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April 25, 2024
Growing demand for anesthesia services at ASCs is being met with a dwindling supply of anesthesia providers....
Bill Isaacson, MDHavertown, Pa.
"About 80 percent of our staff is assigned to specific facilities,
while 20 percent are ?floaters' whom we utilize for specific
types of cases."
In today's era of shrinking reimbursements and anesthesia provider shortages, many are finding that contracting with an anesthesia group is the best bet to ensure that your facility has the best care at a more cost-efficient price than hiring a full-time provider(s). And in some cases, such as adding pain management services, contracting with an anesthesia group may also open new case possibilities.
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I head the anesthesia group that provides anesthesia and pain management services at the Mercy Community Outpatient Campus in Havertown, Pa., where I am also the medical director. My group also provides service to numerous other facilities. Read on as I highlight the benefits of utilizing an anesthesia group.
Controlling spiraling costs
We charge facilities that we staff a "stipend" that is used to cover the rapidly escalating salaries of our anesthesiologists and nurse anesthetists. Depending on the number of providers needed and the type of services, the stipends vary from just under $100,000 annually to several times that amount. We generally charge surgicenters the least and large hospitals that need OB, trauma and heart cases the most.
There is no such thing as "discount" anesthesia anymore, even if you opt for CRNA care. Here in Pennsylvania, the anesthesia reimbursement for cases combined with the ever-increasing malpractice costs (our malpractice carrier just informed us of an across-the-board 59 percent rate increase for next year) do not allow us to meet salary expenses without getting help to keep our providers from leaving to seek greener pastures.
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Facilities that employ their own anesthesiologists face an even more daunting financial task because the salaries they pay full-timers fall toward the higher end of the scale. According to 2001 data compiled by Allied Consulting and Merrit Hawkings and associates, the average anesthesiologist salary is $240,000 and a CRNA's is $118,000. Sharing these high costs between the anesthesia group and the facility is one way to manage these costs. In addition to the stipend, the facility is responsible for providing all equipment related to anesthesia, including drugs. That relieves the anesthesia group from assuming those costs. In return, we help offset some of the other costs and strive to help you maintain the highest possible standards of care. Here's how.
- Flexible scheduling. There are going to be some days when you don't have a lot of cases scheduled. If you're paying for a full-time provider, your facility pays costs regardless of whether the ORs are hopping or mostly empty. With a group, you are only paying for time if the provider is actually handling cases. Plus, we can move our personnel from one facility to another, shifting staff to a busy facility where extra hands are needed on that day.
- Creating surgical team continuity. As you know, the more familiar the members of a surgical team are with each other, the better that team performs. My group is comprised of 30 anesthesiologists and 60 CRNAs, including both part-timers and full-timers. However, we strive for as much continuity as possible. About 80 percent of our staff is assigned to specific facilities, while 20 percent are "floaters" whom we utilize for specific types of cases. Because you have a regular corps of providers covering most of the cases at your facility, there is still the overall continuity of care you'd get with a full-timer.
- Specialized care. Our group plans our facility coverage assignments based on the surgical schedule for the next day. If a provider with a certain highly specialized skill such as pediatric anesthesia is needed, we make certain that the best provider for that specialty is available for those cases.
- Customer service. Just as a good surgical facility understands that its patients and surgeons are its customers, so too should a good anesthesia group demonstrate a commitment to customer service as well as clinical skill. The facility is our customer. As such, you have a right to expect us to respond to your needs and make adjustments as necessary.
- Pain management. Pain management has the potential to be a high-volume addition to your services, without interrupting your surgical cases. An increasing number of anesthesiologists are branching out into this rapidly growing sector of outpatient care. If your center has an interest in offering pain management services and can secure these services through your anesthesia group (or a full-time anesthesiologist for that matter), many new opportunities for increased facility usage and profit can open up.
For one, cases do not have to be done in the OR (unless fluoroscopy is involved). The anesthesia group can have a pain management specialist doing cases in a procedure room while other cases are proceeding. For another, the cases are short (about 5 to 10 minutes for an epidural block for example), with a high profit margin because overhead is low (an epidural tray plus drugs runs in the range of a few hundred dollars per case). Depending on the payer, a profit of about $275 per case is possible. And as with all aspects of outpatient care, it is the pain management doctors who bring the cases to your facility.
Shop around
No single anesthesia arrangement is right for every facility. My best advice to you is to look at what is available in your market, see how much you can afford to pay and make your decision based on what is practical for your facility.
Theodore Lazzaro, MDGreensburg, Pa.
"Using tenant anesthesiologists simply does not match up to
the level of care offered your patients by a carefully selected
staff anesthesiologist."
I founded the Aestique Ambulatory Surgery Medical Center in 1986. While my practice grew quickly and successfully, it took time for my anesthesia arrangement to meet my satisfaction. Finally, four years ago, I hired a full-time anesthesiologist, a decision that has proven beneficial to the practice. I was lucky because opportunity knocked when an exceptional provider I knew and trusted made himself available to us.
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There was more than luck involved, however. Anesthesia service is largely a catch-as-catch-can proposition for outpatient facilities, and the competition is fierce. You have to be as aggressive in looking for the best anesthesiologist as you are in trying to lure the best surgeons. You may have to invest $50,000 to $100,000 more per year than you'd pay for a tenant provider, but if the quality of your anesthesia service is a step behind other services, it weakens the entire practice.
Today, our facility has 35 surgeons on staff and house specialties ranging from plastic surgery, gastroenterology, general surgery and orthopedics to oral surgery, pain management and hand surgery. Let me tell you the story of how we were able to turn anesthesia care from a question mark to an exclamation point.
Hunting for the right arrangement
Using tenant anesthesiologists simply does not match up to the level of care of a carefully selected staff anesthesiologist. Prior to hiring a full-timer, we went through various arrangements that ranged in quality. While some transient anesthesia providers are very good, more are average and far too many are flat out inadequate. The same goes for CRNAs, of course.
I've never seen a bad resume in my life. Every provider that passed in and out of our ORs seemed fine on paper but the quality of service that anesthesiologists provide varies widely. Some are simply more conscientious and more talented than others, both in terms of clinical and people skills.
Our present arrangement costs the facility more than alternative methods of providing anesthesia coverage. In an era of declining reimbursements, I am guaranteeing a full-time salary rather than paying based on a per-case service rate, where I can send the provider home if no cases are scheduled. Alternatively, I could save a bundle (as much as 50 percent) by hiring only CRNAs and letting the surgeons serve as their supervisors. But money is not the primary issue. To me, it all boils down to quality control and customer service.
Optimal quality control
Before I went to medical school to become a plastic surgeon, I was an oral surgeon. That provided me with a bit of a background in providing anesthesia. The experience of putting patients under anesthesia before doing oral surgery was always nerve-racking. I came to appreciate just how difficult it is to be truly proficient at providing consistent, high quality anesthesia.
When I first asked Dr. Guy Leone to leave the hospital to work with me at Aestique, he expressed reservations. There were economic issues to consider, as well as having to adjust from the hospital environment to an ASC. But as he learned more about the benefits of practicing ambulatory anesthesia, he changed his mind and decided to come to our ASC. Although his salary was somewhat lower here than in the hospital, he would no longer have to worry about weekend or night call. He could spend more time with his family, and work with a lower risk, generally healthier group of patients in a more pleasant environment. These are key selling points you can take to any provider you wish to target. In our case, the fit has been perfect.
Dr. Leone not only directs anesthesia services at Aestique, he also runs our pain management services. Our experiences with him have been so positive that we subsequently hired a second full-time staff anesthesiologist away from the hospital. The care of the two doctors is supplemented by part-time CRNAs, who work under the supervision of the two anesthesiologists. Pennsylvania lets CRNAs work under any physician's supervision, but our facility insists on the presence of an anesthesiologist to supervise.
Customer service
It helps to have a top-notch anesthesiologist on staff to not only assess the patient anesthesia needs and plan an anesthesia strategy accordingly, but also to listen sympathetically to patients' concerns, explain what will be happening and answer questions on a level they can understand. As we all know, anesthesia is one of the areas of the surgical experience that scares patients, especially pediatric patients.
It has always been my philosophy to sacrifice a degree of profit margin to go above and beyond even the most stringent standards of safety and patient care, in part because we are not located in close proximity to an acute care facility. It is even more crucial that we take extra precautions to make sure nothing goes wrong with our ambulatory cases.
This ideology manifests itself in many ways, some of which are obvious to the patient, some of which are not. The patient may not care that we are sticklers for maintaining JCAHO accreditation or that we employ a staff anesthesiologist. All they know is that we have a dedicated staff seeing to their care in every way possible.
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