ASC leaders have spent the past year absorbing anesthesia costs that keep climbing. The share of ASCs expecting to pay anesthesia stipends jumped from 28% in 2024 to 44% in 2025, according to a VMG Health survey. One ASC executive told Becker’s in August that anesthesia providers are being paid stipends of around $4,000 “just to walk in the door.”
The pressure is coming from several directions at the same time: private equity, consolidation, workforce contraction and flat reimbursement. A projected shortage of 6,300 anesthesiologists by 2036 suggests it won’t ease on its own.
Those forces framed a panel on anesthesia instability at Becker’s 32nd Annual Business and Operations of ASCs conference Oct. 30 in Chicago. Asked what adjusting to that environment actually looks like, David Mackey, MD, a professor of anesthesiology and perioperative medicine at Houston-based University of Texas MD Anderson Cancer Center, pointed out what he believes is a misnomer in the industry.
“I don’t really think there’s instability at all,” Dr. Mackey said. “I think that there’s kind of a misconception of what anesthesiologists do to begin with.”
“Whether it’s the GI clinic or interventional radiology, or the ASC where I spend most of my time, I just want them to be able to take care of their procedure and I’ll take care of all the other issues,” he said. “If a patient has chest pain, I’ll take care of that. If they have any other kind of issues, I’ll take care of that. And I think that there’s kind of a misnomer there, especially as surgeons and administrators think that all we do is put people to sleep and wake them up.”
That view carries weight as ASCs compete with hospitals and locums firms for a limited pool of anesthesia clinicians.
“If you offer a good competitive salary, benefits, working conditions, job security, you will not have problems getting anesthesiologists and CRNAs to come and work for you,” Dr. Mackey said. “The problem is administrators don’t really understand that and they want to provide just the minimal amount of reimbursement or payment or whatever. And that’s a real problem. They don’t understand the marketplace. Anesthesia is a scarce commodity, it’s very expensive and people need to realize that.”
Kaitlynn Miller, BSN, RN, director of operations at Springfield Clinic Ambulatory Surgery Center in Springfield, Ill., oversees a center with 16 procedure rooms and about 19 CRNAs.
“Our anesthesiologists are partners, so they’re locked in. But our CRNA [workforce] is a very challenging market,” Ms. Miller said. “So much so that I had people applying for our position that are from Florida. They’re flying from Florida to Illinois because they’re going to make almost double what they’re making down there. It’s very highly competitive. We pay more than our local hospitals because we want stability.”
Asked how ASCs should weigh what’s sustainable in their stipend arrangements versus what simply keeps the lights on, Dr. Mackey started with the term itself.
“I don’t like the word ‘stipend.’ I think it’s a misnomer because as I mentioned earlier and it was reinforced by another speaker, there’s much that we do that’s not associated with putting people to sleep and wake them up,” he said. “But that’s not paid for by the government, by the payers, which they’re just paying obviously as minimally as they can. So somehow that service has to be made up.”
This means that ASCs who want true stability will have to pay for it, he said.
“If you’re going to have an attractive job opportunity for an anesthesiologist or for a CRNA, you’re going to have to make sure that they are made whole and that they can make a competitive living out of working at your institution,” Dr. Mackey said. “So if you’re in a healthcare system or a university, that means a salary and not a stipend.”
“But a stipend is a misnomer, and we really need to get away from using that term,” he added.
Ms. Miller described how Springfield Clinic handles gaps in the CRNA schedule.
“We have a different model because we are 100% physician owned. We don’t do stipends, but [we have what’s called] called downtime pay,” Ms. Miller said. “So each CRNA comes, they are guaranteed nine hours of pay, regardless if they work two or if they work 12. Obviously they get paid for the 12.”
When the conversation turned to what individual ASC leaders can do about a workforce shortage driven largely by forces outside their control, Dr. Mackey spoke as an advocate for ambulatory care.
“There’s two biggest contributors to the unsustainable cost in the American healthcare system right now. It’s the payers, which we won’t get into right now. That’s another topic. But the other is the hospitals,” Dr. Mackey said. “When you look at it, you can produce a case in an ambulatory surgery center for 50% to 60% of the cost of doing that same case in a hospital.”
“The growth of hospital administrative personnel is astronomic. It’s literally off the charts,” he added. “And that’s what needs to be cut.”
Federal payment policy drew the same frustration. Responding to an audience question about how centers would fare with a payer mix that was entirely Medicare, Dr. Mackey pointed to the government.
“The only way the federal government knows how to save money is to restrict care. And they do that by cutting fees that people make. And that’s a big problem,” he said. “I can’t speak for CRNAs, but for physicians we’ve had a decrease in [income] according to the AMA of about 23%. … We are already being cut to the bone.”
In his closing remarks, Dr. Mackey turned to where care is heading and how physicians are trained for it.
“Everything is moving to the ambulatory surgery center. And it’s not just surgical, it’s GI. It’s interventional radiology, pulmonary. All of those things are. So we need to reevaluate everything that we’re doing,” he said.
Physician ownership, education and buy-in are levers Dr. Mackey sees as most transformative when it comes to creating a workforce prepared to handle the rising acuity of patients and increasing demand for surgeries in the U.S.
“We need to allow the physicians, the attending staff to be co-owners of, say, an ambulatory surgery center or a GI center,” he said. “And that’s also for the GI docs or the surgeons as well. So they really know how to run a business and they can teach the trainees how to run a business.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
