Here are six things to think about (and some insider advice) to help ensure you get the best fit between an anesthesia provider and your facility.

1. What kind of facility are you?
Simply put, if you're big, think group; if you're small, think an individual or two.

Big, multi-specialty facilities need the depth and flexibility afforded by a large group of anesthesia providers to ensure seamless coverage and to compensate for last-minute changes in surgical postings. Larger groups have a superior ability to recruit new members, which can be a boost as your facility grows, expands its volume and diversifies the scope of its medical/surgical practice.

In contrast, smaller, office-based ORs (often one OR attached to a surgical practice) might find that a close working relationship with one provider is more rewarding. In such close quarters, the anesthesia provider often becomes an integral and indispensable member of the surgical practice, one who is able to adapt practice patterns to better suit the needs of the surgeon and patients alike.

Avoid exclusive contracts, especially any form of exclusive arrangement that might put you at regulatory risk or that impedes your ability to make changes (especially during the unpredictable start-up phase of a new facility). Anesthesia providers would do well to preserve their independent contractor status and perform their own internal management and billing. That way, you and your anesthesia providers will have a similarly aligned business agenda that avoids employee-employer encumbrances, helping productivity and morale to remain high.

2. What kind of anesthesia care do you want?
This depends on what kind of surgical care you provide.

In the case of multi-specialty and ENT-focused facilities where pediatric patients are treated, you should look for either peds-experienced providers or pediatric subspecialty-boarded anesthesiologists. Likewise, in orthopedics, the newer-trained surgeons will often request various types of regional anesthesia blocks, and an anesthesiologist who's uncomfortable with these procedures will quickly stand out.

In the CRNA versus MD anesthesiologist debate, it seems the enduring practice in most states is anesthesia care provided directly by board-certified physicians or in a care-team approach, with CRNAs under the supervision of physicians. Administrators of smaller facilities that might have only a surgeon and CRNA in the OR might want to think long and hard about the rare, but potential, emergency situation in which there might not be an additional pair of qualified, anesthesia-trained hands.

3. Do you want an employee or a long-term partner?
Anesthesia providers are more likely to work long hours, add pain management services and perform at maximal motivation when they are treated as equals to the other staff at the facility. It's important to have a good relationship with your employees, but you have to think about how much autonomy they will have. I've found anesthesia providers are ultimately happier when they have an independent or investor role, which won't be the case if you sign them on as employees.

To have anesthesia providers on as staffers means paying real employee costs: salary, insurance, sick/vacation time, administrative overhead, supplies, incentive packages and other fringe benefits.

4. What's this going to cost?
Anesthesia services delivered by independent groups or providers (those who bill for their own services) have a zero net effect on the facility's balance sheet and avoid the complexities of an employer-employee relationship. Anesthesia providers who bill for their own work (as equals to the other physicians/surgeons who also practice in the facility) won't need incentive packages to perform at their best; their welfare will fluctuate in alignment with the welfare of your center.

A full-time, experienced, ASC-based anesthesiologist in a non-incentivized, employee arrangement (assuming no call or other vehicles for income generation) in 2005 could cost from $175,000 to $450,000. In busy surgical facilities, with contractual incentives tied to center productivity, another $25,000 to $100,000 could be earned in a given fiscal year. CRNA rates tend to be lower, but have increased significantly over the past few years. These are generalizations, and employee contracts exist with numbers that fall outside of this range. Look to pooled cost data to ensure your facility is appropriately competitive and can attract the best talent. Facilities looking for employed anesthesiologists to also function as medical directors will find that supplemental contract arrangements for this added role and responsibility can range from $30,000 to $80,000.

5. What are your ethics?
Anesthesia providers and administrators alike should be particularly leery of getting into practice arrangements with individuals who have a reputation for unethical activity. To avoid the appearance of impropriety in the eyes of the IRS and Office of Inspector General, among others, it's often best to let the anesthesia provider company bill the patient directly for services rendered.

6. Is everyone on the same insurance page?
Facilities that provide multi-specialty services and have negotiated contracts with various insurance and managed care companies may be more flexible in making arrangements or contracts with anesthesia providers. Especially in the context of start-up facilities, as with all new medical staff members, it's vital that all parties share provider arrangements with common insurance entities to avoid embarrassing situations in which patients are scheduled but have to be cancelled because someone doesn't participate with the insurer. Even more problematic is the scenario where services have already been rendered and patients receive an unexpected bill from non-participating anesthesia providers.

Start early
If you investigate these areas when deciding whom you will contract your anesthesia services to, you and your anesthesia providers will be more likely to realize the rich dividends of a healthy working partnership.

Lawyers may seal the terms of the contract between your facility and anesthesia provider (see "12 Contract Must-haves"), but the real deal lies in the chemistry, personality and shared ethics of the parties. It's only in the course of providing patient care and forming relationships with fellow staff members that the true patterns of skill, bedside manner and professionalism are revealed. But if you know the components for success in contracting with an anesthesia provider, you can set the foundation for a long-term, mutually beneficial relationship before any ink is put to paper.