For many physician-owned surgery centers and office-based practices, hiring an anesthesia service is a better option than having anesthesia providers on staff. Whether the advantage lies in convenient staffing and management, reduced employee costs and supply budgets, more flexible scheduling or just having someone else handle your anesthesia billing, hiring independent contractors to provide your anesthesia can make your facility and workflow more efficient. As our panel of administrators explains, the key to efficiency is finding an anesthesia service that's geared to your facility's needs and business model. Here's what to consider.

1 Provider group or individual provider? If you're a mid-sized to large facility or one that hosts multiple specialties, a corporate group or a group of anesthesia staffers based out of a hospital will serve you well in their flexibility, coverage and ability to provide more personnel as your facility builds its volume. If your facility is small, single-specialty or an office-based operation, an individual anesthesia provider or two, working as independent contractors or on regular rotation from a hospital, will fit the bill, offering the additional advantage of fostering a close working relationship with the provider who can specially adapt to your practice's needs.

2 Negotiate a trial period. You'll want several weeks to a month to become familiar with your provider's level of service. "They find out how your office works, you find out how they work," says Richard Troy, MD, a partner at Doctors Gott, Goldrath & Troy, an office-based urology practice in Barrington, Ill. If, after the trial, you decide to keep the group or individual on board and they want to arrange a contract specifying your exclusive use of their services, think twice, as this may restrict the ability to make changes or present potential regulatory risks in terms of referrals.

3 CRNA or MD? Examine your state's rules on the role that CRNAs can play in surgery. Do they have independent practice status (and further, do your surgeons accept that role)? "We were looking for a service that brought in MDs instead of CRNAs," says Dr. Troy. "That way, we [surgeons] didn't have to oversee them."

4 Emergency training. Your anesthesia providers should have emergency training in the event of a difficult airway or other contingency away from an acute care hospital. "Our goals, in terms of anesthesia services, are: one, patient safety; two, patient safety; and three, surgeon satisfaction," says Stuart Katz, FACHE, CASC, executive director of the Tucson Orthopaedic Surgery Center in Tucson, Ariz. "We don't worry about patient satisfaction. A safe patient is a satisfied patient."

5 Outpatient mentality. Ambulatory surgery is a time-driven enterprise, built on precise, and precisely effective, anesthesia. Your anesthesia contractor should have a background in serving outpatient procedures.

"There's a different mentality between hospital and ambulatory surgery," says Debbie Hagendorn, RN, administrator of the South Shore Ambulatory Surgery Center in Lynbrook, N.Y. "If I don't have a good anesthesia group [who's used to outpatient demands], we'll have long delays in pre-op, long turnovers and long delays in post-op or step-down due to nausea or vomiting."

Mr. Katz recommends finding out services' track records in a few key areas. "How fast do patients wake up? Do they come out of surgery with airway management issues or other airway difficulties? Are they ready to go in an hour?" he says. "It might not mean they're bad anesthesiologists, just that they're bad for ASCs."

6 Specialty skills. What anesthesia techniques does your case mix demand? Does your anesthesia service specialize in what you do? Ms. Hagendorn says that was a deciding factor in the hiring of the anesthesia group that's served her facility since it opened more than four years ago. "When our group came on board, knowing that this facility was going to specialize in orthopedics, they promoted that they had at least four providers who could do regional blocks," she says. "On any given day, there's someone here from the anesthesia group who can do a shoulder or sciatic block or who can set up pain pumps for when the patients go home."

7 Their own support staff. Services that provide their own ancillary support can prove valuable. While some hospital-based anesthesiologists rely on nurses to coordinate pre-op preparations, says Dr. Troy, a prepared anesthesia contractor will conduct his own interviews, assist in patient education, gather and manage his own data and ensure that testing is complete. Some services even supply their own PACU nurses, he says.

For Ms. Hagendorn's facility, the anesthesia service's on-site tech saves time for her own staff. "It takes hours to make sure supplies are on hand and equipment is maintained," she says. The tech the service provides to attend to the anesthesia machines, difficult airway carts, malignant hyperthermia drugs and other anesthesia needs is a welcome "second pair of hands," she says.

8 Willing to bill. Most administrators agree that self-billing is one of the most valuable business services that an anesthesia contractor can offer. In a common arrangement, the provider or group conducts its own internal management and billing for services rendered, earning its physician fees with a revenue-neutral effect on your budget.

For physician-owners like Dr. Troy, that's a good solution. "I just don't have the expertise in anesthesia or the time it takes to manage that burden to do it myself," he says, adding that this arrangement can present difficulties in educating and counseling patients who inquire about anesthesia billing.

Some anesthesia contractors, such as those based in local hospitals, may not do their own billing, but rather have outside services take care of it. If the responsibility for anesthesia billing ultimately rests with you, he says, and you're paying them a global fee for services, you've got to know exactly what you're reimbursed for each procedure in order to negotiate a fair payment and not lose money on the deal (see "A Note on Subsidies").

Whichever billing and payment arrangement you contract to, it's imperative to ensure that the facility's surgeons and the anesthesia service's providers all participate in the same insurance networks. If they don't, there's a possibility that a patient whose insurance isn't carried may be billed in full for his anesthesia care.

9 Purchasing assistance. In an ideal arrangement, the anesthesia contractor would purchase and provide the drugs and supplies to be used during your facility's procedures. That's not always the case, though. If meds and supplies are coming out of your facility's fee, are your providers willing to lend their wisdom to your materials manager?

"Since they're not paying for supplies, they're not thinking about it," says Ms. Hagendorn. "But I'm thinking about it." Their advice and expertise in which products are most effective can be a great help in purchasing, she says.

10 Compatibility. Consider the compatibility between the potential provider and your surgeons and staff. "Some surgeons would prefer not to work with some anesthesiologists," says Mr. Katz. "Maybe they're too slow or their blocks don't last long enough and the surgeon doesn't want to get calls at 2 a.m. from a patient in pain."

Ms. Hagendorn says she appreciates anesthesiologists who can deliver bad news to surgeons, such as when a patient awaiting surgery has just revealed that she's eaten that morning. "You can depend on anesthesiologists to discuss the issue with surgeons calmly, without fear that they're going to be eaten alive," she says.