As the anesthesia shortage drives up provider pay and pushes more ASCs and hospitals into paying subsidies, two anesthesia staffing executives say the strongest retention tool isn’t a bigger paycheck. It’s culture.
Compensation still matters, both said. But keeping CRNAs and anesthesiologists in permanent roles and away from the pull of locum tenens work depends on whether providers feel supported, heard and able to see a long-term future at a facility.
“Once you get those providers in the door, you want to lock the door behind them,” said Kiernan Zumwalt, COO of Pensacola FL.-based CCI Anesthesia, a family-owned group focused on rural and non-urban markets.
Adam Spiegel, CEO of Irving, Texas- based North Star Anesthesia, said the facilities winning the talent war aren’t defined by setting or size. “It sounds kind of hokey, but it’s very culturally driven,” he said.
How subsidies became the norm
Before COVID-19, an ASC paying an anesthesia subsidy was usually a sign of inefficiency, Mr. Spiegel said. Roughly 10% to 15% of centers needed one. Today, he estimates about 80% of the ASCs in North Star’s network require a stipend.
Mr. Zumwalt said the gap between falling reimbursement and rising provider costs “needs to be filled by somebody,” and it typically comes in the form of subsidies. For CCI, which works in rural New Mexico, Kansas and North Dakota, that dynamic predates the national shortage.
The cost of the locum tenens pull
High demand has made locum work especially attractive, particularly for CRNAs. Mr. Spiegel described a post-COVID trend he calls “local locums”: providers who work at the same facility as W-2 colleagues but bill as independent contractors at locum rates. Some new graduates now go straight into those roles, he said.
For facilities, the bills add up quickly. Mr. Zumwalt said five to seven months of locum coverage at some rural hospitals could equal the facility’s entire margin.
“It’s just not sustainable,” he said. “Hospitals and a number of surgery centers operate on razor-thin margins.”
Locum providers can deliver strong care, Mr. Zumwalt said, but they often live far from the sites they cover and are less likely to be invested in the facility’s long-term success. Permanent teams, by contrast, build working rhythms with surgeons, communicate more easily and improve OR efficiency.
He added that facilities relying heavily on locums can undercut their own recruiting. If five openings are all filled by rotating contractors, there is little reason for a provider to commit to a permanent job. Once a few positions are signed, he said, “it’s amazing how often you see the floodgates open.”
Culture starts with local leaders
Both executives said culture is set less by corporate headquarters or hospital administration than by the leaders on site.
Mr. Spiegel said a facility’s chief CRNA and medical director set the tone. A strong pair can recruit and retain well even at an average organization, and a medical director who treats CRNAs poorly can drive staff away from even a top health system.
“You don’t quit your job, you quit your boss,” Mr. Zumwalt said. “If you have a great leader, you’re going to think twice about taking another job an hour away because they’re offering a 5% raise.”
For many providers, a supportive culture means autonomy and a real voice. Mr. Zumwalt said anesthesia teams are often treated as an afterthought in the OR, such as when a surgeon stacks cases from 7 a.m. to 9 p.m. without consulting them. At CCI, local anesthesia chiefs, whether CRNAs or anesthesiologists, are expected to attend committee meetings and bring provider concerns forward, with company clinical and medical leadership backing them up.
“You don’t want any kind of complaints or problems going on deaf ears,” he said. “There needs to be a response of some sort.”
Mr. Spiegel said scope of practice is another cultural marker. Two sites with the same patient acuity can give CRNAs very different latitude, depending on whether physicians are comfortable extending it. The sites where CRNAs practice more broadly are typically better staffed, he said, because CRNAs want to work alongside partners who respect them.
When pay stops being the deciding factor
As anesthesia compensation has climbed, Mr. Zumwalt said, providers’ priorities have shifted. “If I’m making $400,000 or in that ballpark as a CRNA, I’m not going to uproot myself and my family and my practice to take even maybe a $25,000 raise down the street,” he said. What drives them instead is work-life balance, time off to avoid burnout and time with family, especially when many field recruiters call daily.
Mr. Spiegel said the goal is to become what North Star calls a “destination employer,” a place providers can see themselves staying for 10 to 20 years. That requires more flexibility than the traditional model of working long hours until making partner.
He pointed to a new graduate carrying student loans who may later want to step back to start a family, then return to the workforce years after that. With much of the incoming workforce made up of new residents and CRNA graduates, employers need a compelling long-term path for them, he said.
“Those people who can create that, they’re going to win,” Mr. Spiegel said.
Look past the bottom line
Both executives cautioned leaders against choosing an anesthesia partner based on the lowest quote. Mr. Spiegel said many facilities issue generic request for proposals and compare only totals. Some groups quote below market, then return after struggling to recruit and ask for more money, leaving the facility stuck after already switching groups.
“What on paper was a more expensive group ends up being cheaper in the long run,” he said. He urged CFOs to examine the underlying revenue and cost assumptions and ask why one group can recruit more cheaply than another.
Mr. Zumwalt said leaders should weigh the full cost of instability, not just the anesthesia line item. A closed OR or canceled cases from poor coverage won’t show up in anesthesia spend, but the lost revenue lands elsewhere in the budget.
“That’s not a light switch,” he said of changing anesthesia models. “You can’t flip it back next year.”
There are signs of relief. Mr. Spiegel said more CRNA programs are graduating students, fewer providers are retiring early and locum rates are stabilizing. Until supply catches up, both executives said, the facilities that hold onto their permanent teams will be best positioned.
“Once you get that person in the door, you have to keep them there,” Mr. Zumwalt said. “It’s really truly a group effort.”
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