Rule No. 1 of selecting an anesthesia services company is to know how much anesthesia your facility can afford. This means figuring out how much anesthesia revenue your center's case volume generates.

Many independent contractors provide their services at no charge to the hiring facility, bill for themselves and have a neutral effect on the facility's bottom line. They're paid by insurers' anesthesia reimbursements and patients' remittances for the cases in which they serve, the same way that the surgery center's facility fee and the surgeon's professional fee are recouped.

As a result, the anesthesia revenue that your cases generate should cover the amount that the anesthesia company wants to earn for the personnel with which it will staff you. Otherwise, you may end up subsidizing them for the shortfall, which will cut into your profits.

It's not hard to figure out your center's potential anesthesia revenues using your recent data on case loads, average OR time and payor reimbursement. Alternatively, you can hire an anesthesia-billing consultant for assistance. Or the companies bidding for your contract can help you calculate it, given your case volume for a month, 2 months or a quarter.

The base revenue requirements for anesthesia services are going to vary from company to company and will depend on each facility's staffing needs, but keep in mind that providers' salary and benefit packages are a primary driver of this amount. According to recent surveys, the average CRNA earns about $150,000 plus benefits, while the average anesthesiologist earns about $350,000 plus benefits.

If you're a busy surgical facility in a market with lots of anesthesia service companies, you'll probably be able to call the shots and find one whose offerings meet your needs. If, on the other hand, you don't do a high volume of anesthesia cases and have few outsourcing options available to you, you may find yourself paying out of pocket for the contracted services.

Determine your staffing needs
In addition to your projected anesthesia revenues, you — and the companies you're considering — will also want to know your parameters in order to calculate the anesthesia staff required. These are important variables:

• How many cases do you see in a year?
• How many ORs at your facility?
• How many surgical days in your week?
• How many simultaneous room starts per day?

These figures, which you should include in your request for proposal, will notify the bidding companies what your facility's demands are and will let them accurately correlate your staffing needs to their revenue needs. In terms of the types of anesthesia providers with which a company can staff your ORs, there are 4 scenarios:

• anesthesiologist(s) only.
• CRNA(s) only.
• anesthesiologist(s) medically directing CRNA(s).
• anesthesiologist(s) and CRNA(s) working collaboratively.

As with any healthcare service, your decision on one scenario over another will be guided by the factors of quality, cost and access. Professional debates aside, each of these scenarios will provide a surgical facility with high-quality care. Cost and access, however, require some examination.

Each of these scenarios has its own price range for its level of service. In most regions, the CRNA-only option is typically the most economical, based on their average revenue-to-salary requirements. However, supply and demand, the ratio of CRNAs to anesthesiologists, insurer requirements and state laws and regulations are all factors that can have an impact on your market. These factors require thorough exploration when you're determining which scenario is the most economical for your facility.

Here in Spokane, Wash., we've got a lot of Medicare patients and plenty of available CRNAs. As a result, many surgery centers are staffed with the all-CRNA model. New Jersey, on the other hand, has regulations which, in many circumstances, essentially require that anesthesiologists supervise all CRNAs administering anesthesia. It's the only state with laws restricting the CRNA-only model in this fashion. It isn't always state law that affects a facility's access and ability to choose among the staffing scenarios. Sometimes a facility's medical staff bylaws come into play as well.

Whether you're planning to contract with anesthesiologists, CRNAs or a combination, you'll want to review their experience and seek out the skill sets that your cases demand. Certification in Advanced Cardiac Life Support is a given, as is Pediatric Advanced Life Support if you treat children. If your pediatric patient population is fairly large, providers who have extensive experience in treating children may be beneficial. And your orthopedic surgeons most likely want providers who know their way around regional anesthesia blocks.

Note well that while anesthesiologists must be licensed to practice, they aren't required to be board-certified or board-eligible to do so, and no state bars them from practicing anesthesia if they're not. As their name indicates, however, CRNAs must be certified by the Council on Certification of Nurse Anesthetists in order to practice in any state.

Confirm that the anesthesia providers or companies you're considering have valid contracts with at least the most common insurance carriers that cover your patients. This will prevent the possibility that uninsured and unreimbursed anesthesia services will lead to canceled cases if patients find they can't pay or large bills when providers don't participate with patients' insurers.

Don't hire any company unless and until you can talk to administrators and surgical personnel at other facilities that have hired and worked with them. Be wary of hiring providers who also work at local and regional hospitals, for fear that vacations or other staffing coverage conflicts at the "big house" may leave you hanging: You should be their first priority. And find out if they can offer any value-added services, such as assistance in staff training, in-services and participation in your quality improvement projects (or development of their own projects).

Unlike capital equipment purchases, there's really no way to trial anesthesia services before you bring them aboard. That's why your contract with the provider or company you eventually settle on should include a 60-day or 90-day "without cause" clause, which will let you evaluate their performance before signing a permanent contract and to cut them loose within that time if their results are not to your approval. A service's customers on this front are surgeons, OR staffers and patients. Judge anesthesia personnel on promptness (it's no secret that surgeons hate waiting on anesthesia), teamwork and willingness to put in extra time if cases run long.

Size up the source
Outsourcing anesthesia services can be an ideal option for startup centers looking to staff their ORs and for existing centers expanding their facilities, case volumes and specialties. These independent providers serve as equals to surgeons in your ORs without adding staffing costs to your budget, and since their success depends on the success of your center, you're practically assured of solid efforts.

Conventional wisdom says that large, multi-specialty centers are best served by the growth and flexibility of a nationwide company's big staff of providers, while smaller and office-based operations gain from a familiar working relationship with local companies or individual independent providers. But the large companies' seamless coverage and the smaller companies' personal attention to practice needs might benefit any facility. In the end, the service that best satisfies the foundational issues we've addressed here is your best deal.

Anesthesia Healthcare Partners
(800) 945-6133
www.ahphealthcare.com
National coverage
Contract details: "Typically with our ambulatory surgery center partnerships, there is no cost to the center, due to our ability to bill the various third-party payors for our professional anesthesia services," says AHP Vice President Timothy W. Beisner. "Dependent upon each unique partnership, we may possibly require a subsidy payment, if the facility's anesthesia collections do not cover the dedicated anesthesia practice's expenses."
FYI: "Our facility partners will typically benefit from improved anesthesia financials, since AHP leverages our national presence when negotiating commercial payor rates," says Mr. Beisner.

Coastal Healthcare Resources
(866) 877-2762
www.coastalhcresources.com and www.crnalocums.com
National coverage
Contract details: In addition to providing independently contracted, self-billing anesthesia management for surgical facilities, the company also provides permanent placement recruitment for direct employment and locum tenens staffing, explains CEO Lanora Allen, RN. "We personally meet with facilities to develop a cost-effective anesthesia model based on their specific staffing, recruiting, billing, retention and delivery needs."
FYI: Owned and operated by anesthesia professionals with more than 40 years of combined experience in the industry, Coastal Healthcare Resources boasts Joint Commission certification and, as a result, anesthesia providers credentialed to Joint Commission standards.

Mobile Anesthesiologists
(866) 997-7770
www.zzzmd.com
Serving the greater Chicago area, with an affiliate in Houston, Texas.
Contract details: An independently contracted, direct-billing provider, Mobile Anesthesiologists requires set minimum revenues and/or case volumes for its services, but has never charged subsidies, says founder and CEO David Barinholtz, MD.
FYI: The AAAHC-accredited company caters to the office-based surgery market with ambulatory anesthesia services ranging from physician-anesthesiologist staffing to turnkey solutions that include support staff and all necessary drugs, supplies and equipment, with an eye on providing services that meet or exceed those provided by hospitals' and ASCs' anesthesia staffs.

Nationwide Anesthesia Services
(800) 235-8986
www.nwanesthesia.com
National coverage
Contract details: Nationwide Anesthesia Services specializes in the placement of CRNAs and anesthesiologists for permanent or locum tenens staffing. "We do not require any minimums, other than a 40-hour work week for the provider," says Rick King, director of recruiting operations. Permanent placements are based on contingency-based fees and can be hired on as employees or self-employed contractors. "(For locum tenens placements), payroll generally runs through Nationwide, while billing runs through the hospital or group." Clients may choose between an all-inclusive or straight hourly rate, with no increases for overtime, or call on either option.
FYI: In addition to staffing, Nationwide offers practice management and consulting, as well as per diem malpractice insurance for a low daily rate with no agency fee. "Our staffing consultants are experienced and knowledgeable, and are committed to providing outstanding personal service," says Mr. King.

Sentry Anesthesia Management
(800) 338-9612
www.sentryanesthesia.com
National coverage
Contract details: The company offers its services as an independent, self-billing vendor or, if desired, as a management firm supervising facility-employed providers. An evaluation of a facility's request for services and possible practice models, potential anesthesia revenues and projected operating expenses determines the pricing structure. "If a facility selects an operational model that is profitable, we will contract as a strict fee-for-service vendor," says Sentry Principal Barry Cranfill, CRNA, MHS, MBA, FAAPM. "If the facility selects an anesthesia service model that is unprofitable, we require an income guarantee." If the latter model eventually turns a profit, he notes, Sentry will repay the facility any subsidies it has remitted as long as the model remains profitable.
FYI: Sentry Anesthesia Management specializes in developing and implementing anesthesia solutions such as full-service turnkey operations, management of existing anesthesia departments, billing and collection services and recruitment and staffing, with an eye on financial transparency, increased revenues, decreased costs and customer satisfaction.

Somnia Anesthesia
(877) 476-6642
www.somniainc.com
National coverage
Contract details: Somnia is an independently contracted, self-billing service. Required revenues and subsidies are dealt with on a case-by-case basis, according to Marketing Manager Laura Herrera, who says that "90% to 95% of our clients do not have subsidies."
FYI: A physician-owned and operated clinical anesthesia management company, Somnia's customized solutions are designed to yield the highest quality of care, reliable coverage and improved financial performance, notes the company, which says it delivers expert leadership, recruiting, revenue cycle management, payor contracting and quality assurance.