As ASC leaders seek to get soaring anesthesia costs under control, they are turning towards several clinical and operational shifts to get the job done.
More in-depth collaboration with anesthesia providers
ASC leaders have found success in building strong, collaborative relationships with their anesthesia partners and being more open to adjustments they may suggest.
“The most impactful improvement came from meaningful collaboration with our anesthesia group to sit down and discuss how we can trust their guidance on efficiency strategies. We took actionable steps on suggestions like adjusting block times, starts, asking for slightly more productive case mixes (such as sprinkling in some commercial cases, when possible),and even looking at ways that our providers could help with providing anesthesia to patients that we had traditionally excluded them from,” Tracy Helmer, BSN, administrator of Tri City Cardiology Surgical Center in Mesa, Ariz., told Becker’s.
Because surgery center management often centers surgeons’ preferences and schedules, collaboration with anesthesia professionals may open up new perspectives and opportunities for improved efficiency.
“We didn’t realize, until they helped us see, just how much unproductive time can occupy an anesthesia provider’s time, so we have to respect their time and work with them to show them that we really do appreciate them being here in our centers,” Mr. Helmer added. “It helps everyone and at the end of the day, care is shifting toward the ASC, so we want to make the ASC environment conducive for our anesthesia friends to come work. Getting them involved and trusting their advice is a great way to do so.”
Opioid-sparing techniques
As surgical procedures shift towards the outpatient setting, patients and physicians alike are increasingly interested in anesthetic techniques that lead to smoother, speedier recoveries, particularly those that can reduce or eliminate opioid use.
“Especially in ASCs … they don’t want prolonged recovery,” Gavin Baker, CRNA, CEO of New Orleans-based Krewe Anesthesia, recently told Becker’s. “They don’t want post-op nausea. So [enhanced recovery after surgery protocols], opioid-sparing protocols and increased reliance on peripheral nerve blocks, neuraxial blocks to where you can spare those narcotics and you can get patients in and out and with less pain and complications associated with narcotics.”
Armen Voskeridjian, MD, the director of anesthesia services at Jefferson Surgery Center at the Navy Yard in Philadelphia, is on the cutting edge of opioid-sparing techniques. He and his colleagues recently conducted two studies that examined the enhanced effectiveness of liposomal bupivacaine, a local anesthetic, when combined with the steroid dexamethasone.
The studies, being prepared for publication, found that the addition of the steroid drastically reduced and in some cases, eliminated opioid use in patients recovering from orthopedic surgeries.
This technique could not only improve outcomes for patients, but adds value to anesthesia services overall.
“ASCs are finding themselves being asked to subsidize the anesthesia group, and this becomes a very raw point of contention,” Dr. Voskeridjian said. “But if the anesthesia group says, ‘Look, this is what I’m bringing to the ASC. I’m bringing a zero to no narcotic use experience,’ patient satisfaction scores go up. And now that we know that reimbursements are going to be related to patient satisfaction, this becomes an imperative that I think all anesthesiologists should adopt that are doing regional anesthesia.”
Thinking more creatively about staffing models
With a projected physician anesthesia shortage in the next three to five years, ASC leaders are increasingly exploring alternative staffing models that may combine the expertise of physician anesthesiologists along with certified-registered nurse anesthetists and other anesthesia care team members.
“Our center has changed from an all-MD anesthesia model to an MD/CRNA anesthesia model, after 20 years of business, due to the need for our center to supplement reimbursement to the anesthesia providers,” Suzi Cunningham, administrator of Advanced Ambulatory Surgery Center in Redlands, Calif., told Becker’s.
A 2023 white paper from Medicus Healthcare Solutions found that 75% of CRNAs reported practicing without physician oversight. They now account for more than 80% of anesthesia providers in rural counties and administer over 50 million anesthetics annually.
“Most of the ASCs in my area are also becoming CRNA-only,” Jesse Johnson, CRNA at Springdale, Ark.-based Chief Anesthesia Services, told Becker’s. “This helps keep costs down for anesthesia services.”
The question of CRNA autonomy remains contentious. Advocates point to studies showing comparable outcomes to physician anesthesiologists, while critics warn about patient safety risks.
“There is a significant push this year at the federal level and in several states for passing laws to permit practice of clinical care by non-physician professions without any oversight or involvement from physicians,” Udaya Padakandla, MD, an anesthesiologist at Baylor Scott & White Health in Dallas and immediate past president of the Texas Society of Anesthesiologists, told Becker’s. “Proponents for this legislation tend to focus on legal and financial aspects of the healthcare marketplace to justify their course of action. They consistently miss the overwhelming concern physicians emphasize, which has to do with safety for patients.”
Melissa Croad, CRNA, government relations director for the Massachusetts Association of Nurse Anesthetists, challenged the basis of these safety concerns. “There have been numerous studies showing that nurse anesthetists’ outcomes are the same as physician anesthesiologists,” she told Becker’s. “It’s already happening — CRNAs are already working independently. If we were unsafe and killing people, we would know it. My response to that would be, ‘Where are we stuffing the bodies?’… The best study is the status quo. Especially in rural areas like Nebraska and Montana, they are receiving care from about 99% CRNAs. It is hard for me to qualify where [ASA] is coming from with safety concerns when this type of care is happening all day, every day.”
