesia services due to the shortage of anesthesiologists resulting from a significant decline in reimbursement from third party payors to anesthesiologists. In addition, many ASCs are being asked to provide stipends or guaranteed minimum compensation to their existing contracted anesthesia groups, which has created a fiscal burden and driven down their profit margins. The one thing I would change is to have third-party payors significantly increase their reimbursement for anesthesia.
James Flaherty, MD. Professor of Cardiology at Northwestern Medicine (Chicago): Shortage of providers. Where possible, I would utilize CRNAs in ASCs as much as possible. They are typically well-trained and clinically astute.
Michael Gale. Administrative Director at Sentara Health’s Obici Ambulatory Surgery Center (Suffolk, Va.): Anesthesia coverage is a difficult proposition for most ASCs. I have an exclusive contract with an anesthesia provider. They provide a rotating anesthesiologist who functions as the medical director on any given day of operations. They have personnel shortages of CRNAs from time to time but generally manage it well. The contract is expensive. There are a limited number of competing Anesthesia groups in our state. As an alternative, there are companies that act as registries for CRNAs and anesthesiologists. But that would require us to manage that staff, to bill for anesthesia and to hire our own medical director. The cost would be prohibitive. And even if that made financial sense, the chances of retaining CRNAs or to recruit a medical director are remote. There are no easy solutions. Reimbursement continues to be very low for anesthesia services. And as long as that is true, ASCs and acute care facilities will continue to be asked to subsidize the ever-increasing labor expense of CRNAs and anesthesiologists employed by anesthesia groups.
Nathan Garner. Director of Area Operations at Sutter Surgery Center Division (Sacramento, Calif.): The nationwide anesthesia shortage has been greatly challenging for many ASCs. Anesthesia groups are losing providers to retirement or market pressures and are unable to provide the same level of coverage as they did in the past without charging costly stipends to the ASCs for their services. ASCs have had to scramble to find alternative options for anesthesia, often resorting to paying minimum guarantees and penalties to anesthesia groups or even using costly locum tenens to ensure they have the coverage they need. The uncertainties of coverage and new costs associated with anesthesia have been difficult for ASCs to bear and have sometimes strained relationships between ASCs, anesthesia groups and surgeons.
There is no easy solution for the current anesthesia crisis. Professional fees need to improve for anesthesia providers across the board, so they are less reliant on stipends to supplement their pay. We need more anesthesia [graduate medical education] programs, possibly larger class sizes and more CRNA training programs. Lastly, there needs to be less animosity and more collaboration between the physician and CRNA anesthesia associations so we can work together on addressing our nation’s anesthesia challenges.
Jon George, MD. Catheterization Lab Director at ReVascMedProfessionals (Philadelphia): Anesthesia regulations and requirements vary geographically from state to state. While the availability of anesthesia providers vary regionally, some of the state-specific challenges that we face in Pennsylvania are related to moderate sedation or conscious sedation cases. Since the majority of the cardiac and endovascular cases are performed with moderate — conscious —sedation, they are typically performed by the administration of anxiolytics, like Versed, and narcotics — like fentanyl. These are typically administered by the nurse in the procedure room under the supervision and order from the operating physician in the hospital setting. However, in the ASC setting in Pennsylvania, there is an archaic rule in existence that requires the operating physician to administer the sedative drugs. This requires the physician to step away from the procedure being performed to administer the sedation only then to return to the procedure at hand, which does not make clinical sense and begs to be updated to modern hospital-based protocols. The alternative would be to have a second physician in the room administering the drugs which would increase the cost of the procedure and nullify the advantages of ASCs reducing the cost of care.
Sean Gipson. Division CEO and President of Remedy Surgery Center (Hurst, Texas): I believe that one of the more significant challenges that we face with anesthesia in an ASCs setting is ensuring patient safety and managing the variability of anesthesia requirements for all the different patients that we encounter on a day-to-day basis. Unlike hospitals, [ASCs] typically deal with a higher volume of patients and more varied surgical cases, including outpatient procedures that may require different anesthesia techniques. This variability in patient medical history, the complexity of procedures, and the need for efficient, safe anesthesia management can create pressure for anesthesia providers.
Secondarily, we also must make sure we are ensuring adequate anesthesia staffing. There is often a shortage of anesthesiologists and nurse anesthetists, especially in areas with high demand for outpatient surgeries. Recruiting and retaining skilled anesthesia providers can be difficult for ASCs these days.
Another area to keep an eye on is with regulatory compliance. Anesthesia in ASCs is subject to strict regulations. ASCs need to stay compliant with both local and national standards, such as those from the CMS, while still offering cost-effective care.
Lastly, patient experience. Anesthesia, especially sedation or general anesthesia, can lead to post-procedure side effects like nausea or confusion. Managing patient expectations and minimizing these side effects in an outpatient setting is crucial and most certainly lends to patient outcome ratings.
If I could change one thing to address this, it would be improving the integration of advanced anesthesia monitoring technologies and predictive analytics. This would enable anesthesia providers to more accurately predict and tailor anesthesia regimens based on individual patient risk factors and the surgical procedure at hand. These technologies could provide real-time data to adjust doses, minimize adverse effects and ensure a smoother recovery for patients. By utilizing AI-driven predictive tools and enhanced monitoring, ASCs could optimize both safety and efficiency, helping to overcome staffing challenges and improving overall patient care.
Seth Gross, MD. Clinical Chief of Gastroenterology and Hepatology at NYU Langone Health (New York City): There are two key challenges ASCs face in regard to anesthesia. There is a shortage of both CRNAs and anesthesiologists, which can limit patient access. Secondly, reimbursement for the service to align with rising operational costs.
Krishna Jain, MD. CMO at APEx Health Network (Chicago): As everyone knows, there is a shortage of anesthesiologists and CRNA. In the long term there need to be more residency slots to train anesthesiologists. In the short-term ASC needs to employ anesthesiologist/CRNA and look at it as an expense while creating a pro forma. This is the only way to guarantee coverage. There are anesthesiologists unhappy with the hospital systems or burnt out, because of working conditions, call autonomy and are willing to work in an ASC.
Les Jebson. Executive Director Orthopedics Sports Medicine at Prisma Health (Greenville, S.C.): Consistent, efficient, high-quality anesthesia coverage can literally make or break an ASC. We have had some historical challenges with anesthesia coverage in the past, largely in part to consistently growing patient demand.
However, we are blessed to have an exceptional team of anesthetists/anesthesiologists. As such, we wouldn’t want to change a thing.
Thomas Jeneby, MD. Plastic Surgeon (San Antonio): The biggest challenge is for Anesthesia at this point as a rising reimbursement caused by a shallow pool of available anesthesia outside of large/midsize groups. Anesthesia is looking at locum tenants and pay by the hour gigs and trying to translate that to long-term assignments which have more stability but pay less.
This is opposite when I went to residency in 1996 where they couldn’t bribe enough people to go into anesthesia. There was a shortage in the late ’90s and now because these groups are getting high paying locum jobs they are filling the value is the same as a long-term stability job
Neal Kaushal, MD. Chief of Gastroenterology and Chair of the Department of Medicine at Adventist Health (Roseville, Calif.): I think the biggest challenge ASCs face regarding anesthesia today is the potential for site neutrality legislation to cause major changes in cost structures and reimbursement patterns in ASCs in a hospital outpatient setting versus stand alone centers. I think it is important for physicians and managers to recognize potential changes to reimbursements in the near future and adapt their operations accordingly.
Omar Khokar, MD. Gastroenterologist of Illinois GastroHealth (Bloomington): Simple — rising wages and workforce shortages. Anesthesia helps us run more efficiently so it’s important to have a mutual conversation with them on staffing, CRNA scope of practice and intraprocedure responsibilities so that it’s a “win-win” for the center.
Neeraja Kikkeri. North Texas Team Care Surgery (Mesquite): The primary challenge faced by ASCs is the shortage of anesthesia coverage and the significant costs associated with staffing. As insurance reimbursements continue to decrease, ASCs are forced to subsidize anesthesia staffing in order to retain qualified professionals. This presents a major issue and unless insurance companies acknowledge the impact of this situation, it remains unclear how ASCs can effectively move forward.
Benjamin Levy, MD. Gastroenterologist and Clinical Associate of Medicine at University of Chicago Medicine: ASCs need to recruit more anesthesiologists and nurse anesthetists due to increased demand for colonoscopies. After the American Cancer Society and GI societies recently changed the screening guidelines to begin screening colonoscopies at age 45 instead of 50, approximately 19 million additional individuals entered the pool of patients needing procedures. Furthermore, the U.S. is experiencing a relative shortage of anesthesiologists and CRNAs due to preferences for propofol during GI endoscopy, increased surgical volume, in general at ASCs, the baby-boomer generation aging, and an aging workforce. It would be great if the federal government could increase funding for graduate medical education in order to expand the number of residency spots to train more anesthesiologists and physicians in general. In 1997, Medicare capped the number of residency positions it funds. In 2021 and 2023, Congress voted to expand Medicare support for graduate medical education and added a limited number of new residency slots. However, it has not been enough to keep pace with the number of anesthesiologists needed, especially when considering the increased needs in gastroenterology endoscopy. In gastroenterology, we are working hard to increase colorectal cancer screening rates nationally to remove polyps before they turn into cancer — so we need additional gastroenterologists and anesthesiologists to help this effort.
Justin Marburger. Director of Surgical Services at Plastic and Cosmetic Surgery Center of South Texas (San Antonio): The biggest challenge ASCs are facing today in regards to anesthesia is the shortage of qualified anesthesiologists and CRNAs. The general predilection identifies three issues — lengthy training, burnout and an aging workforce. The consequences of such can lead to cost and insurance reimbursement issues, patient safety and complications as well as legal challenges. Our facilities prefer to use an anesthesiologist but have found that to be difficult at times and have to rely on a CRNA to fill the void. Our biggest answer to this has been to stack our operating rooms. Physicians must follow each other on a first-come, first-serve basis in order to take full advantage of the anesthesiologist we do have. Colleagues have suggested a fast tracked option to produce more anesthesiologists. Although, I remain suspiciously reserved as this may further complicate patient safety issues.
As someone who likes to think out of the box, let us explore another idea originally hypothesized 20 years ago in the combat theaters of Iraq. Faced with the same anesthesia shortage, compounded by fierce fighting and mass-casualty situations, an idea was born to allow one anesthesiologist to monitor multiple operating rooms through electronic monitoring, dubbed “McSleepy.” Elementary conceptual understanding meant an algorithm could be programmed to think like an anesthesiologist, analyze biological information and constantly adapt its own behaviour, even monitoring and recognising medical impairment. McSleepy could then assist the anesthesiologist in the same way that automatic transmission assists people when driving. In 2011, advancements were made to further facilitate these theories with the introduction of another robotic system dubbed KIS, The Kepler intubation system, developed by Dr. Thomas Hemmerling. These two conceptualizations teamed with the da Vinci robot are pushing the extremes of teleanesthesia.
While still in its infancy phase, and marred by obstacles such as cost, advances into artificial intelligence and high-tech equipment will revolutionise the way surgery is done, allowing physicians to perform with higher precision and with almost no physical effort, theoretically eliminating the need for more staff at a higher patient safety rate.
Brett Maxfield, CRNA. Director of Madison Avenue Surgery Center (Idaho Falls, Idaho): The biggest challenge facing ASCs concerning anesthesia today is the overall shortage of anesthesia providers. This shortage has caused an increase in demand with a corresponding increase in reimbursement to the anesthesia providers and an increased cost to the ambulatory surgery center. The loss of revenue due to increased anesthesia expense is putting a significant strain on many centers. At this time, the only real solutions I see for this problem are creative scheduling to maximize use of each anesthesia provider, and allowing each anesthesia provider to practice to the full capacity of their licensure. Allowing each type of anesthesia provider, whether it is a physician anesthesiologist, nurse anesthesiologist or dental anesthesiologist to practice to the top of their licensure could potentially free up additional providers whose talents are being under utilized in a supervisory role.
Kathy Meccia, RN. Administrator of Lake George Surgery Center (Fremont, Ind.): Reimbursement from insurance companies continues to be very poor in the ASC settings. We are constantly trying to negotiate for better payor contracts and to collect a minimum of 30% billed charges. Anesthesia costs just keep rising; the anesthesia providers charge high salaries and the insurance companies pay even less for the anesthesia charges, which is then turned over to the ASC to cover. Anesthesia providers have a high responsibility and in my experience are highly skilled and valued providers. We are past the COVID-19 era and need to get back to actual reasonable salaries because if this trend continues it will be very difficult for many surgery centers to stay in operation.
ASCs need to bond together for fair anesthesia charges, negotiating the “no call, holidays or weekends” as a direct benefit working at an ASC, to lower the salaries and help with financial stability of the centers.
Adamina Podraza, MD. Medical Director at Deerpath Ambulatory Surgical Center (Morris, Ill.): The biggest challenge in anesthesia today is ensuring consistent coverage. Having a consistent team of surgeons, nurses, and anesthesia providers in the operating room enhances efficiency and improves patient outcomes in ASCs.
One change I would make is expanding the licensing of anesthesiologist assistants. Allowing AAs to practice in more states under anesthesiologist supervision would strengthen physician-led anesthesia care, enhancing patient safety and more reliable coverage for ASCs.
Myra Ray, RN. Manager of Surgical Services at Franciscan Healthcare (West Point, Neb.): As the opioid crisis continues to bring challenges to pain control, an ongoing issue among anesthesia providers is finding complementary pain control modalities that payors recognize as reimbursable. While CMS will reimburse for Iovera procedures and peripheral nerve blocks, some private payors do not recognize Iovera or peripheral nerve blocks as medically necessary. With a growing population of physicians who do not prescribe narcotics postoperatively, research has shown that peripheral nerve blocks and mutli-modal analgesia does in fact decrease the number of postoperative narcotics administered. In addition to the challenges of payor authorization, is the number of skilled anesthesia providers who administer nerve blocks that are effective to control pain during the immediate postoperative period.
Greg Schooler. COO of Cincinnati GI Anesthesia Associates: The practice has a wholly owned subsidiary which supplies anesthesia to our endoscopy center. We have part time contracted CRNA anesthesia and we employ a number of CRNAs within the practice. The cost of CRNA labor per hour has rapidly and dramatically increased over the last few years, that is our biggest issue. Unfortunately, there is no resolution in the short term because the per hour labor cost is market driven.
Tammy Smittle, RN. CEO of Stonegate Surgery Center (Austin, Texas): The biggest issue that my facilities have is not having enough anesthesia providers. We are a high-volume orthopedic center where many patients receive preoperative blocks. These blocks take one anesthesia provider out of the mix to be able to roll back into the OR. We are currently looking at adding anesthesia assistants to our credentialed providers in order to have enough providers. There seems to be a significant shortage of anesthesia providers in the Austin, Texas, area.
Vijay Sudheendra, MD. President of Narragansett Bay Anesthesia (Providence, R.I.): The biggest challenge ASCs face regarding anesthesia today is the staffing shortage and declining reimbursement from the government (Medicare and Medicaid) and commercial payers. The shortage and declining reimbursement force ASCs to subsidize anesthesia services to maintain quality while attracting talent. The disparity between ASC and hospital salaries for anesthesia providers has progressively widened, making it almost impossible to compete with hospitals without offering substantial financial incentives.
If one significant change could be made to tackle this issue, it would be implementing a more equitable reimbursement model for anesthesia services across all payers. Such a change would help stabilize the financial landscape for ASC, enabling them to cover the cost of anesthesia services without relying heavily on subsidies. An equitable reimbursement model would also encourage more providers to work in ASC by offering competitive compensation, addressing the shortage and reducing the need for subsidies.
Strategies to support the change:
- Efficient scheduling: Adopt efficient scheduling practices to maximize the productivity of anesthesia providers.
- Operational efficiency: To enhance overall operational efficiency, standardize start and end times, minimize overtime, and improve workflow.
- Payer mix management: Strategically manage the payer mix to balance reimbursement levels.
- Innovative anesthesia models: Explore alternative anesthesia delivery models that can lower costs while maintaining quality and growth.
Anthony Torolani, MD. Cardiothoracic Surgeon (New York City): Optimal utilization of surgical care requires the integration of hospital inpatient surgery and ASCs. This is difficult due to distinct aims and needs of these endeavors. However, the invasiveness of the intervention, the requirement for pain control, general, regional or local, and, sedation and physiological monitoring by the anesthesiologist frequently assisted by residents and CRNAs requires continuous record keeping pre-, intra- and post-operatively. In the ASCs to obtain optimal utilization, frequently repeated procedures are performed. In one operating room, the number may exceed eight to 10 per day. With brief turnover time, the pace may be unrelenting, still requiring optimal care and record keeping which cannot be delegated, thus providing stress and burnout.
Due to differing aims and needs of governing boards and patient communities, the inpatient surgical suites and ASCs are invariably separated which adds to the stress of all caregivers especially anesthesiologists and/or nurses. At present, AI utilization and increasing complex case volume and extenders are not a solution, and reimbursement remains a chronic issue.
An immediate approach for anesthesia staff and consistent with individual ability and interest can be that integrated and clinical rotations be allocated to inpatient surgical units where procedures are longer, pace is slower and stress may be diminished.
The basic approach for the best utilization and efficiency of a limited number of anesthesiologists, requires the avoidance of silos. Integration, cooperation and constant communication with joint decision making at all levels of leadership within a single organization or with neighboring health provider institutions must be established. The optimization of limited resources in anesthesia will help avoid unnecessary stress and maintain the highest level of surgical care.
Sap Sinha. COO of Allied Health (New York City): There is a general shortage of anesthesia providers partly due to retirements post-COVID and the increased movement of outpatient procedures across most specialties. This has led to a higher demand for a smaller pool of anesthesiologists, driving up costs. Additionally, there is ongoing rate pressure from payors, which has squeezed margins.
One potential solution is to allow CRNAs to work independently without MD anesthesia supervision for low-risk cases. This would expand the available pool of anesthesia providers and enable facilities to continue performing procedures.
Elaina Turner, RN. Administrator of Advanced Surgical Institute New Albany (N.Y.): There are currently many challenges related to anesthesia. Many of those challenges are directly related to one another. We are offering more procedures, and more patients are requiring sedation for even minor procedures. Additionally, the small pool of qualified individuals poses a serious problem for healthcare facilities. This increasing demand coupled with the limited supply of qualified practicing professionals leads to higher salary demands for CRNAs and anesthesiologists. Reimbursements for anesthesia services can’t keep up and the difference is left for the facility to cover. There are a few things that facilities can do to mitigate some of these issues. Perhaps the easiest change is to optimize scheduling and group patients that will require an anesthesia provider together making the schedule more efficient for the provider. Bundled payments, ensuring accurate coding and documentation and negotiating contracts are some ways to manage the financial portion.
Mark Wainner. Senior Director of ASC Acquisition and Development at Community Health Systems (Franklin, Tenn.): The biggest challenge is obtaining sufficient anesthesia coverage without paying an exorbitant subsidy, which significantly impacts the bottom line. The one thing I would do to change this is to ensure that anesthesia providers are reimbursed adequately so that they don’t require subsidies from ASCs.
Alan Wagner, MD. Ophthalmologist of Wagner Kapoor Institute (Virginia Beach, Va.): One of the biggest challenges ASCs face regarding anesthesia today is the management of anesthesia staffing and availability. With the increasing demand for outpatient procedures, finding qualified anesthesiologists and CRNAs can be difficult, leading to potential delays in scheduling surgeries and increased costs.
If I could change one thing to address this issue, it would be to enhance training programs and incentives for anesthesia providers focused on the ASC environment. This could include developing specialized training that emphasizes efficiency, safety and the unique aspects of outpatient care. Additionally, creating more flexible work arrangements or partnerships with anesthesia groups could help ensure that ASCs have consistent access to qualified professionals, ultimately improving patient care and operational efficiency.
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