Here, Thomas Wherry, MD, practicing anesthesiologist and principal of Total Anesthesia Solutions and consulting medical director for Health Inventures, shares his insight into the current state of anesthesia in surgery centers.
Rapid growth of ASCs is spreading anesthesiologists thin
In the past, surgery centers were the preferred choice for many anesthesiologists because they offered a more productive schedule and preferred payor mix than hospitals. Recently, however, with the growth of ASCs and the continued movement of procedures from the hospital to the multi-room surgery center and then from multi-room surgery centers to single-room, office-based centers , many anesthesiologists and their groups are required to cover more locations without having more revenue, according to Dr. Wherry.
“As we see a trend towards more single-specialty or single-OR surgery centers, anesthesiologists are spread thin,” he says. “Many groups have had to hire more people to cover all of the operating rooms in an area, without seeing an increase in the number of procedures. It’s becoming harder to cover costs.”
Dr. Wherry notes that surgery centers are seeing a growth in the number of Medicare patients they treat, where in the past fewer procedures were covered by Medicare. As a result, reimbursement for anesthesiologists in the surgery center setting is not as profitable as it once was.
“Many centers are not as productive as they used to be,” Dr. Wherry says. “Anesthesiologists are also becoming less tolerant of inefficient scheduling because they are receiving generous subsidies from hospitals, which are allowing them to be made whole. As a result, some are thinking of pulling out of the surgery center setting.”
However, for many anesthesiologists, the surgery center is still a preferred setting, as they are not required to work on-call weekends and often have to deal with fewer demands than in other settings.
Increasing obese population presents challenges
According to Dr. Wherry, the growing number of obese patients and those with obstructive sleep apnea can present challenges for anesthesiologists as far as determining which patients they can safely treat in the surgery center environment.
“Many anesthesiologists are faced with difficult choices when it comes to these patients,” Dr. Wherry says. “They need to decide where they draw the line. Is it at 300 pounds? 350 pounds? They need to determine the safest way and place to perform the surgery.”
As a whole, surgery centers are seeing “less healthy cases” than they saw in the past, according to Dr. Wherry, which is due in part to the growing obesity problem and the increasing numbers of Medicare patients seen at centers.
“These populations are testing the skills of the anesthesiologist and their pre-op protocols,” he says. “Scheduling and patient screening is ultra important. Delays on patient, surgeon, facility and even anesthesia’s part can have huge domino effects.”
Dr. Wherry notes that the decision to operate can be complicated by indirect pressure by surgeon owners or others who are also looking at the revenue a procedure can bring to a center. The anesthesiologist may also be the only one on staff; therefore, the decision to operate or not to operate may fall solely on his or her shoulders.
“Anesthesiologists often need to become the gatekeeper of safety in these procedures. It is very difficult to set a standard ASA cutoff — an ASA 3 patient for cataract [surgery] is not the same as one for a shoulder or gall bladder removal,” Dr. Wherry says.
Evolving techniques require new technology
More orthopedic surgeons are requesting regional nerve blocks for their patients, often in combination with light general anesthesia, says Dr. Wherry. However, many new anesthesiologists who are coming out of their training have only learned to do this procedure using ultrasound machines, which can cost around $30,000. This may be a capital investment some surgery centers cannot afford.
“Surgery centers don’t have the capital of hospitals, and many administrators are operating on a shoestring budget, so they cannot afford that kind of a cost to bring on a newer anesthesiologist,” Dr. Wherry says.
Dr. Wherry also says that many anesthesiologists are working with older machines and older monitors, which can often make performing these blocks and providing quality anesthesia a challenge, especially for those who are coming out of training.
Surgery centers need to work with their anesthesiologists
In spite of these challenges, surgery centers are still excellent settings for anesthesia groups, according to Dr. Wherry. Surgery center administrators and physician owners need to be willing to work with anesthesiologists and groups to keep them pleased with their experience in the ASC.
“Surgery centers should make every effort to preserve their relationships with their anesthesia groups and should understand how things are working for the group at the center,” Dr. Wherry says.
He suggests establishing a point person for larger anesthesia groups who the center can meet with to check in with the group and make sure that the group is satisfied with how operations are going. Sending out satisfaction surveys to the anesthesia group, which are typically sent only to surgeons, can also help centers keep on top of how their anesthesiologists are doing, according to Dr. Wherry.
Most importantly, Dr. Wherry says surgery centers should get input from their anesthesia group and make sure they are part of critical discussions about the center’s operations. One area of particular interest to anesthesiologists is scheduling.
“Most anesthesiologists prefer vertical scheduling to horizontal scheduling,” Dr. Wherry says. “Rather than spreading fewer surgeries across several rooms, it can be more beneficial for the anesthesiologist and the center to rearrange the schedule so you can do the same number of cases in fewer rooms.” By doing this, he notes that less staffing is required by both the surgery center and the anesthesia group, and this can result in more productive, and happier, anesthesiologists.
“It is also important that the anesthesia group provides a contact for pre-op screening questions,” Dr. Wherry says. “Typically, successful centers will have a ‘go-to’ or ‘on-call’ anesthesiologist to help with difficult pre-op questions. While ensuring patient privacy, the centers should also use technology like mobile e-mail or texting to stay in touch with their lead anesthesia providers.”
Talking with the group and keeping them involved in surgery center decisions can help the center and the group establish a solid and positive working relationship.
Opportunities exist for anesthesiologists at surgery centers
Dr. Wherry points out that opportunities still exist for anesthesiologists at surgery centers, especially those who are considering a change in their career or looking for new paths.
One opportunity he suggests is become a surveyor for the AAAHC or other accreditation company. “Anesthesiologists can lend their views to developing new policies and procedures for multiple surgery centers to use,” Dr. Wherry says.
The difficult economic market can also provide some opportunities for anesthesiologists. “Many centers are on the decline because of lower case volumes and may be in the process of being taken over,” Dr. Wherry says. “Anesthesia groups can see this as an opportunity to step in where another group pulled out.”
Dr. Wherry compares this to the foreclosure market. As the struggling center turns around, he says that the anesthesia group can use this time to work hard and establish a strong and secure position in the surgery center. “Then, in a few years when the case volume increases and the center starts to do better, the group will be in a good place with the surgeons and the management,” he says.
Dr. Wherry is the co-founder of Total Anesthesia Solutions (www.totalanesthesiasolutions.com), a company dedicated to addressing the emerging anesthesia subsidy crisis and developing innovative anesthesia service solutions for practitioners, hospitals and major health systems. He is also medical director for the Surgery Center of Maryland and consulting medical director for Health Inventures and has collaborated with professionals in the United Kingdom, Japan and Kuwait to improve the delivery of ambulatory surgery.
