ASC leaders face a uniquely challenging landscape when it comes to anesthesia. Provider shortages are causing salary inflation, while at the same time, third-party payers are systemically cutting anesthesia reimbursements.
To learn more about the importance of maximizing anesthesia efficiency in ASCs, Becker's Healthcare spoke with Tracy Young, MSNA, CRNA, co-founder and COO at Essential Anesthesia Management and member of the American Association of Nurse Anesthesiology (AANA) board of directors.
Question: Why is it important to achieve anesthesia efficiency in ASCs today?
Tracy Young, MSNA, CRNA: Historically, anesthesia and ASCs have been able to cover their own costs, but that's becoming much more difficult in today's environment. ASC operators must take a closer look at pulling other levers to gain efficiencies. Without gaining efficiencies, we'll continue to see anesthesia subsidy requests increase in frequency and size.
Q: Do you see a time in the near future where the supply of anesthesia providers will start to catch up with demand — why or why not?
TY: That's a tough question to answer since forecasting models are only as good as the assumptions used to make the forecast. Innovation in technology and surgical procedures, as well as new medications, are constantly changing trends in surgery and anesthesia. That makes it harder to accurately forecast future demand, in my opinion.
However, we do know that the supply of anesthesia providers is increasing. Anesthesia residency matches are at a record high for the fifth year in a row and CRNA programs have been increasing their admissions and class sizes. In the U.S., there are now 137 accredited CRNA programs, with 15 new programs in capability review. All of this points to an increase in supply in the near future. That should help the imbalance, as long as there isn't a black swan event that causes a drastic increase in retirements.
Q: During this time of anesthesia provider shortages, what are operational strategies that ASCs should consider implementing?
TY: The primary focus in anesthesia should be that all providers deliver care safely and at the top of their skills, training and licensure. All providers functioning as such is the most efficient strategy. From a general standpoint, I like to look at operations using a framework developed for healthcare policy that focuses on the three E's of healthcare delivery: effectiveness, efficiency and equity.
- Effectiveness means safety and good outcomes for your patient population. ASCs are fortunate because they typically have lower anesthesia risks. The two main risk factors in anesthesia are patient comorbidities and the length of time needed for general anesthesia. ASCs usually have healthier patient populations and shorter anesthesia times, which lead to increased safety. In addition, anesthesia has become much safer in the last 30 years.
- With that baseline knowledge, we can turn toward efficiency. This is all about getting the most output with the least input or cost from anesthesia in ASCs. The question to ask is, what is the optimal anesthesia staff in terms of numbers and provider mix to deliver care at an ASC. It's important to consider the number and type of anesthesia providers in the geographical area, as well as the ASC's financial resources. For example, does the ASC have the capital to support an all-MD anesthesia model, an all-CRNA model or some mix of the two where everyone practices to their fullest ability, training and scope — to most efficiently meet the needs of the patient population?
- Equity is all about access to care. It's often a more macro discussion than an individual ASC staffing model, but the goal is to identify an anesthesia practice model that can best meet the needs of the population in terms of care access.
Q: Besides operational efficiencies, what opportunities for financial efficiencies should ASCs consider?
TY: Historically, people have immediately looked at cost-cutting as the way to improve financial efficiency. I'd like to steer readers away from that. Anesthesia provider compensation makes up 85% to 90% of the total cost of delivery, with the remainder consisting of billing costs, medical malpractice, scheduling, credentialing, software, etc. That leaves few options other than cutting provider compensation. Unless you are already paying way above market compensation, I'd argue that it would be a bad idea to cut provider pay in this market of under-supply.
I’d recommend looking at revenue generation and making sure that revenue cycle management functions are operating efficiently in today's environment. Questions to ask related to revenue generation include:
- Have you renegotiated your commercial contracts to keep pace with wage inflation?
- Are you meeting industry benchmarks on collections activity?
- Are you converting cases to clean claims and getting cash in the door quickly for anesthesia services?
Efficient operation of operating rooms and anesthesia provider utilization are also essential. Key questions include:
- Are you enabling anesthesia providers to generate revenue? If they are in cases for 60% or more of an eight-hour day, that's a good sign.
- Are surgeons starting and ending on time? That decreases gray schedule space in the middle of the day and reduces the number of cases that run after hours.
Q: Where can our readers find more information about anesthesia efficiency and the topics we discussed?
TY: Anesthesia Facts' website is a great source. It includes information about the three E's and more.