The biggest mistakes ASCs make with anesthesia — and what it could cost them

Anesthesia coverage has become one of the most pressing issues facing ASCs today. As provider shortages worsen and reimbursement rates fail to keep pace with rising costs, many ASC leaders are struggling to establish and maintain sustainable anesthesia partnerships.

Ten anesthesia leaders joined Becker’s to discuss the common mistakes ASC leaders make when developing anesthesia partnerships. 

Question: What are some common missteps ASC leaders make when developing or managing anesthesia partnerships?

Editor’s note: Responses have been lightly edited for clarity and length. 

George Anastasian MD. Chief of Anesthesiology at White Plains (N.Y.) Hospital: There is pressure to do sicker patients and more complicated surgeries in ASCs these days. Contracting with a group that has little experience taking care of ASA [class] 3 or 4 patients would be a misstep. Another misstep would be if all your anesthesia clinicians come from outside the ASC catchment area. There is a certain level of pride, connectivity and extra care taken when you are providing anesthesia and perioperative care to outpatients who reside in your own local community.

Eric Callan, CRNA. CEO of LifeLinc Anesthesia (Memphis, Tenn.): Unrealistic expectations of the current anesthesia market and the need for the ASC to maximize their OR utilization and resources to minimize their costs. While ASCs often cater to surgeons to improve their experience compared to the local hospital, today there is an increasing need to maximize their OR utilization. This leads to less surgeon convenience in terms of guaranteed work times that are best for the surgeons. However, working together we can introduce and implement an effective block schedule that will grant the surgeons the needed OR time they desire while minimizing wasted resources. Additionally, timing is important. A well-planned strategy to implement change will lead to future success. While a wait-and-see approach may be the best way to evaluate future demands, a well-designed strategy with multiple staffing options should be immediately available prior to planned implementation. If an ASC wishes to have success with their anesthesia partner, as well as overall operations, data-driven analytics should be reviewed often in order to plan for staffing expansion or contraction that can be timed well with the current challenging anesthesia market. 

Luc Corriveau, CRNA. Chief Nurse Anesthetist at Androscoggin Valley Hospital (Gorham, N.H.): A common and costly mistake is hiring an anesthesia group simply to fill a slot, treating it like hiring a body to administer anesthesia for the day rather than securing a well-managed anesthesia service. Anesthesia should be viewed as a strategic clinical partner, not a line-item expense. When you reduce it to “just coverage,” you forfeit leadership, quality oversight and operational value that come from a fully engaged anesthesia team.

This often happens when groups are selected solely based on offering the lowest rate or undercutting the incumbent provider. While cost is always a consideration, shortchanging yourself to save a few dollars up front often leads to significant downstream problems including workflow disruptions, poor communication, and lapses in quality oversight.

Another misstep is trusting large private equity-backed groups that overpromise and underdeliver. Many of these groups are more focused on meeting quarterly projections than on building a reliable, lasting partnership with the ASC or supporting the local community. They often lack the staff to follow through on their commitments, which can erode trust and compromise performance.

Suzi Cunningham. Administrator of Advanced Ambulatory Surgery Center. (Rancho Cucamonga, Calif.): Over the last more than five years, we have had issues securing anesthesia coverage, but it isn’t that there aren’t enough providers in our area, but the fact that we can’t afford them. Unfortunately, the reimbursement for anesthesia services just hasn’t kept up with the market, so I believe we are all, at the facility level, having to subsidize their reimbursement. And it seems each year, it is getting more expensive.

Megan Friedman, DO. Anesthesiologist and Director of Pacific Coast Anesthesia Consultants (Los Angeles): One major misstep is approaching anesthesia as a plug-and-play service rather than a clinical and operational partner. Not all anesthesia groups bring the same level of quality, alignment or engagement. Another frequent mistake is failing to involve anesthesia leadership early in key decisions like scheduling, staffing and case-mix strategy. Anesthesiologists have a unique, systemwide view of workflow and patient flow — excluding them from these conversations limits the ASCs ability to run efficiently and grow sustainably. Strong anesthesia partnerships start with shared goals, open communication and mutual respect.

Robert Johnstone, MD. Professor of Anesthesiology at West Virginia University (Morgantown): We keep pushing the limits on what can be done in an ASC, for example, obese and diabetic patients and complex surgeries. A good mechanism for vetting patients ahead of time is needed.

Jay Kiokemeister, DO. President of Ambulatory Anesthesiologists of Chicago: ASC leaders in the past often considered anesthesia as an ancillary service and not as a ASC partner. The leader’s focus had been always on the surgeon’s demands and concerns. Part of the reason for the overall change in anesthesia workforce issues has been this sentiment conveyed by the ASC leaders. The Chicagoland market has had several high-profile groups collapse as a result. Today, I believe the ASC leaders have been forced to understand this and now are collaborating with anesthesia groups that provide services. 

Scott Mayer. CEO of Ambulatory Anesthesia Care (Chicago): Work to understand the anesthesia financial model and what is same/different about the ASC and surgeon’s optimal financial goals and outcomes versus anesthesia. Different payers and CMS versus commercial reimbursement is very different for surgeons and facility fees versus anesthesia. 

No. 1. Understand that any government (Medicare or Medicaid) patients/surgeries brought into your center will require financial support for anesthesia. That can be done through a stipend, additional commercial cases, bundling and more throughput/volume per OR, etc., but needs to be taken into account.

No. 2. Understand that guaranteed coverage for any ORs that the facility wants open comes at a price. There has to be a decision on who and what are being prioritized. Surgeon’s scheduling freedom and dictating OR utilization, which could require a cost for anesthesia coverage versus optimizing the schedule and OR utilization for throughput, efficiency and resource optimization, which will improve the overall facility bottom line, but may upset surgeons because they will have to be told when they have block time and can do their surgeries. Every decision in the current environment comes at a cost and/or consequence and that’s very true with the anesthesia relationship, and coverage needs. So being united and clear on this is vital.

No. 3. Being fooled by an initial proposal and offer to not have a stipend or require OR optimization for anesthesia from a new group coming in and thinking that is a forever commitment. This is a bait-and-switch strategy that has been around for years, especially from larger conglomerate groups, and is used too much and continues to hurt centers. They will take a loss upfront to get into the center and then a few months down the road they will come back with a big financial requirement, which many times is worse than what the facility and former anesthesia group were working with. They are hoping the switching costs, lack of other options with enough staff to step in quickly and noncompetes will force the facility to give into their demands. 

No. 4. Not being transparent with metrics and numbers, clinical or financial, on each side

Vijay Sudheendra, MD. President of Narragansett Bay Anesthesia (Providence, R.I.):

No. 1. Underestimating financial realities and reimbursement gaps. Many ASC leaders fail to understand the evolving financial model of anesthesia services fully. With a growing proportion of Medicare patients and decreasing anesthesia reimbursement rates, especially from Medicare, ASCs often do not account for the fact that anesthesia reimbursement may only cover a fraction of provider costs. This leads to financial shortfalls and the need for direct subsidies from the ASC or its physician owners. Leaders who ignore this shift or believe switching anesthesia groups will solve the problem often face repeated operational disruptions and strained relationships.

No. 2. Treating anesthesia as a commodity instead of a strategic partner. A common misstep is viewing anesthesia services as a staffing need, rather than a critical partnership. This mindset can result in transactional relationships focused only on cost, rather than collaborative efforts to improve quality, efficiency and patient outcomes. Strong anesthesia partners bring leadership, analytics and innovation — qualities often overlooked when decisions are made solely on price or coverage.

No. 3. Succumbing to a “revolving door” of anesthesia groups. Some ASC leaders believe changing anesthesia providers will resolve financial or operational issues. However, frequent turnover often leads to greater dysfunction, OR closures and canceled surgeries due to inadequate anesthesia coverage. This instability can damage surgeon and staff morale, patient experience and the ASC’s reputation.

Jeffrey Tieder, MSN, CRNA. Clinical Assistant Professor at University of Tennessee at Chattanooga: One of the most critical and often overlooked components of a successful ASC-anesthesia partnership is clear, ongoing communication. ASC leaders and anesthesia providers must work collaboratively to define appropriate patient selection criteria, ensuring alignment on which patients are safe and suitable for the outpatient setting. Without clear boundaries, anesthesia teams may face last-minute surprises or unsafe situations, leading to case cancellations or unexpected transfers to the hospital — outcomes that are frustrating, costly and potentially damaging to the ASC’s reputation. Continued dialogue around case complexity, comorbidities and escalation protocols is essential to minimize disruption and ensure a smooth, efficient workflow that prioritizes patient safety.

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