Anesthesia Alert: Services Without the Subsidies: Here’s How

A veteran CRNA’s strategies to maintain sustainability and profitability.

A concerning trend in ambulatory surgery is the growing need to subsidize anesthesia services. ASCs, designed to provide cost-effective and high-quality surgical care, are grappling with the financial burden of maintaining anesthesia coverage without compromising on safety or patient satisfaction. Increasingly, ASCs are being asked to subsidize anesthesia services, meaning they pay fees to their anesthesia groups to cover the gap between the revenue their services generate and the costs of providing them.

Let’s examine the factors contributing to rising anesthesia costs and, more importantly, the strategies that can decrease or mitigate your ASC’s need to subsidize anesthesia.

Driving factors

Here’s why subsidies have come into play.

• Increased competition for anesthesia providers. Demand, particularly in outpatient settings, has outstripped available supply, leading to rising costs. In many regions, the bar for a competitive salary is rising every six months.

Historically, ASCs attracted anesthesia providers with lifestyle perks such as set working hours and no holidays or weekends, coupled with a strong commercial payor mix. That was once enough to draw anesthesia providers on a fee-for-service basis. It’s no longer enough, however.

The gap between ASC and hospital salaries has widened to the point where providers are increasingly willing to forgo lifestyle perks in exchange for higher pay. With hospitals increasing their subsidies and salaries, and Medicare reducing anesthesia reimbursement, the appeal of higher hospital pay — despite concerns about operational efficiency or declining per-case revenue — has become too significant for anesthesia providers to ignore. As a result, ASCs are finding subsidies necessary to attract and retain qualified anesthesia providers.

• Shift in payor mix. An increasing number of ASC cases are covered by Medicare, Medicaid or other government payors, which offer lower reimbursement rates than private insurers. Because these payors provide less compensation for anesthesia services, ASCs face reduced revenue per case, making it difficult to cover anesthesia provider salaries without subsidies. This shift directly impacts ASCs’ profitability.

• Case complexity. Demand for specialized anesthesia care grows. These cases often require highly experienced — and more expensive — anesthesia providers. For example, outpatient total joint surgeries rely heavily on anesthesia providers who are proficient in ultrasound-guided nerve blocks. This not only reduces the pool of qualified anesthesia providers, but ASCs also must invest in high-quality ultrasound machines, along with the associated maintenance and disposable supplies, further driving up operational costs.

How ASCs can adjust

Given these current challenges, ASCs should adopt the following proactive strategies to reduce reliance on anesthesia subsidies.

• Enhance OR efficiency. Scheduling cases well into the evening on some days while other days have few to no cases is inefficient. Paying staff overtime on long days and underusing them on others is not cost-effective, and leads to burnout, low morale and high turnover.

This problem is compounded by pressure placed on anesthesia providers to approve marginal cases that may not be appropriate for an ASC setting. Often, patients are already in pre-op before anesthesia providers can thoroughly review their charts for appropriateness.

This puts them in a difficult position. They feel pressured to make rushed decisions, increasing the risk of costly errors in judgment that can lead to poor outcomes and the risk of lawsuits against the provider and the center. When anesthesia providers feel pushed into unsafe situations, it often leads to a decrease in job satisfaction, making it even more difficult for ASCs to retain them.

To combat these problems, ASCs would be well-served to implement policies that eliminate 11th-hour add-ons and mandate definitive stop times to prevent late-running cases. By standardizing case start and end times and enforcing strict adherence to the schedule, ASCs can better predict and control anesthesia staffing needs. This not only can significantly reduce overtime pay and staffing-related inefficiencies but also improve overall workflow. It ensures anesthesia providers and other staff are utilized optimally each day while having the ability to truly vet whether patients are appropriate for surgery at an ASC. A more structured schedule allows a center to better control labor costs, improve job satisfaction and create a safer work environment for anesthesia providers, staff and patients.

ASCs must shift from a surgeon-centric model to one that prioritizes operational efficiency and cost control across the board.

• Optimize surgeon block utilization. ASCs that indulge surgeon-driven priorities, such as individual preferences for block time or inconsistent scheduling, are no longer viable in today’s hypercompetitive environment.

When surgeons efficiently fill their allocated blocks, OR resources are maximized, leading to increased revenue. Underutilized blocks result in wasted resources and unnecessary costs, particularly when anesthesia providers are left idle. In the context of daily anesthesia rates, where providers will go elsewhere if not guaranteed a miminum, it becomes unreasonable to expect anesthesia groups to absorb the cost of non-productive staff.

A focused, efficiency-driven block model can avoid such waste. Encourage your surgeons to fully utilize their current block times before requesting additional slots to prevent the need for multiple ORs running half-day schedules. By adopting a more structured approach such as sequentially filling ORs or ensuring that a full day’s schedule is completed in one room, the need for additional anesthesia teams is reduced, lowering the ASC’s overall financial burden.

• Transition to an efficiency-driven anesthesia model (EDAM). Certified registered nurse anesthetists (CRNAs) like me are highly skilled providers who deliver the same high standard of care as physician anesthesiologists at a lower cost. CRNAs are fully qualified to administer anesthesia in a wide variety of settings, including complex surgeries performed in ASCs. By shifting to a CRNA-only EDAM model, ASCs can significantly reduce anesthesia expenses without sacrificing quality or patient safety. CRNAs can perform independently in most states, offering ASCs greater flexibility and autonomy in managing anesthesia services. Learn more about EDAM.

System reset

The increasing need for anesthesia subsidies in ASCs is not just a temporary financial hurdle. It’s a sign of fundamental challenges in how many ASCs operate. However, it also presents ASCs an opportunity for strategic reform.

ASCs must shift from a surgeon-centric model to one that prioritizes operational efficiency and cost control across the board. These measures will help ASCs retain providers, improve patient outcomes and become more sustainable in the long run.

Successful implementation of these strategies requires active collaboration among surgeons, anesthesia providers and administrative teams, all of whom must embrace an efficiency-driven model. By prioritizing collective goals over individual surgeon preferences, ASCs can minimize anesthesia subsidies and ensure long-term success in a rapidly changing healthcare landscape. These cost-saving initiatives can help ASCs maintain their mission of delivering high-quality, accessible care while staying financially viable.

Only those willing to innovate will secure their place in the future of surgical care. The time to act is now. OSM