As the outpatient surgery landscape rapidly expands, anesthesia practices are undergoing a pivotal transformation.
Ten anesthesia leaders joined Becker’s to discuss how their roles are shifting to meet the demands of increasingly complex procedures, rising patient acuity, and evolving financial and technological pressures in ASCs.
Question: How do you see the role of anesthesia evolving as more procedures shift to outpatient settings?
Editor’s note: These responses have been edited lightly for clarity and length.
Yusuf Ahmad, MD. Anesthesiologist in Berkley, Calif.: Outpatient facilities need to mature in their way of thinking in order to be successful. The old model held anesthesia teams to be third-party, contracted services that were non-essential but necessary for the facility to operate. And this model held ground because the supply-demand curve was in favor of the facility with anesthesia groups competing with one another to gain ASC contracts. That supply-demand curve has shifted dramatically, especially given the dire shortage of clinicians and the no-holds-barred attitude hospitals have taken towards supportive stipends to keep and retain clinicians. Given this macroeconomic shift, as well as the declining reimbursements from commercial payers for anesthesia services, ASCs need to think differently. This new way of engaging anesthesia services resembles how ASCs have engaged surgeons: they must be seen and treated as essential, productive partners that contribute value. In turn, the anesthesia group has buy-in as partners and an economic incentive for remaining engaged with the center and driving efficiency. When the center becomes more efficient and outcomes improve, surgeons gain confidence and bring more cases, driving value up. This positive feedback loop enables a mutual win for all stakeholders. The ASCs that adopt this strategy the earliest will partner with the best and most talented groups while ASCs that remain on the old model will forever be stuck on a downward spiral of diminishing quality or get trapped into a losing battle of stipends with the larger health systems in attempting to attract talented anesthesia providers, only to lose them when the stipend bar moves. Ultimately, the best operating suites are the ones where anesthesia has a central role in medical directorship, quality control, and outcomes management. This is the case in the hospital, and most definitely will be the case in the most successful ASCs.
Matt Bell, MSN, CRNA. Self-employed CRNA in Morganton, N.C.: Anesthesia personnel shortage and cost: Anesthesiologists’ role will diminish, if not disappear, from outpatient centers as surgeons/stakeholders come to realize that the cost-benefit ratio isn’t justifiable in the ASC setting.
Business: Skin in the game is a powerful motivator. Anesthesia providers should be offered ownership stake and/or clearly defined financial incentives to identify and incorporate efficiencies in practice, personnel utilization, logistics and workflow.
Technology: AI modalities will usher in timely, reliable and evidence-based, clinical decision support.
Practice: Anesthesia needs to be intimately involved in patient selection, OR time management, and anesthesia-specific logistics on top of providing the actual anesthetic. Robust peripheral block utilization where appropriate should be standard, opioid-free/sparing anesthetic techniques for all. The name of the game is providing safe, cost-effective, evidence-based anesthetic while minimizing pre- and postoperative course times.
Justin Calvert, MD. Anesthesiologist and Assistant Professor at Loma Linda (Calif.) University: Perioperative medicine, which involves coordinating care across the preoperative, intraoperative, and postoperative phases of care, will become increasingly vital as patients with more complex comorbidities are managed in outpatient settings. The American Society of Anesthesiologists’ Center for Perioperative Medicine is leading the way in this approach. Applying perioperative medicine frameworks ensures that surgical care is not an isolated event or disjointed process, but a coordinated glide path that begins when surgery and continues through recovery.
Outpatient surgery, while associated with many benefits, faces limitations, including reduced opportunities for day-of-surgery labs or studies, decreased ability to modify chronic conditions or medications, and significantly reduced ability to handle unexpected complications. Therefore, preoperative assessment and risk stratification are essential.
The shift to outpatient surgery also increases the need for collaboration among the care team to ensure a smooth recovery process. Surgeons, anesthesiologists, primary care providers, and supporting care providers, including physical therapists and home health providers, will need to work together with a shared understanding of the patient’s perioperative plan. Multidisciplinary discussions similar to those used in oncologic surgery, total joint surgery, and enhanced recovery pathways will become more common and necessary.
Newer technology, including personal vital monitoring equipment, will also become increasingly useful for patients who were previously cared for in the hospital postoperatively, but will now recover at home.
Gloria Diab, CRNA. Anesthesia Consultants of Morris (Homer, Ill.): The ASCs are pushing hard for number of cases, regardless of patient comorbidities. I am a CRNA, with 23 years of experience working at ASCs only. I’m very involved in chart review every day for upcoming cases. The surgeon offices were given guidelines as to what is appropriate to schedule and what is not. They ignore the guidelines and schedule the cases. Then it becomes my job to sift through and decide who may come to ASC versus having surgery at the hospital. This becomes a bigger issue when the surgeon is an investor in the ASC; they want their patients there for personal financial gain. Once I cancel a case, the ASC administrators want a dissertation as to WHY I made the decision I made. Most of the time it’s a “level of care” issue, either intra- or post-operative.
Anesthesia groups are a contract service to ASCs. We pay our own malpractice insurance policies. When an administrator or surgeon pressures us to proceed with a case against our better judgment, the liability falls squarely on the anesthesia provider if the patient has an event under anesthesia.
Antonio Hernandez Conte, MD. Past President, California Society of Anesthesiologists: Demand and growth for anesthesia services in outpatient settings, including ASCs, as well as Non-Operating Room Anesthesia locations will continue to rapidly increase over the next 5-10 years due to external pressures to divert care from costly hospital settings and coupled with surgical/anesthetic innovations. First and foremost, anesthesiologists and nurse anesthetists will need to have increased involvement in managing outpatient surgical schedules in order to facilitate the high demand of cases. Triaging of cases requiring anesthesia services will need to be factored into designing efficient and cost-effective schedules that will maximize an anesthesia practitioner’s time and throughput.
Second, financial allocation and support for implementation and utilization of an electronic medical records will be essential in order to optimize preoperative assessments and review pertinent medical records for increasingly more complex patients who will present themselves in an outpatient setting. Many outpatient settings have not made costly investments in an EMR, and this will be vital to ensuring high quality anesthesia care in a setting where high throughput and production pressure will increase.
Third, while outpatient settings have typically managed patients with commercial insurance, this sector will see enhanced growth in both Medicare and Medicaid patient populations. Therefore, a thorough understanding of shifting payor mix demographics and sound fiscal oversight will be needed to ensure an outpatient center’s financial viability. Considering the downward trend in reimbursement by commercial payors, processes maximizing efficiency and throughput will need to be considered. As the cost of staffing anesthesia providers continues to rise due to the growing demand for anesthesiologists and nurse anesthetists, the outpatient center will be tasked with ensuring that surgeon’s case schedules are closely aligned and designed to match anesthesiologist and nurse anesthetist availability.
Mark Hylton, MD. Anesthesiologist at University of North Carolina at Chapel Hill: This is a great question to ask, as we see it more and more, especially since the COVID-19 pandemic. I suspect greater than 70-80% of all surgeries in the U.S. are performed on an outpatient/ambulatory basis. We are seeing surgeries that used to be associated with multiple hospital day stays post-operatively, now being done same-day. I’m talking about hysterectomies, total hip arthroplasties, total knee arthroplasties, various abdominal procedures and much more. The development of Enhanced Recovery after Surgery (protocol and pathways with significant input from anesthesiologists has allowed for patients to safely recover in the comforts of their own homes.
From employment of regional anesthesia techniques to multimodal analgesia regimens and PONV regimens, it is crucial to tailor the anesthetic plan to the patient and surgery. These advancements have allowed for this shift to more outpatient surgeries. However, an anesthesiologist must balance the patient’s medical co-morbidities, the procedure that is occurring, and those risks when deciding the candidacy for ambulatory surgery. There are plenty of surgeries that can be done in an outpatient setting, but does the patient qualify? Meaning, do they have significant cardiac (heart failure, dysrhythmia), respiratory (severe COPD, oxygen requirement), metabolic (obesity), or other medical conditions that limit them from having an operation at a free-standing surgery center versus at the hospital, where, if needed, their stay could be extended. We have to consider what resources are available at each facility where anesthesia is administered. The anesthesiologist, along with care team members, has to be vigilant and must adhere to strict safety standards with careful patient and procedure selection. Ultimately, there isn’t one bill that fits all when it comes to anesthesia and surgery. But with a multidisciplinary team with anesthesiologists as leaders, the patients, hospitals and surgery centers all benefit. And our role as anesthesiologists continues to evolve not only as experts in anesthesiology, but now we are experts in perioperative medicine, researchers, teachers, leaders in operating room and non-operating room management and efficiency, and leaders in patient safety and quality.
Jesse Johnson, CRNA. Chief Anesthesia Services (Springdale, Ark.): I have seen many gradual changes in the ASC setting over the last 20+ years. Of course, anesthesia practice has evolved as the patient population and the types of cases have changed. Early on, we only did very quick minor surgeries on very healthy patients, but over the years, the cases have become much more complex. We would only do ENT cases, cataracts, knee scopes, tubal, plastics, etc. Now we also do total joint replacements, ACDF — which are cervical neck fusion cases — and spinal discectomies, hysterectomies, neurospinal pain stimulators, etc. Many surgeons have shifted their primary case loads to ASCs. The ASCs are so much more efficient. A surgeon can perform seven or eight total joints in the same time he can do three or four at a hospital. All the changes I have noted above lead to pressures to take on patients who are sicker and have very high acuities. Most ASCs have a list of guidelines for patients we can and cannot do at our ASCs. But frequently, anesthesia is pressured to clear patients with BMIs over 45 or patients who are O2 dependent or have high blood sugars or major cardiac histories. All of this requires anesthesia providers at ASCs to be more highly skilled to deal with a sicker population in a setting not set up for these patients. We do it more and more. The other changes I have seen in my area are because most ASCs are for-profit facilities that are physician-owned. We do not have extra providers floating around to help with difficult cases. Most of the ASCs in my area are also becoming CRNA-only. This helps keep costs down for anesthesia services.
Dennis Jones, CRNA in Dillon, Mont.: Anesthesia must become more involved with screening patients before surgery. The pressure from ASC corporations to accept more risk will intensify. (ASA III class patients)
The importance of more sophisticated monitoring (art lines, cerebral oximetry) will arise as patients with more comorbid factors increase. BMI/sleep apnea patients continue to trouble providers on a daily basis. It is a near-chronic source of conflict between surgeons and anesthesia. Hours of operation will expand to handle the increase in volume. No longer will providers work till 1 or 2 p.m. and be done for the day. The experience of anesthesia providers will become more valuable as patients who are considered “acceptable risk” present unusual scenarios where good judgement counts to mitigate problems.
Kathleen Mattes-Longo, CRNA. Anesthesia Associates of Boise (Idaho): Appropriate patient selection is critical for surgeries performed in the ASC setting. Anesthesia personnel are typically screening patients in advance of ASC cases. We are the last line of defense against potential adverse events that stem from a patient/setting mismatch. As we push for more complex cases to be performed in the “same-day-discharge” environment (for example, TKA in surgery center), we are dealing with an older, heavier and less healthy patient population: this is a challenge I know well. Even the children now test the limits of our weight limits at our ASC. The exploding prevalence of obesity brings with it more sleep disordered breathing and sleep apnea — a challenge for post-op management (when patients have received sedatives/opioids).
Proper screening in advance of surgery is important (to avoid cancellation on the day of surgery). I see more of a need for a telehealth, pre-op evaluation with video of airway exam and body habitus.
What is the ownership/financial structure of the ASC? Cases often move forward based on these “other” variables. Does anesthesiology defer to the surgeon (shareholder) on case appropriateness/cancellation? Are the anesthesiologists/CRNAs shareholders? I see boundaries shift based on the power dynamic that is founded on the finances.
Physical plant considerations in an expanded ASC environment: Does the ASC have capacity for longer PACU stays to assure patients are ready for discharge, or is it a “treat ‘em-and-street ‘em” philosophy? Does the ASC have the monitoring and rescue equipment to manage adverse events that are inevitable (especially as you expand case complexity). More regional blocks and local anesthetics increase the risk of a LAST event (local anesthetic toxicity). Is the ASC in a state where calls to 911 and transfers to hospital for admission are reportable to the state? Is there a “table time” limit in the state for ASCs? At the end of the day, who is left in the building as patients recover?
Jeffrey Tieder, MSN, CRNA. Clinical Assistant Professor at University of Tennessee at Chattanooga: As more procedures shift to outpatient settings, the role of anesthesia is rapidly evolving. Outpatient surgery centers demand streamlined workflows, cost-effective care, and rapid patient turnover without compromising safety. These demands are driving a transition toward CRNA-led and CRNA-only models, which align more closely with the clinical and financial objective of these facilities.
Anesthetic techniques are also adapting to meet these new expectations. Opioid-sparing and opioid-free approaches, the increased use of regional anesthesia, and fast-track protocols are becoming the norm. These strategies support faster discharges, minimize complications, and reduce unplanned admissions.
The growing pressure to contain costs while maintaining safety is elevating the visibility and necessity of CRNAs. With the physician anesthesia shortage looming and reimbursement models shifting, CRNAs will continue to be at the forefront of innovative and sustainable anesthesia delivery.
