Anesthesia stipends have gone from rare to routine at ASCs, with 44% of centers now paying them, up from 28% a year ago, as a nationwide anesthesiologist and CRNA shortage collides with reimbursement that hasn’t kept pace.
CMS anesthesia payments fell 8.2% from 2019 to 2024, then took an additional 2.83% cut in 2025, pushing more of the cost onto facilities just to keep rooms staffed.
Thirty-four ASC leaders and anesthesia providers weighed in on what’s driving the squeeze and how they’re fighting back, from employing their own anesthesiologists and CRNAs to tying stipends to block utilization and productivity.
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Editor’s note: Responses have been edited lightly for clarity and length.
Question: What’s the biggest way anesthesia is squeezing ASC finances right now and what would actually solve it?
Vijay Bachani. President and Chief Growth Officer of New York Bariatric Group (Roslyn Heights): The biggest squeeze is the anesthesia stipend. Anesthesia used to cover itself, and sometimes generated revenue through out of network billing. That’s gotten much harder. The anesthesiologist shortage has driven up compensation, and while IDR isn’t gone, it’s become tougher to rely on as payors go after ASCs that allow out of network providers. So groups now ask the ASC for a subsidy just to keep coverage, and those stipends keep climbing for the same service.
For us, the fix has been to employ our own anesthesiologists instead of contracting an outside group. You capture the professional collections and cut out the group’s margin, so the net cost drops and you control it. It takes volume, the right structure, and a strong network of per diems for call and vacation coverage, but at the right volume it beats subsidizing someone else’s group indefinitely.
Anesthesia also has to be part of payer negotiations. When a case moves to an ASC, we’re saving the payer a real site-of-service cost. If they want that savings, and don’t want us using out of network providers, they need to pay a fair in-network anesthesia rate. They can’t have it both ways.
Peter Bravos, MD. Chief Medical Officer of Sutter Health Surgery Center Division (Sacramento, Calif.): Anesthesia coverage has become one of the biggest threats to ASC margins. What was once routinely included is increasingly subsidized through stipends, driven by flat reimbursement, workforce constraints, and consolidated anesthesia groups negotiating from strength. These costs are becoming harder to absorb without compromising margin.
Paying stipends without changing the operating model only accepts that leverage as permanent. A more disciplined approach is to tie subsidies to performance expectations, including block utilization, guaranteed hours, on time starts, and reliability, and building owned anesthesia coverage where volume justifies it. These agreements can carry even more weight when negotiated regionally, rather than center by center.
Anesthesia is no longer a clinical afterthought, it is a strategic operating expense. ASCs that manage it with the same discipline applied to labor, payer mix, and block utilization will protect margin. Those that don’t will keep losing ground, one canceled case at a time.
Lisa Cooper. CEO and Administrator for Santa Cruz (Calif.) Surgery Center: The biggest issue I see is when anesthesia providers have not been successful in securing adequate reimbursement from certain payers. The result is that the surgery center is increasingly expected to make up the difference, which can significantly impact ASC finances. Bundled payments are one option if the payer is willing. We were successful to get into a bundle payment with a managed Medi-Cal plan. Another approach is to go to the payer together and explain that without competitive reimbursement for anesthesia services, the surgery center ultimately cannot afford to continue supporting that payer’s members. We have found that approaching the payer as a team — the ASC and anesthesia group together — is much more effective than either side trying to address the issue independently. With the rising cost of anesthesia services, I think that type of collaboration is increasingly important.
Dan Decker. Co-founder and Urologist at Vitality Plus Urology Clinic (Mountain Home, Ark): There are ongoing and well-documented attempts by various payers to reduce anesthesia pay while there is concurrently a supply and demand crunch for anesthesia. The inevitable result is a squeezing of ASC finances given these amplifying factors. Then you compound it further with national growth in ASC volume against competing hospital entities that are well-versed at subsidizing providers with pay structures that are not realistic or sustainable. That seems like an insurmountable hurdle for ASCs unless the entire framework of reimbursement is significantly transformed.
I think the idea out there that has the most potential for an actionable and timely solution is the concept of bundling the entire patient experience at ASCs. Hospitals already benefit from this model so why at ASCs that have proven high quality and cost reducing care is the reimbursement structure fragmented? The processes related to a smooth ASC patient experience/outcome separated into individual payment buckets seems counterproductive when it is self evident that a cohesive team approach is a key strength of the ASC healthcare delivery model.
Can ASCs combine the clinical judgment for intervention on a patient with the safe pre-surgery/anesthesia evaluation by a multidisciplinary team to include the surgery and anesthesia itself as well as the postoperative care and then document the patient perspective and standard outcome metrics into one overall bundled experience? Taken further, capture and present this data using the advanced healthcare technology tools now available and present this for enhanced payment within a value-based care paradigm.
Carlos Dominguez. Director of Maximus Plastic Surgery Center (San Antonio): With third-party contracts and locum anesthesia companies charging high rates, the primary relief for us is finding independent CRNAs and anesthesiologists. Having at least one or two in-house anesthesia providers is a life-saver. While most surgery centers still need to utilize third-party anesthesia, employing in-house providers allows us to assign the more expensive third-party coverage to shorter cases. This strategy makes a significant difference in reducing the overall anesthesia bill. Additionally, reaching out to the offices sometimes and utilizing their personal anesthesia provider can help lower costs as well. You will need to create a special pricing to cover the cost of all anesthesia medications used for the case, but it’s better than paying a hefty anesthesia fee.
Deena Edwards, RN. Administrator of The Surgery Center of Southwest Ohio (Moraine): This challenge stems from a broader systemic imbalance within healthcare economics. While facility reimbursements for ambulatory surgery centers and hospitals have seen incremental adjustments, payer compensation for anesthesia services has not kept pace with escalating operational and labor costs. To alleviate the growing financial strain and reduce the reliance on facility-funded coverage stipends, an upward adjustment in CMS reimbursement rates are critically needed.
Bruce Feldman. Former Administrator of Eastern Orange Ambulatory Surgery Center and Current Founder of an ASC Consulting Firm (Cornwall, N.Y.): Due to the shortage of anesthesiologists, the decrease in anesthesia reimbursement and increase in salaries for CRNAs many ASCs are now confronted to pay stipends to their anesthesia groups which cuts into their profitability. Many facilities are also having to reduce the number of cases they do because of lack of anesthesia coverage which further reduces their revenue and profitability. I don’t see a solution to this ever increasing nationwide problem unless we come up with creative strategies such as employed physician models or offering anesthesia groups an equity stake in the ASC. We need to be looking at anesthesia coverage no longer as a service/vendor but rather a partner no different than our surgeon investors who have an equity stake in our facility.
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia Consultants (Los Angeles): I would hesitate to characterize anesthesia as “squeezing” ASC finances. The real challenge is the mismatch between the cost of maintaining reliable anesthesia coverage and actual ASC utilization. Anesthesia staffing is largely a fixed cost for the day, while ASC volume is variable. Late starts, underutilized blocks, cancellations, gaps between cases and opening additional rooms for limited volume can all create paid anesthesia hours without corresponding procedural revenue.
The solution is not simply lowering anesthesia compensation. It is better alignment between staffing and actual demand by consolidating schedules, improving block utilization, releasing unused time earlier and opening additional rooms only when the volume justifies the incremental staffing cost.
Nyleen Flores. Administrator and COO of Lake Oconee Orthopedics (Greensboro, Ga.): The biggest financial squeeze for ASCs right now is the growing anesthesia stipend required to maintain reliable coverage. As anesthesia reimbursement continues to decline while staffing and operating costs rise, ASCs are increasingly forced to subsidize anesthesia services just to keep their ORs running. The real solution is meaningful increases in anesthesia reimbursement, not continued annual reductions or reduced reimbursements with continued limitations and scrutiny. Adequate reimbursement would allow anesthesia groups to remain financially sustainable without shifting an ever-growing portion of the cost to ASCs.
Ramis Gheith. Chief Medical Officer, DxTx Pain and Spine (Chicago): The biggest pressure anesthesia is putting on ASC finances right now is the significantly increasing cost of coverage. Anesthesia compensation, guarantees, stipends, and locum rates have increased significantly, while facility reimbursement has not kept pace. In many centers, we are paying for anesthesia availability rather than actual productive clinical time, which becomes especially expensive when schedules are light, rooms are not fully utilized, or cases cancel. The long-term solution is to have more control over the anesthesia staffing model rather than continuing to absorb escalating third-party coverage costs. We should seriously evaluate hiring our own anesthesia staff where the volume supports it, whether that is anesthesiologists, CRNAs, or a combination of both. We should also look internally at utilizing anesthesia-trained pain physicians to help fill anesthesia coverage gaps when their schedules allow. That will not solve every staffing need, but strategically using physicians who are already within the organization could reduce unnecessary outside coverage, locum expense, and overhead while giving us greater flexibility.
At the same time, we need to better align anesthesia staffing with actual OR utilization. If we are paying for two or three anesthesia providers, we need enough cases and rooms running to justify that expense. Better block utilization, tighter scheduling, fewer late cancellations, efficient room turnover, and matching staffing levels to daily volume can materially improve the economics. Ultimately, I think the answer is less dependence on expensive outside anesthesia groups and more ownership and control of the staffing model. If we can build our own anesthesia team, supplement it intelligently with our anesthesia/pain physicians when appropriate, and maximize utilization of the staff we are already paying for, we should be able to significantly reduce anesthesia-related overhead without compromising patient care.
Monte Goldstein, MD. Chief Medical Officer of Virtua Health ASC Joint Ventures (Ramsey, N.J.): One major “squeeze” area is that anesthesia groups covering ASCs are insisting on contracts based on revenue guarantees. It seems almost counterintuitive for both parties long term since essentially the anesthesia groups are asking the ASC’s to take on 100% of the anesthesia financial risk without the upside potential. Long-term I believe the principles of the ASC will demand control of all aspects of anesthesia operations if they are taking on all of the financial risk of anesthesia coverage. I believe strongly that if goals are aligned, efficient use of OR times and case placement, ensuring the right provider mix/care teams are associated with the appropriate acuity of cases, and strategic stipends to incentivize additional throughput, then everybody can benefit.
April Hansard, RN. SWAT Administrator for United Surgical Partners International: Anesthesia is getting various stipends for their services at the ASC. The ASC are all getting squeezed with reimbursements but when anesthesia is asking for their portion it really takes a hit in the bottom line.
Patrick Haley. Vice President of Aptos (Calif.) Surgery Center: The fundamental issue is a fairly simple imbalance of supply and demand. While anesthesia providers remain in short supply relative to the number of ORs running, the problem will persist. The disparity in reimbursement between governmental and commercial payers exacerbates the problem by shifting the cost to facilities least able to afford large subsidies. California’s Medicaid program values an anesthesiologist’s time at between $40 and $50/hour, leaving the burden of the delta between $45 and the market rate on the facility to cover. Increasing what providers receive from payers will soften the blow to facilities, but it does not solve the fundamental labor shortage. Facilities have all been working independently to become more efficient with their time usage, but until the provider pool grows, the providers will continue to migrate to the facilities able to offer the best subsidies. The only true “solution” is to increase the number of anesthesia residencies nationally and expand CRNA training programs to graduate more qualified providers.
Narasimhan Jagannathan, MD. Professor and Division Chief of Anesthesiology at the University of Arizona College of Medicine (Phoenix): My perspective:The biggest challenge is that anesthesia staffing costs are rising faster than reimbursement, while many ASCs still have variable case volumes, gaps in the schedule, and unused OR time. This makes it difficult to provide reliable anesthesia coverage without putting additional pressure on the ASC’s finances. The solution is a more coordinated approach: better scheduling, more consistent case volume, fuller OR utilization, and anesthesia staffing that matches actual demand. When professional reimbursement alone does not cover the cost of dependable coverage, ASCs need a transparent and sustainable financial model for anesthesia services, whether anesthesia clinicians are employed directly or provided through an independent group.
The days of treating anesthesia as a service that simply appears when a case is scheduled are over. In today’s market, anesthesia has to be managed as a strategic operational resource. Centers that create a stable core team, supplement intelligently when volume requires it and eliminate avoidable downtime will be in a much better position to protect both access to care and financial sustainability.
Maggie Jeffries, MD. President of the Ophthalmic Anesthesia Society (Houston): The cost of providing anesthesia services continues to increase while reimbursements decrease. This often means an ASC may need to consider subsidizing anesthesia coverage. Driving an efficient, vertically stacked schedule is one way to help increase anesthesia profitability and decrease the need for subsidies.
Natasia Jones. Clinical Operations Director at Pegasus Surgery Center (Anaheim, Calif.): The biggest way anesthesia is squeezing ASC finances right now is that ASCs are increasingly being asked to subsidize anesthesia services, guarantee minimum daily rates, or otherwise make up the difference between what anesthesia providers collect. For a surgery center already operating on tight margins, that can turn anesthesia from a service that historically functioned independently into a detrimental operating expense.
At our center, we recently cut our anesthesia cost down by almost half by using single anesthesiologist, rather than a group, we pay them an hourly rate with a 4 hour minimum, which gives us much more control over our anesthesia spend and allows us to align coverage more closely with our actual surgical schedule. We also recently hired our first CRNA, which gives us another coverage option at a rate that is competitive with our physician anesthesia coverage.
For us, the solution has been more about changing the structure altogether. ASCs need flexibility in how they build anesthesia coverage and should be looking closely at case volume, scheduling, provider mix and actual hours of coverage needed. A model that combines individual anesthesiologists and CRNAs can significantly reduce the financial burden without sacrificing reliable anesthesia coverage.
Ultimately, I think ASCs have to stop looking at rising anesthesia subsidies as an unavoidable cost of doing business. There are opportunities to restructure the model, eliminate unnecessary overhead and create coverage that makes financial sense for both the facility and the anesthesia providers.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: Anesthesia shortage has become an issue throughout the surgical specialties. Stipends are common. This takes from the bottom line of an ASC. To offset these costs, a few things can be considered. First, directly involve the anesthesia team in anesthesia costs, whether that be vendors, types of blocks, or efficiencies. Second, cost share with them. For example, have a sliding stipend based on volumes. The higher the volume for the day, the lower the stipends, etc. Lastly, some are hiring then billing for anesthesia. This is extreme and represents a new service line but not unheard of.
Maher Kodsy, MD. Chair of the Department of Anesthesiology at University Hospitals Elyria (Ohio) Medical Center: The surgical schedule serves as the foundation for the entire cascade of events, determining the success or failure of the operation.
Leaving excessive gaps in the surgery schedule without proper utilization significantly reduces the profitability of anesthesia services. Additionally, surgeons’ convenience in scheduling their surgeries, either due to a desire for a better lifestyle with more free time during the day or due to their busy schedules, often leads to the squeezing of cases based on availability.
These factors collectively contribute to a decrease in anesthesia revenue from operations, resource wastage, and consequently, the need for increased subsidies.
Competition to attract anesthesia providers from the same region is artificially inflating costs to compensate for scheduling inefficiencies. Anesthesia provider shortages are a genuine challenge, and poorly managed surgery schedules exacerbate this issue. All of these factors place a financial burden on ASCs. There are strategies to mitigate these challenges:
- Optimize the surgery schedule to achieve a minimum of six hours of anesthesia productivity per room.
- Consolidate rooms to their full capacity and utilize all available “holes” on the schedule.
- Open new rooms when room utilization is maximized.
- Surgeons and anesthesia providers should be aware of these challenges and collaborate to address them. Opening multiple rooms for a single or two cases per room to complete before 12:00 noon is no longer acceptable in today’s practice.
- Hold management companies accountable for maximizing productivity.
- Eliminate complacency where some players assume that someone else’s problem is to be solved.
- Replace supervision with collaboration between anesthesiologists and CRNAs whenever permitted by the state. It is not uncommon to see one anesthesiologist collaborating with more than four CRNAs to staff multiple operating rooms.
- Negotiate better minimum hour guarantees with anesthesia providers.
- Avoid frequent changes in anesthesia groups, as these are often perceived as instability and an opportunity for higher bidding.
- Finally, reserve the use of the more expensive locum to the last resort. Instead, ensure a substantial pool of local, cost-effective PRN anesthesia providers to fill gaps with reduced expenses.
- The solution is not solely the responsibility of the management company. It requires collaboration among all parties involved to establish a productive, efficient, safe, and profitable business model.
Jessica Lam, PhD. Practice Manager of Pacific Coast Anesthesia (Los Angeles): From a practice management perspective, one of the biggest financial challenges is the unpredictability of ASC scheduling. Anesthesia groups have to ensure adequate coverage, often before the final case volume for the day is known. When cases cancel, schedules change at the last minute or rooms finish much earlier than anticipated, the staffing cost has already been committed.
The best solution is greater predictability and coordination between the ASC, surgeons and anesthesia group. Anesthesia practices recruit and retain physicians based on an anticipated and consistent level of work, so staffing cannot simply expand and contract with last-minute changes in volume. More accurate forecasting, earlier schedule finalization and consistent utilization of planned capacity allow anesthesia groups to maintain reliable coverage while helping ASCs control unnecessary costs.
EJ Ledesma. CEO of 360 Orthopedics (Sarasota, Fla.): Anesthesia access — not surgeon or facility capacity — is emerging as the primary constraint on ASC growth heading into 2026.
Three related pressures are driving this challenge:
- A persistent shortage of anesthesiologists and certified registered nurse anesthetists.
- A continued shift of surgical volume to outpatient settings, which is intensifying reimbursement pressure — rates have declined 5.5% since 2019.
- Rising ASC expenses, including labor, occupancy, supplies, and contracted services.
Our center in Southwest Florida is not immune to these national trends. Because this pressure will continue, we are taking a proactive approach built around five priorities:
- Optimize workflows. Use available tools and standardized processes to eliminate waste, reduce cost per case, and control overhead.
- Manage case and payer mix. Prioritize the center’s “sweet spot”—higher-margin cases, procedures that support rapid room turnover, and orthopedic and spine volume.
- Balance capacity and utilization. Schedule operating rooms to create predictable anesthesia staffing needs, avoid peaks and valleys, and reduce the risk of increased subsidy requirements caused by inefficient scheduling.
- Strengthen change management. Maintain consistent communication between anesthesia providers and ASC management, monitor key performance indicators, and foster a deliberate culture of continuous improvement.
- Conduct sensitivity testing. During the budgeting process, model anesthesia support across multiple economic, reimbursement, staffing, and volume scenarios.
We view anesthesia support as an integral part of the ASC’s strategic plan — not simply as a line item on the profit-and-loss statement. Long-term success will require management, anesthesia providers, and physicians to align around shared goals, with a shared understanding that anesthesia constraints are likely to persist.
Benjamin Levy III, MD. Gastroenterologist at University of Chicago Medicine: An important financial burden arises when anesthesia providers are paid to work at an ASC, but cancellations create unused openings in their schedules. One solution is to use a nursing navigator and an urgent gastroenterology wait list to fill the schedule with waiting EGDs and colonoscopies. This requires frequent schedule monitoring, prompt logistics, and excellent communication to facilitate the schedule changes.
Justin Marburger. Regional Surgical Director of Maximus Plastic Surgery Center and Chrysalis Cosmetic Surgery Center (San Antonio): The biggest financial pressure from anesthesia right now is the widening gap between the cost to guarantee reliable coverage and what the ASC and anesthesia provider are actually reimbursed for that care. With the nationwide shortage of anesthesiologists and CRNAs, centers increasingly compete for a limited workforce through higher compensation, stipends and costly contract coverage. At the same time, reimbursement has not kept pace with those rising labor costs.
We have been fortunate to mitigate some of that pressure by employing our own anesthesiologists and supplementing them with contracted CRNAs when additional coverage is needed. That gives us greater control over our core anesthesia costs while allowing us to flex staffing based on case volume rather than carrying unnecessary fixed coverage every day. I don’t believe there is a single staffing model that will solve the anesthesia crisis for every ASC. The larger solution is better alignment between anesthesia staffing, surgical scheduling and reimbursement. ASCs must become much more intentional about consolidating schedules, maximizing room utilization and matching anesthesia coverage to actual demand. At the same time, reimbursement has to recognize the true cost of maintaining safe and reliable anesthesia coverage.
Kathy Meccia, RNBC, Nurse Administrator at Lake George Surgery Center (Coldwater, Mich.): We had an issue with the amount of overtime charged with Anesthesia providers. It is very difficult in an ASC to be done in 8 hours, especially when the provider comes in an hour before case starts. How we resolved it was to agree to a 40 hour work week at regular pay and overtime paid after the 40 hours. This has helped with the balance between short case days and longer case days.
Jamison Pearlman. Vice President of Managed Care at Fresenius Medical Care North America (Brentwood, Tenn.): Anesthesia coverage has become one of the most significant financial and access challenges facing ASCs. Workforce shortages, rising compensation, and continued migration of procedures to outpatient settings have intensified competition for anesthesiologists and CRNAs. Many ASCs rely on contractor-based anesthesia coverage with almost half having and including contractor arrangements with stipends.
For ASC operators, these pressures are occurring alongside labor and supply inflation and reimbursement that has not kept pace with the cost of delivering care. Anesthesia groups face similar reimbursement compression, which often shifts the remaining financial gap back to the facility through higher rates, collection guarantees, or coverage stipends.
At Azura Vascular Care, the issue is amplified by our Medicare and Medicare Advantage-heavy payer mix and our focus on essential vascular access procedures. Reliable anesthesia coverage is necessary to support access creation and other vascular interventions, but the reimbursement associated with these services provides limited flexibility to absorb escalating anesthesia costs. Our lower case volumes, Medicare concentration, difficulty securing contracted anesthesia services, and the increasing use of subsidies and guarantees are our central set of challenges.
There is no single solution. ASCs should build longer-term, more transparent relationships with anesthesia groups; consolidate schedules to improve room utilization; reduce downtime and fragmented coverage days; and link subsidies to measurable commitments such as reliable staffing, coverage guarantees, on-time starts, and productivity. Formal RFPs, regional benchmarking, and appropriate exit protections can also bring greater discipline to stipend arrangements.
Managed-care negotiations are another important lever. ASCs should demonstrate the savings generated by moving appropriate procedures out of hospital outpatient departments and quantify the anesthesia expense required to preserve that lower-cost access point. Payers cannot continue to promote outpatient migration without recognizing the infrastructure and workforce costs necessary to sustain it.
Azura is also developing a more integrated approach by employing CRNAs through an in-house anesthesia model, subject to applicable state law and regulatory requirements. The intent is to create more dependable coverage, improve scheduling and clinical integration, and gain greater control over cost, quality, and the patient experience. The contemplated structure includes employing CRNAs through a wholly owned practice, directly billing for anesthesia services, and supporting the operation through centralized staffing, billing, payer contracting, credentialing, and scheduling capabilities.
Ultimately, the solution is not simply asking anesthesia providers or ASCs to absorb more pressure. It requires better alignment among facilities, anesthesia professionals, physicians, and payers. ASCs that combine disciplined operations, sustainable provider partnerships, stronger managed-care contracting, and appropriately structured in-house capabilities will be best positioned to preserve patient access while managing this increasingly important cost.
Michelle Punshon: CEO of Charleston (S.C.) Surgery Center: In addition to the stipend, our anesthesia group requires a second MD on site if you go beyond four ORs (including endo). They WILL NOT run three ORs and an endoscopy room with only one MD. We have four ORS, but are unable to use all four if we are also doing GI cases, unless they have a second MD present and charge us the fee for an additional MD.
Riley Orr. Chief Operating Officer of Regent Surgical (Nolensville, Tenn.): Anesthesia is squeezing ASC finances on the mismatch between guaranteed hours and guaranteed coverage. Anesthesia groups are locking in hours for CRNAs and MDAs to retain them in competitive markets, while physician partners desire flip rooms, early starts, and reliable coverage independent of volume. That combination is exactly what we’re paying for, staffed hours that don’t match the actual caseload. The centers managing this well aren’t pushing back on physician preferences. They’re making the cost visible, showing that a given block or schedule setup is running under the utilization needed to justify the anesthesia hours behind it. Once physician partners see that tradeoff tied to their own schedule, instead of a number buried in the P&L, they tighten blocks, consolidate starts, or make whatever adjustment keeps the room full enough to justify the coverage. It’s less about limiting what physicians want and more about getting everyone optimizing the same schedule instead of working against each other. We’re in the business of meeting the needs of our patients and physician partners while ensuring the long-term success of our partnerships, and Regent makes that visibility possible — turning a P&L line item into a schedule decision physician partners can actually act on.
Michael Redler, MD, Orthopedic Surgeon at The Orthopaedic and Sports Medicine Center’s Connecticut (Trumbull): The relationship between anesthesia and ASCs is a very important one. Our ability to do high acuity cases in a surgical center setting is so dependent on outstanding anesthesia including regional anesthesia. It is well known that there is an anesthesia shortage nationwide. The ASCs would love to be able to run all rooms so that surgeons may get flips and get through the schedule very efficiently. Anesthesia on the other hand, based on staffing restrictions, may find that challenging. Sometimes the ASCs may feel as though they are being squeezed by anesthesia with lower staffing. We know, however, that this lower staffing sometimes is based more on staff availability as well as their economic model of efficiency. Hopefully in the future anesthesia groups can make more use of CRNAs and a win-win situation can be created.
Raghu Reddy. Chief Administrative Officer of MiOrtho Surgery Center and a member of the Ambulatory Surgery Center Association’s Education and Quality Committees (Southfield, Mich.): ASCs currently face significant financial pressure over anesthesia coverage. Rapidly rising labor costs for physician anesthesiologists and CRNAs—driven by a widespread provider shortage—are colliding with falling reimbursement rates. CMS anesthesia reimbursement dropped 8.2% from 2019 to 2024, followed by an additional 2.83% cut in 2025, while commercial payers in several states continue to reduce CRNA rates. Historically cost-neutral, anesthesia now requires 44% of ASCs to pay stipends simply to secure coverage, up from 28% last year. Because most centers rely on contractor-based models, unfilled block time directly impacts profitability and drives stipend demands even higher. Continuing to pay larger stipends without a strategic shift is unsustainable. To address this, ASCs should consider the following strategies:
- Transition to guaranteed, exclusive coverage contracts: Securing real block-time commitments — even at a higher fixed cost — provides predictable, maximized OR utilization that outweighs temporary spot-market savings.
- Optimize delivery models: Shift toward CRNA-led or care-team models where scope of practice allows.
- Consolidate vendor relationships: Aggregate anesthesia coverage across multiple sites to build negotiating leverage.
- Secure surgeon commitment: Ensure strong surgeon alignment to maintain utilization, preventing stipends from spiraling out of control.
While these measures do not resolve the overarching provider shortage, they provide a structured approach to stabilizing coverage and controlling costs.
Kristen Richards. Vice President of Ambulatory Care at Cardiovascular Logistics (Phoenix): Anesthesia coverage is one of the most expensive line items in ASC operations, but the real problem isn’t the cost — it’s that the anesthesia economic model and the ASC operating model were never built to align. We spend so much energy negotiating stipends that we lose sight of the actual fix: a true partnership structured around coverage commitments, case productivity, clinical acuity, and shared financial performance. This is especially true in cardiovascular ASCs, where case complexity demands anesthesia partners who are invested in the center’s growth, not just its schedule. Get the incentives aligned, and the cost conversation takes care of itself.
Randy Robbins, MD, President of Valiant Anesthesia Associates (Southlake, Texas): First of all, I’d like to say that I don’t think it’s completely accurate to characterize anesthesia as “squeezing ASC finances” right now! The anesthesia work force took a major hit coming out of Covid and is likely years away from recovery, so the issue is really the current demand for anesthesia is far outpacing the supply of coverage. The inefficiencies with surgeon and facility demands for flip rooms and increased down time between cases has also led to a significant increase in anesthesia cost while in turn driving down anesthesia revenue. Coupling those issues with the increasingly aging population that carries with it an increase in Medicare coverage you face a crisis in anesthesia revenue production in a time of significant labor shortage. Unlike our procedural counterparts, the reimbursement from Medicare is roughly 20% of their commercial counterparts and that gap will continue to widen unless congress addresses the issue. The only solution physicians, CRNAs, and AAs have is to demand higher reimbursement from either the commercial payers or subsidy from the facilities. The only real short-term answer is for facilities and anesthesia practices to truly partner together and seek efficient OR utilization and revenue production and oftentimes understand that quality coverage very likely will come with a subsidy request in the near future if it hasn’t already. On the Anesthesia delivery side, we must be sure that we seek equitable solutions that work for all parties and avoid the risk of taking advantage of the current situation in order to provide short-term increased revenue. We should all be looking for long term stable partnerships that allow both facilities and anesthesia practices to continue working together for the foreseeable future.
Amanda Ryan, DO. Interventional Cardiologist and CEO of the Advanced Heart and Vascular Center of New Mexico (Carlsbad): The escalating financial burden of mandatory anesthesia stipends is significantly straining ASCs budgets amidst severe provider shortages and declining reimbursements. To protect operating margins, facility leadership must implement strategic countermeasures such as adopting leaner staffing models, optimizing block time efficiency, and restructuring contracts. Our model at Current Clinic includes internal anesthesia leadership who serve as active, strategic participants across our core committees. This integrated governance structure aligns clinical excellence with operational efficiency, ensuring anesthesia insights directly inform our quality, safety and utilization initiatives.
Tammy Smittle, RN. Chief Operating Officer and Chief Nursing Officer of Northwest Hills Surgical Hospital (Austin, Texas): Stipends are the new fixed operating expense for ASCs. Last year, 44% of ASCs were expected to pay anesthesia stipends. ASC margins run so thin that I believe this new requirement could cause many to fail. ASCs need their surgeons and anesthesia teams to partner up. We will have to start compressing the OR schedule, which many surgeons will dislike. I also think a hybrid subsidy model should be considered. This could be based on a specific number of patients per day or a payer mix situation. I do not believe that this issue can be fixed by paying a bigger stipend, we will need to partner to redesign the OR schedule so we pay for productive capacity, not idle time.
David Shapiro. Risk Manager at Red Hills Surgery Center (Tallahassee, Fla.): The use of the term in this context might be interpreted to imply consumption of financial resources without providing value. As an anesthesiologist, I do not believe that this implication comports with the value that anesthesia providers provide to healthcare, and ASCs in particular. Anesthesia staff is positioned to offer both leadership and quality clinical care in the peri operative setting. The financial aspects of this dynamic could of course be addressed in part by both better reimbursement and more efficient scheduling.
Tian Xia, MD. Director and Pain Management Specialist at American Health Care Centers and CEO of Integrated Pain Management: This is a hard question. Anesthesia cost is every mounting, cost is the impact afterall. The only way to reduce this in the long term is to have more anesthesiologists available.
Kevin Youmans. CEO, Central Wyoming Outpatient Surgical Center (Casper, Wyo.): Our experience is somewhat different from what many ASCs are facing today. Anesthesia is not currently creating financial pressure for our surgery center. We have a long-standing relationship with an anesthesia group that provides reliable coverage, adds significant value to our clinical operations and bills independently for its professional services. We do not currently provide an anesthesia coverage subsidy. I don’t believe there is a single anesthesia model that will solve the financial pressures facing ASCs nationally. Local workforce availability, reimbursement, case mix and coverage requirements all matter. From our experience, however, long-term alignment between the ASC and its anesthesia providers is extremely important. The arrangement has to be sustainable for both parties. Rather than viewing anesthesia simply as a coverage expense, we’ve benefited from treating our anesthesia providers as long-term clinical partners. That stability has significant operational and financial value to our center.
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.
