Russ Greene, administrator of Physicians' Surgery Center in Fayetteville, Ark., lists seven mistakes ambulatory surgery centers make when contracting with anesthesia providers.
1. Using the same group as another ASC. A center that uses the same anesthesiology group as a competing surgery center in the area may find some inside information gets picked up by the competitor. "Anesthesia providers love to talk," Mr. Greene says. "The surgeon may start discussing issues about the facility in the operating room during a case. You can count on it getting back to your competitor."
There are exceptions. If the center is using a very large anesthesia group, different providers may be permanently assigned to different facilities. But even in this case, an anesthesia provider may be switched to another location when someone goes on vacation.
2. Hiring hospital-based providers. Hospital-based providers may be inexperienced with outpatient surgery. "It's a different mindset," Mr. Greene says. While cardiac surgery in the hospital requires the patient to be asleep for many hours, outpatient anesthesia requires use of different kinds of drugs that allow the patient to awaken more rapidly.
However, not all hospital-based anesthesia providers lack outpatient experience. For example, the provider may have worked at a rural hospital that focused on outpatient cases.
3. Selling shares to anesthesia providers. The center might have promised shares to providers to attract them into the ASC, but unless they are performing pain procedures, fewer shares will be going to revenue-producing physicians. Also, when anesthesia providers hold shares, it is more difficult to switch to a new provider. "We were in this situation once," Mr. Greene says. "It tied up the shares for a long time and we ended up having to pay the anesthesiologist the highest allowable rate to buy back his shares."
4. Not using CRNAs whenever possible. Anesthesiologists may not like it, but certified registered nurse anesthetists are capable of doing their work. "My experience is that CRNAs can be just as effective as anesthesiologists," Mr. Greene says. "They don't always have the ego that some MDs have, and they are generally easier to get along with." However, regulations in some states still require on-premises supervision of CRNAs by anesthesiologists. Also, some surgeons insist on using an anesthesiologist rather than a CRNA. This can be worked out. Having one anesthesiologist on site supervising several CRNAs can still be cost-effective in a very large ASC.
Reimbursement considerations also come into play. Medicare and some private payors won't cover CRNA administration of certain blocks, such as for total joints. And in some situations, an anesthesiologist can bill at a higher rate than a CRNA, which means more money for the center when it employs the anesthesiologist.
5. Signing a management agreement. In exchange for handling a center's anesthesia services, an anesthesiology group might insist on managing the center through a surgery management agreement. The anesthesiologists see this as a way to increase their revenue and a few sympathetic surgeons on staff may back them up.
"Don't let this happen," Mr. Greene says. "It puts anesthesiologists in control of your surgery schedule." But if the ASC is forced to accept a surgery management agreement, it should have the option of dropping out if the anesthesiologists fail to provide a certain level of services. For example, poor turnover times might be cited as a reason to get out of the contract. Furthermore, the board should be able to overrule the group on key management decisions.
In some locales, the anesthesiology group may be the only game in town, forcing the center to accept the management agreement. "If you are forced to do this, don't get involved in a long-term agreement," Mr. Greene says. "You never know when another option may come along."
6. Letting anesthesia determine case mix. Contracted anesthesiologists may decide they cannot provide support for total joint or spine cases, effectively vetoing the center's ability to add those cases and grow volume. "Letting anesthesia providers determine what cases can and cannot be done in your center is a big mistake," Mr. Greene says. "Agreeing only to do the easy cases doesn't make your center competitive." The governing board, not the anesthesia providers, should be deciding what cases can be done at the center.
Before taking action against the reluctant anesthesiologists, a middle step would be to ask them to get some training with another anesthesiologist who does cover the procedure at another center. But if they won't agree to that, there should be a way to replace them. "If an anesthesia group does not want to handle certain cases, there should be a clause in the anesthesiology contract allowing the center to bring in anesthesia providers who will do those cases," Mr. Greene says.
7. Hiring semi-retired providers. Semi-retired anesthesiologists are often slower than younger colleagues and are accustomed to inpatient anesthesiology. "The older anesthesiologist wants to slow down and not take call anymore," Mr. Greene says. "Furthermore, he may have worked at the hospital for 30 years and is not used to the outpatient setting." Younger anesthesiologists are more likely to be trained in outpatient procedures during residency and they will have the energy needed to staff a dynamic center.
An exception might be a center that has both young and old anesthesia providers because they can develop a synergy between each other. "They can bounce ideas off one another, and the younger physician may be able to teach new approaches to the older one," Mr. Greene says. "They can collaborate."
Learn more about Physicians' Surgery Center.
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