If you agree with the Marxist philosophy that you're entitled to a piece of the profits when you control the means of production, then you really can't fault surgeons who own surgical centers for shaking anesthetists down for a cut of their fees.

The patient belongs to the surgeon. The building, anesthesia machine, anesthesia drugs and infusion sets belong to the facility he owns. That gives surgeons a licence to extort, right? Absolutely not.

"Should hospitals charge admitting physicians for IV fluids, antibiotics, patient meals, water and electricity bills?" asks anesthesiologist Vikram Singh, MD, a pain management specialist from West Hills, Calif. "That is not the way the medical system is set up to function."

Good point, Dr. Singh, one we're thankful that the government agency charged with protecting the integrity of our country's healthcare programs agrees with (see "OIG to Surgeons: Hands Off Anesthesia Fees!").

A single surgical procedure that's performed in an ambulatory surgical center produces 3 claims: 1 from the surgeon (), 1 from the surgery center () and 1 from the anesthesiologist (). Why should the enterprising surgeon settle for 2 out of 3 when he can go 3-for-3 by helping himself to anesthesia's piece of the pie, even though the facility fee covers the costs of the anesthesia drugs. To pull off this rare trifecta, some surgeons, in true greed-is-good fashion, employ 1 of 2 sophisticated shakedown schemes:

' Charge their anesthetists a per-patient fee for the privilege of working his cases. Not much. Maybe $50. Asking for a kickback — "Jay, if you want to provide anesthesia at Main Street ASC, you've got to pay us 20 ? cents on the referred dollar" — is criminal.

' Force anesthetists to become employees of the ASC's sham anesthesia company. The ASC bills for anesthesia and siphons part of the fees back to the ASC owners. "Jay, if you want to work cases at Main Street ASC, you've got to work for our group, Main Street Anesthesia Services. We'll pay you 80 ? for every dollar we collect on your behalf."

"The carrot is the cases," says Dr. Singh. "If you're not busy, then you say to yourself, '50 bucks a case is better than sitting at home.' It's just straight greed. It's not like these surgery center owners aren't making boatloads of money. But some people will not leave a single penny on the table for anyone else."

It's safe to wonder how physician-owners who tax anesthetists view the people at the head of the patient: as partners or as parasites, subcontractors they hustle in to do their small part of the job and then send home until they're needed again? Clearly, you wouldn't exploit a colleague by extorting them.

Before the OIG denounced these revenue-sharing arrangements last month, there was little anesthesia providers could do to avoid paying off surgeons. Complain? Quit? Don't let the door hit you on the way out. If one anesthetist isn't willing to pay up, plenty of others gladly will. The OIG Advisory Opinion gives anesthetists the courage of their convictions.