Based on my experience as a CRNA-trained managing partner of a busy ophthalmic surgery center, it might be time to find a new anesthesia service if your providers:

1. Are too expensive.
Once you've determined the amount of anesthesia revenue you generate (see "How Much Does Anesthesia Bring In?" on page 70), start negotiating with anesthesia services. How much these services charge is largely dependent on the salaries and benefits they pay to their providers.

Anesthesiologists typically get paid about twice as much as CRNAs do ($336,451 vs. $154,567), so if you're a busy center caring for lots of patients with commercial insurance plans, you'll likely be able to afford working with anesthesiologists. However, smaller single-specialty centers like mine with a caseload comprised mostly of Medicare patients might be better served by the CRNA-only staffing model.

It's important to note that anesthesia reimbursement is black and white: Per-case reimbursements are the same, regardless of how many anesthesia professionals provide care to the patient. The single-facility fee charged by the ASC is presumed to include all costs of anesthesia service with the exception of the professional fee of the anesthesia provider. This covers Medicare and Medicaid, and the vast majority of commercial insurers (in fact, that's the case at my facility for all commercial insurers). So whether you have an anesthesiologist medically directing CRNAs, anesthesiologists working cases alone or CRNAs working solo, you're on the hook for paying the professional fees for your anesthesia providers out of the same reimbursement pot. In addition, remember that all costs for anesthesia equipment, supplies and medications (everything other than the professional fee) must come out of your facility fee, so penny-pinching anesthesia professionals who are careful stewards and less resource-intensive can really boost your bottom line.

2. Don't fit your local market.
Variables such as the expectations of surgeons in your market and the local regulations that govern anesthesia care will factor into whether you retain your current service or shop around for alternatives. Research your community to see what is the preferred anesthesia model and why it persists. In some urban areas, the anesthesiologist-only and anesthesiologist-CRNA care team models are most common, while in many rural and other medically underserved areas the CRNA-only model is the norm. Similarly, there may be differences in care based on the type of medical specialty: Ophthalmic ASCs often have all-CRNA teams, while orthopedic centers might have anesthesiologists providing pain management services and supervising or medically directing CRNAs. However, the most common model in your area might not be the best fit for your situation, so consider all factors and possibilities before deciding to make a change.

3. Are behind the times.
Anesthesia delivery in the outpatient setting presents unique challenges, so be sure your providers remain up to speed with the latest techniques and familiar with the newest technologies. Are they able to perform efficient and effective regional blocks? Do they use short-acting muscle relaxants and sedatives? Are they proficient in the use of laryngeal mask airways? Do they have a light anesthetic touch so patients are awake and responsive shortly after arriving in PACU and ready for timely discharges?

Also be sure your scheduling needs mesh with the availabilities of the service's providers. Tension can develop quickly between anesthesia and your surgical team when scheduling expectations are not clearly established and maintained throughout the partnership. How many rooms do you want to run simultaneously? When do cases start in the morning and how late in the day do they run? Providers need to be punctual and have patients sedated and ready for on-time starts so surgeons aren't kept waiting. Can you call providers back after they've gone home if you need coverage for add-on cases? Your anesthesia professionals should also be willing to extend their days if delays in PACU demand coverage past the scheduled quit time.

4. Refuse to adapt.
You want to work with personable providers who come to your center each day with a "can-do" attitude. They should blend seamlessly with your surgical team, be willing to work through clinical challenges and constantly strive to educate your staff and improve your anesthesia care. Today's providers, thanks to widespread drug shortages, must also be flexible enough to work with alternative anesthetic agents. I recently spoke to the administrator of a center who was desperate to replace his current anesthesia team because they refused to move away from using succinylcholine, which is in short supply in our area. Their unwillingness or inability to use another short-acting muscle relaxant left that administrator with no other choice but to cancel cases. Be sure your anesthesia service employs providers who are willing to adapt to changing clinical circumstances so you're not faced with the same predicament.

5. Aren't saving you money.
Are your providers open to and skilled at using less expensive drugs that have the same effects as costlier options? Here in Washington the propofol shortage has bumped the cost of a 20ml vial to $12. Since smaller quantities are unavailable and Medicare surveyors are cracking down on single-dose drugs being given to multiple patients, plenty of propofol and money are being wasted after the standard 3cc to 6cc doses are administered during a case.

At my facility, instead of propofol we use midazolam, which costs 37 cents for a 2mg single-dose vial. It takes a good deal of skill to deliver just the right amount so the results come close to matching propofol's rapid onset and offset. Thinking outside the box and making that switch saves my facility hundreds of dollars each month. Expect your providers to look for ways to do the same for you.

One of your own
If you're in the market for a few providers to supplement an already solid anesthesia service, contracting with a local firm might be the way to go. If, however, you're looking to clean house and replace an entire staff of underachievers, working with a national firm could provide the needed clinical resources and manpower. Whichever type of service you decide to use, demand that they treat your facility like their own. When it comes to delivering safe and efficient patient care, no one should be on the outside looking in.