Ophthalmic ambulatory surgery centers (ASCs) face the ongoing challenge of managing costs while maintaining high-quality patient care. Anesthesia, a critical component of surgical procedures, represents a significant portion of these expenses, and ASCs are pulling out all the stops to hold them in check. However, ongoing shortages of anesthesiology providers, the rising cost of supplies, and regulations that vary by state with respect to governing anesthesia services make controlling anesthesia-related expenses very difficult. Moreover, there is no single strategy, or combination of strategies, that will work for every facility. 

“I wish there were some very helpful tips that can work for everybody, but every locale is different, and every ASC has a different set of circumstances,” says Dan Chambers, CEO of Key-Whitman Eye Center in Dallas, Texas. “There is no one solution that fits all, and surgery centers have to be creative in adapting to the constraints they have in their local region.”

That said, ASC leaders do have options. Implementing clinical changes in anesthesia protocols, managing labor expenses, optimizing patient volume, and efficiently utilizing operating room (OR) time and space can all help keep anesthesia services affordable.

Improve Staffing Efficiency

Providing anesthesia services is one of the most costly aspects of operating an ASC; it is likely to become even more expensive due to declining reimbursements, a continuing shortage of providers, and increasing salaries. Medicare reimbursement for anesthesia base units has declined by nearly 9 percent over the past six years, from $22.27 per base unit in 2019 to $20.44 in 2024, according to the Centers for Medicare and Medicaid Services (CMS).¹ Meanwhile, the shortage of anesthesiologists nationwide is expected to reach 12,500 by 2033, according to a recent American Association of Medical Colleges (AAMC) report, and the shortage of certified registered nurse anesthetists (CRNAs) could reach 7,800 by 2028.² 

All these factors are generating increased competition for anesthesia providers—and not just among ASCs. Some CRNAs, for example, are establishing their own ketamine clinics and increasingly working with dental practices. In the former, they work with psychiatrists to treat mental illnesses such as depression and post-traumatic stress disorder with the anesthetic ketamine. In the latter, they’re working with oral surgeons who are increasingly creating their own surgery centers inside their clinics.

“The problem is that with the burnout of W2 employed anesthesia providers, they are transitioning to being independent contractors where they can make more money, work less, and enjoy their lifestyle a little bit more—do more traveling and take more time off,” says Ami Grube, chief financial officer of Aurora, Colorado–based practice CPR Anesthesia, Inc. 

“At smaller clinics and ASCs, they may only go in and do one or two procedures for the day, but it’s paying very well, so now they don’t need to go and work an eight-hour day at the surgery center or hospital. They can go and work a couple cases and be done for the day.”

Anesthesia provider pay has been rising dramatically in recent years. According to the MGMA 2023 Provider Compensation and Production Survey Report, from 2021 to 2022 anesthesiologist pay increased 15 percent while CRNA pay increased 4.4 percent. As a result, average anesthesiologist compensation is now nearly $500,000 per year, while CRNAs are commanding an average of $214,200, up from $181,040 in 2019.³ In some cases, CRNAs are commanding anywhere from $250,000 to $300,000, depending on market, says Cassie Syme, a consultant with Progressive Surgical Solutions. Independent contractors can make upwards of $300,000 to $500,00 per year, Grube adds.

“In Atlanta for instance, the price for CRNAs is exorbitant because CRNAs talk to each other,” Syme observes. “One will tell their friend, ‘I’m getting paid this much over here. You should be getting the same amount where you are.’ This behavior has pushed salaries to a place that is not sustainable.”

Figures like these force ASCs to look for ways to optimize staffing models. One strategy is to match surgical schedules to prevent overstaffing and underutilization of anesthesia providers. For example, implementing flexible staffing schedules, where anesthesia personnel are on call or part-time during low-volume periods, can align labor costs with demand. Cross-training perioperative nurses to assist with anesthesia-related tasks, such as monitoring patients during and after surgery, can reduce the need for anesthetist presence in the OR, freeing them for other cases.

“Our CRNAs also don’t necessarily go into the operating room,” Chambers says. “We only do local topical anesthesia, so our cases run fairly quickly, and the CRNA spends most of the time, if not almost all of the time, in the preop area sedating patients for the next procedures.” Key-Whitman employs four part-time CRNAs between its two surgery centers.

Key-Whitman, however, is a large clinic and ASC in the Dallas metro area. Many ASCs in smaller markets, particularly rural locations, must turn to locum tenens agencies to supply per diem CRNAs. Some with low patient volume are going so far as to import CRNA help from distant locations, requiring an agency to pay for mileage and overnight stays in hotels, says Syme, who spent 12 years working with a recruiting firm that specializes in anesthesia providers.

“We even had to pay for flights. As long as a CRNA has their license in that state, you can fly them in, and sometimes it’s cheaper to fly them in than pay for [CRNAs who are from the local area],” she says.

“We’ll bring people down from the city,” agrees Grube. “We’ll have to put them in hotels if we need to from time to time, especially weather pending. [It’s important for ASCs] to know they have options outside of their local market.”

Standardize Anesthesia Protocols

Adopting a consistent approach to anesthesia selection and administration can help reduce variability, streamline drug use, and minimize waste. Utilizing local or regional anesthesia balances patient comfort with safety and the best outcome in a highly cost-conscious climate. Newer surgical techniques for eye surgery have somewhat reduced the need for peribulbar and retrobulbar blocks and increased the popularity of topical anesthesia. Also, anesthesia providers are utilizing shorter-acting drugs with fewer side effects, such as propofol. These can reduce recovery time, accelerate OR turnover, and lead to considerable savings, says Syme. CPR Anesthesia also advises providers not to draw too much medication for too many cases too far in advance to reduce the risk of wasted anesthetics.

“One or two cases is one thing, but what happens when a case cancels, and now you have to waste all those medications,” Grube says.

Optimize Patient Selection

Ensuring efficient scheduling to maximize the number of cases performed each day helps distribute fixed anesthesia costs over a larger number of patients, reducing per-case cost. For instance, block scheduling to reserve specific times for high-volume surgeons can enhance OR efficiency and ensure consistent patient flow. Reducing cancellations and no-shows with automated reminders can also help maintain steady patient volume, maximizing resource utilization. One important component of this strategy is to perform preoperative patient assessments to identify potential health issues that could increase the risk for anesthesia-related complications. 

Some patients—such as those with diabetes, heart disease, and/or obesity—will need a more extensive review to ensure they are healthy enough for anesthesia. Syme says. A thorough evaluation will help reduce overall risks for the patient and potentially decrease complications, delays, and cancellations. 

“Say they have a cardiac crisis because of a condition that wasn’t previously caught. Now you’re spending more time because you need to take care of that patient, and you’re taking away from time that you could be using to perform procedures,” Grube notes.

Leverage Technology

Although the HITECH Act requires hospitals and physician practices to use electronic medical record (EMR) systems, ASCs are instead subject to the Centers for Medicare and Medicaid Conditions for Coverage regulations, which do not specifically mandate EMR use. Nevertheless, an EMR system can help streamline recordkeeping as it relates to anesthesia billing and coding, says Syme. “A lot of EMRs have additional applications that can record the patient’s blood pressure and oxygen levels directly to the EMR and it doesn’t have to be manually written down. They cost extra, but they’re amazing because the anesthesia provider doesn’t have to spend time writing and documenting this information,” Syme says.

ASCs can also turn to third-party anesthesia management companies for administrative help when it comes to credentialing, billing, and coding. 

“If you don’t credential that anesthesia provider with … Medicare, Medicaid, and your commercial carriers, you’re not going to get paid on that provider, no matter what your efforts in billing and coding look like,” says Grube, who adds that ASCs must use American Society of Anesthesiologists (ASA) codes, a subset of CPT codes, to bill for anesthesia services. Dedicated billers and coders can ensure accuracy and timely reimbursement, but navigating the time-consuming complexity of proper coding may be handled more efficiently and economically by an outside agency, Grube says. 

Everything’s Negotiable

Finally, the importance of negotiating contracts with anesthesia service providers and anesthetic suppliers should not be overlooked as a cost-saving measure. Although larger facilities typically have more power to negotiate favorable rates, small ASCs can join to form group purchasing organizations.

“It’s like with anything else, it’s how big are you in the market?” Syme says. “If you have a group of surgery centers that come together, then they have a bigger seat at the table, so then you have more negotiating power. If you’re just one little ASC out there with three rooms, forget about it. You cannot name your price because the suppliers can go to someone else down the street.”

Conclusion

As reimbursements continue to fall, ASCs must take a multifaceted approach to managing anesthesia costs. As Syme points out, “Things have changed. It was once a revenue driver, but now anesthesia is a cost center.”  

However, by optimizing staffing models, improving scheduling efficiency, selecting cost-effective anesthetics and protocols, and negotiating favorable contracts, ASC leaders can effectively control anesthesia expenditures without sacrificing high-quality patient care.

“ASCs do have options and resources, and tapping into those resources when they feel that they’re at a crossroads of how to handle a situation, whether that be anesthesia providers, protocols, or supplies, is the way to go,” Grube says. OASC

References

1. Centers for Medicare and Medicaid Services. Anesthesiologists Center. January 25, 2024. Accessed June 17, 2024. https://www.cms.gov/medicare/payment/fee-schedules/physician/anesthesiologists-center

2. Kaplan KC, Polanco K. Where Have All the Anesthesia Specialists Gone? Insights for Healthcare Leaders. October 12, 2023. Accessed June 17, 2024. https://www.veralon.com/where-have-all-the-anesthesia-specialists-gone-insights-for-healthcare-leaders/

3. Wallace C. Seven CRNA Updates in 2024. Becker’s ASC. June 12, 2024. Accessed June 17, 2024. https://www.beckersasc.com/anesthesia/7-crna-updates-in-2024