Imbalances of supply and demand in the anesthesia workforce are causing paradigm shifts in how ASCs are ensuring they can meet their anesthesia service demands. To accomplish this, practices need to think outside the box and get creative in their approaches to anesthesia staffing.
Since the COVID pandemic shutdown, demand for surgical services, and hence anesthesia services, has exploded. Primary factors for this surge in demand are an aging population, greater access to health care, and an overall increase in the need for anesthesia in areas outside the operating room.1 This demand has outpaced the number of new anesthesia clinicians entering the workforce, leading to labor shortages.
Combined with the labor shortage, there has been a declining reimbursement trend for anesthesia services. Medicare anesthesia payments have decreased 20.8%, adjusting for inflation, between 2000 and 2020.2 That trend continues. Medicare’s cuts for anesthesia services for 2025 are another 2.2%.3
Commercial carriers in your payor mix may help offset these cuts, but it is estimated that Medicare anesthesia payments are 12 to 33% of commercial carriers.2 (Liang et al., 2024) As the population ages, more and more patients will be presenting with Medicare as their primary insurance.
This is the perfect storm of increasing demand, workforce supply shortage, and declining reimbursement. The resulting disequilibrium has led to rising anesthesia salaries in a sinking reimbursement environment. Many have already felt the pain of having far more demand for anesthesia services than the anesthesia provider supply can support, leading to no coverage, or are having to pay premiums and stipends above the anesthesia revenue generated to ensure coverage for surgical cases.
Our Model
Consider a Hybrid
What can be done? How can we avoid this financial Armageddon? Get creative. We won’t go into the myriad of arrangements of how anesthesia services are procured for ASCs. We use a hybrid employment model of CRNAs that has managed to keep anesthesia services profitable, the CRNAs compensation is in the top percentage bracket, and most importantly, surgical demand is met with quality anesthesia services.
What is this hybrid model? A hybrid of what? It is a hybrid of a 1099 employment model and a W2 employment model for CRNAs. 1099 employment models for CRNAs generally amount to the ASC and the CRNA contractually negotiating coverage. The contract is tailored to the needs of the ASC and CRNA.
The CRNA can be an independent contractor, do their own billing and receive the revenue from the fees generated by providing anesthesia service. They can contract as a 1099 employee and negotiate their fees. The actual dollar amounts tend to be higher in a 1099 scenario because there aren’t any employment costs such as providing benefits associated with this model. The W2 model is quite familiar for most. CRNAs are hired by the ASC for an established salary, are provided a suite of benefits, and work directly for the ASC or practice.
Actual salary amounts trend lower than the 1099 arrangement because benefits are provided. We have created a hybrid of the 1099 and W2 models.
Benefits
The ultimate goal of any model should be to provide the care patients are needing in a timely fashion. This model creates alignment among patients, surgeons, the ASC, and anesthesia providers to achieve that goal. With having dedicated anesthesia providers, surgery schedules can be maximized and patient wait times can be minimized. Another attribute of this model is there are built in incentives for increased production.
In this model, the more we do, the more we make. It’s as simple as that.
We will provide the framework of this model. We are classified as W2 employees. We receive a suite of benefits such as health, dental, life, and short-term disability insurances, 401k retirement, and other benefits typically provided all employees. Paid time off is not part of the suite of benefits. Compensation, time off, and coverage for any absences is the 1099 component of this model.
For time off, we are responsible for finding locum tenon coverage and those fees are paid by us. We do everything in our power to make sure we cover each other as much as possible, to keep those revenues in house. Invariably there are times where we need locum coverage. We have a pool of locum CRNAs, credentialed at our ASC, that we can count on to cover in our absences.
Yes, you read that correctly earlier. We are responsible for paying those locum fees. Read on for my explanation of how that works.
More on Compensation
Our compensation is based on receiving a percentage of the anesthesia revenue per case. We each keep track of our case counts and make sure we are equally sharing higher volume, higher revenue generating cases such as anterior segment cases with lower volume, lower revenue generating cases such as oculoplastics. In the case of needing locum coverage, our percentage of revenues are high enough, and volume of cases are high enough, that they will cover the hourly fee we pay our locum tenon CRNAs. It maintains a revenue- neutral situation when we take time off.
Also, raises and increasing compensation are tied to the performance of the ASC. Growth in ASC volumes provides growth in CRNA compensation.
The mechanics of how we accomplish this model are noteworthy. We each take a salary. The salary is essentially a draw on our portion of the anesthesia collections. Each quarter, we receive a statement. We see the topline revenue we generated, minus expenses. Expenses are the salary we were paid, any locum tenon expense paid, and any legitimate business expenses such as educational seminars, certification fees, and licensure fees.
Whatever revenue that remains is paid as a bonus.
There is also a cost, if you will, involved with this model. It is imperative to maintain surgical volumes at a level that allows for adequate revenue. If the surgical volumes aren’t maintained, this model has the potential to fall apart rather quickly.
Cost and Production Pressures
This has been a winning formula for the surgeons, the ASC, the CRNAs, and most importantly, the patients we serve. There are costs to be borne by the ASC. There are employment costs. All the employment costs typically associated with a salaried employee are present in this model.
There are also production pressures inherent in this model. For the ASC and ophthalmology practice to remain profitable, and for the CRNAs to be compensated at a level where their compensation will be in a range to keep them motivated and engaged, a certain volume of surgeries must be coming through the ASC.
This model is dependent on adequate surgical volume for the numbers to make sense.
A Winner on Every Measure
In the current environment of increasing anesthesia salaries and costs and decreasing reimbursement, ASCs need to be creative in how they procure anesthesia services. Many of the old models are either too expensive, do not provide enough coverage, or both. This model has been a win for us.
By sharing the revenue generated, we have achieved alignment between the surgeons, the ASC and CRNAs. We are able to meet the needs of our patients in a timely fashion. We are maintaining a top percentile compensation package for CRNAs. We are maintaining anesthesia coverage for the ASC—and accomplishing all of this while remaining profitable. OASC
References
- Moura T. Breaking down the anesthesia workforce imbalance, strategies to address crisis. OR Manager. 2024, June 26, 2024. Accessed: May 23, 2025. https://www.ormanager.com/briefs/breaking-down-the-anesthesia-workforce-imbalance-strategies-to-address-crisis/
- Liang CJ, Gal JS, Miller TR, Hannenberg AA. (2024). Medicare payment trends compared to inflation for anesthesia services. Journal of Clinical Anesthesia, 97, 111505. https://doi.org/10.1016/j.jclinane.2024.111505
- CMS Releases CY 2025 Medicare Physician Fee Schedule Final Rule | Insights | Holland & Knight. (2025). Hklaw.com. https://www.hklaw.com/en/insights/publications/2024/11/cms-releases-cy-2025-medicare-physician-fee-schedule-final-rule
