Current Trends in the Ambulatory Surgery Center Marketplace

What are some anesthesia trends/advances you're seeing in the ASC setting?

Lagging marketplace perception concerning the non-congruency between ASC and anesthesia financials. ASC facility fees almost always dwarf anesthesia professional fees.  As a result, a surgery center may turn a profit for a given operating room surgical volume on a given day but this volume may not provide ample compensation to support an anesthesiologist working for market rates.  For instance, let’s take a single room ASC performing three knee arthroscopies, each one hour—two Medicare patients and one commercial payer.  Illustratively, the ASC generates $3,750 and the anesthesiologist generates approximately $800 ($175, $175, $450), or about $208,000, $208,000, and $1,000,000 annually. For a small, single OR ASC, direct and indirect costs for the day may be covered and the ASC may turn a profit; for the anesthesiologist, however, the situation may not be ideal since $800 may not be fair market compensation for the day. As more and more surgery centers sprout up, the volume of surgery occurring in any one ASC operating room is unlikely to keep pace and what may be a compelling and profitable venture for a surgeon or ASC management company, may not be so for the anesthesia clinician. Over the next five to ten years, we predict that anesthesia subsidies will become more commonplace in the ASC setting.

What other challenges do ASCs face regarding anesthesia services?

Not uncommonly, when surgical volume does not provide for anesthesia department solvency, anesthesia clinicians will bill out-of-network to stay afloat. This, however, often taints the payor relationships ASCs may have worked long and hard to develop. It will also poison relationships between patients and surgeons and, even more concerning, relationships between surgeons and their referral bases.  Other times, anesthesia departments, satiated with robust out-of-network payments, will waive co-payments and deductibles.  Although this mitigates the previously mentioned acrimony of surgeons and patients, it creates compliance risks for the anesthesia group which can negatively affect the ASC’s reputation. Claims that your anesthesia group has been charged with UCR fraud will not help with the recruitment of patients or surgeons. 

The other major challenge ASCs face is anesthesia quality management.  In today’s world, providing stellar service requires clinicians to prove it.  This proof takes the form of quality measures that are recorded, abstracted, collated and analyzed. There are a myriad of quality measures and even more organizations that hold themselves out to be the authoritative sources. Making heads and tales of this is somewhat of a mix of art and science but more important, it’s the experience the “right” anesthesia management company can bring to the table that can make the difference.  One that offers a genuine and documented track record is critical. Sometimes, partnering with a large national provider of anesthesia services will ensure a focus on meeting accreditation standards while instituting a quality management program to help improve outcomes.

How do ASCs cope with anesthesia not reimbursed for many GI procedures? 

Anesthesia services are not free. Few would argue that they are anything other than valuable.  In fact, some studies have shown that having an anesthesiologist providing propofol sedation improves polyp detection. Payment for anesthesia services can come from three sources—patients, insurance companies, or the facility.  ASCs have to weigh multiple variables:

• Improved of polyp detection and utility to society
• Improved patient satisfaction and potential impact on patient recruitment
• Reduced  recovery time and the use of fewer nursing resources
• Fewer  side effects and more hasty recovery
• Patient ability to pay
• Patient unrest concerning out of pocket payments for their healthcare 

In the final analysis, some facilities may choose to subsidize the anesthesia group for those payors who choose not to reimburse while others may ask the anesthesia group to charge patients.  Asking your anesthesia provider to provide free care to a group of patients who are not covered, for access to patients who can pay, is nothing short of a kickback. After all, the anesthesia clinician is providing something of value (free anesthesia services) in exchange for referrals.

Tell me why you think anesthesiologists play an important role in the efficiency of an ASC.

The efficiency of an ASC can be dissected down to its components—preoperative, intraoperative and post-operative. In each of these areas an anesthesia company with broad and deep tenure in the ASC venue can marshal this experience to heighten efficiency. For instance, deploying screening questionnaires, efficiently completing preoperative evaluations or the use of preoperative regional blocks, all have the potential to improve efficiency outcomes. Intraoperative efficiency can be improved in a multitude of ways as well —from starting the intravenous prior to entering the operating room, to applying blood pressure cuffs or other monitors preoperatively, to choosing fat onset and quick offset techniques – all can all pare down the turnaround time.  The last way to improve intraoperative efficiency can also improve post-operative efficiency. A patient who arrives bright-eyed, pain free, and devoid of nausea may be able to go home sooner or even bypass recovery altogether. Similarly, being judicious with sedative and narcotic-based post-op remedies may help reduce recovery time.  All in all, the ability to improve efficiency extends as far as the experiences, know-how, and initiative of the anesthesia provider.

What are some benefits to providing anesthesia in an ASC?

Anesthesiologists who favor the ambulatory environment fall into several camps. Some prefer the lifestyle….no weekends, night and call duties.  Others might value what might be considered a more “collegial” environment. Since turnover, efficiency and teamwork can make or break an ASC, anesthesia clinicians who consider themselves connoisseurs of this type of clinical practice gravitate to the ASC. 

Some advice for those wanting to increase their anesthesia services in an ASC.

An increase in anesthesia service can be viewed through multiple lenses. If the goal is to have more hands on deck, coverage models that use anesthesiologists, certified nurse anesthetists, anesthesia assistants, and nurse practitioners for anesthesia-related tasking, often permit more coverage for the same or less cost. If greater service breadth is desired—such as regional anesthesia, pediatric anesthesia, medical director, or the like-- than recruitment of anesthesia clinicians or a group that offers these skills is a certain solution. Of course, working with the current group to have them increase their skill set is always a wise choice, assuming they are so inclined.