Anesthesia leaders say a convergence of workforce instability, reimbursement pressure and cultural strain is pushing the specialty toward an inflection point. From staffing models and pay inequities to workplace culture, safety and care team alignment, these are the long-standing challenges leaders told Becker’s can no longer be deferred.
Question: What is one issue in anesthesia that deserves more attention right now?
Editor’s note: These responses have been lightly edited for clarity and length.
George Anastasian, MD. Chief of Anesthesiology at White Plains (N.Y.) Hospital: Complacency among clinicians who are contract workers (i.e., 1099, locums) as many are on the younger side and have only seen a great market. Indeed, predictions of a continuing shortage of anesthesia clinicians are widespread. Those in the know, however, see lots of underutilized capacity as so many in the field work as fractional full-time equivalent. Thus, even a small tightening in the market will cause a marked response, as those who are contract workers will desire to seek stable permanent employment. Rural areas will be least affected, while those who reside in more cosmopolitan areas will be most affected.
Neal Cohen, MD. Professor Emeritus of Anesthesia and Perioperative Care and Medicine at the University of California San Francisco: As anesthesia practices have evolved alongside expanding health systems, the specialty has lost much of its sense of community. Care is now dispersed across inpatient and ambulatory settings, the workforce is more diverse, and departments increasingly rely on locum tenens providers. At the same time, work-life balance initiatives, increased transitions of care, subspecialization and the compartmentalization of perioperative care have created clinical silos.
Together, these trends have weakened connection within anesthesia departments and with the broader healthcare community. Rebuilding community requires reinforcing a shared departmental vision while recognizing site- and subspecialty-specific goals. Yet opportunities for connection are limited, as anesthesiologists often work in isolation and in-person meetings are far less common than in the past.
With the loss of shared physical spaces and informal interactions, practices must intentionally create new ways to align goals, foster belonging and rebuild trust within departments and with surgeons, clinical colleagues and health system leadership to support both patient care and professional satisfaction.
Dan Cole, MD. Vice Chair of the Department of Anesthesiology at the University of California Los Angeles: A critical issue that has reached a pivotal moment, and is expected to worsen, is whether the U.S. healthcare system will have a workforce capable of meeting the access and quality needs of the American population.
The growing imbalance between anesthesia workforce supply and demand is especially concerning as it coincides with a rapidly aging population. Older adults undergo a disproportionate share of surgical and procedural care, carry a higher burden of chronic disease and experience increased rates of complications.
This workforce imbalance has far-reaching consequences: it strains healthcare facilities, limits patient access to care, drives up costs, impedes innovation and jeopardizes the mission of educating the next generation of clinicians needed to meet the nation’s healthcare demands.
Brian Daniel, CRNA. The Jackson (Tenn.) Clinic-Baptist Outpatient Campus: The most common issue I see in anesthesia is a lack of flexibility, often more so than an actual shortage of providers. Staffing models, compensation structures and operational processes all require adaptable solutions, as no single approach works for every institution. Some facilities succeed with medical direction, others with CRNA-only models and many benefit from varying supervision ratios depending on acuity and setting.
Greater flexibility allows providers to practice at the top of their license, improving job satisfaction and retention while reducing unnecessary recruitment and salary costs. Compensation should also be customizable, as providers value different mixes of benefits and time off. In my experience as an anesthesia management company owner and now as chief CRNA at an ASC, retention improves when organizations ask providers what they want and adjust compensation accordingly.
Finally, anesthesia providers want greater involvement in perioperative processes. With extensive frontline experience, they are well-positioned to identify practical solutions that save time and money. Hospital leaders should empower anesthesia leadership and give them the flexibility to implement those solutions.
Samuel DeMaria Jr., MD, Professor of Anesthesiology; Vice Chair for Research at Mount Sinai Health System (New York City): The most urgent issue in anesthesia today is the persistent culture of harassment, incivility and disrespect (HID) in many operating rooms and perioperative settings. Having lectured extensively on this topic and recently published The Invisible Cut: Incivility’s Silent Toll on Healthcare, I am deeply committed to raising awareness within and beyond our specialty.
While staffing shortages and reimbursement challenges rightly draw attention, normalized cultural toxicity, ranging from dismissiveness to outright harassment, undermines team performance, fuels burnout and threatens patient safety. American Society of Anesthesiologists initiatives, including its November 2024 statement, ad hoc committee recommendations and recent ASA Monitor coverage, highlight how HID impairs communication and decision-making, contributing to errors and workforce attrition.
As pressures to do more with less intensify, cultural erosion will only worsen staffing and safety risks, especially for newer generations of clinicians. A respectful workplace culture is not optional; it is essential safety equipment.
Richard Dutton, MD. Chief Quality Officer for U.S. Anesthesia Partners (Dallas): The biggest anesthesia issue is the significant gap between Medicare and Medicaid reimbursement and the actual cost of services. Market-driven commercial rates are between $80-$100 per unit, while Medicare is $22. This requires hospitals to pay huge amounts of money in direct support if they want to have anesthesia services at all.
Allan Escher, DO. President-Elect of the American Osteopathic College of Anesthesiologists (Lexington, Ky.): Moral distress is increasingly affecting anesthesia clinicians as they navigate high-acuity care, staffing shortages and ethical tensions that can’t always be resolved at the bedside. When moral distress is ignored, it contributes to burnout, workforce attrition and ultimately threatens the well-being of physicians and healthcare professionals. Structured reflective debriefs are a practical, evidence-informed way to support anesthesiology teams, strengthen ethical practice and sustain a resilient workforce.
Joseph Patrick Hall, CRNA. Upper Cumberland Anesthesia Associates (Cookeville, Tenn.): The number one issue affecting the future of anesthesia is falling reimbursement globally. At the same time, specific private insurance carriers are changing reimbursement for QZ or CRNA-only billing to only 85%. The QZ anesthesia billing modifier is the most commonly used in the anesthesia industry, so this impact affects the anesthesia community globally. In the long run, all this does is shift stipend costs or employment costs to healthcare institutions. These institutions already have paper-thin margins, so it is not hard to see how this cycle eventually becomes untenable for the healthcare institutions.
Antonio Hernandez Conte, MD. Past-president of the California Society of Anesthesiologists: The anesthesia workforce shortage will continue to persist for the next decade, and it is imperative that every single state licenses and utilizes certified anesthesiologist assistants. This highly trained anesthesia practitioner is a vital and proven member of the anesthesia care team, and roadblocks to their licensure should be immediately removed.
Robert Johnstone, MD. Professor of Anesthesiology at West Virginia University (Morgantown): The increasingly hazardous operating rooms deserve attention. Ceiling booms and suspended lights are banging heads, but if you look up to avoid head strikes, you will trip on the increasing clutter of cords, lines and hoses criss-crossing the floor. Robotic surgeries in light-dimmed ORs are making the situation worse. We need solutions before people get hurt and quit.
Cory Koenig, DO. Vice President of Operations at Providence Anesthesiology Associates (Charlotte, N.C.): The main issue revolves around reimbursement for the anesthesia services. Our speciality has long been undervalued in the current system compared to other specialities.
This has long been referred to as the 33% rule, which has now become closer to the 25% rule. Furthermore, with no inflationary adjustment and the yearly small-but-steady cuts to the conversion factor. This has left anesthesia in a situation where the expected revenue for providing services does not come close to matching the value or costs of the services provided. The overall financial situation has placed extreme pressures on organizations, which are ultimately absorbing the costs. To make matters worse, demand is higher than ever, and a staffing shortage looms. Now, there is an argument that extreme inefficiency and poor utilization is also a huge driving factor for anesthesia costs, but ultimately someone is paying for the anesthesia services besides the revenue it actually generates.
With an expected increase in government-paying cases, it will eventually reach a breaking point.
Michael Nurok, MD, PhD. Professor and Co-Chair in the Department of Anesthesiology at Cedars-Sinai Medical Center (Los Angeles): The anesthesiology community, including physicians, nurses, proceduralists, certified registered nurse anesthetists and certified anesthesiology assistants, must find solutions to the shortage of anesthesiology caregivers in the U.S. An inordinate amount of energy and resources have been wasted debating who should provide care while doing nothing to address the underlying personnel shortage. Patients with advanced diseases or those undergoing complicated procedures need a different level of vigilance than patients having more straightforward procedures. We need to collaborate on standards and models that map the skills of different anesthesiology professionals to the full range of care needs. Our collective goal must be value-driven care, defined as providing the best outcomes at the lowest cost.
Michael O’Connor, MD. Executive Vice Chair in the Department of Anesthesia and Critical Care at the University of Chicago: The uncoupling of Medicare compensation (and all compensation indexed to it) for anesthesia services and the actual compensation that anesthesia providers are commanding in the marketplace at present. Richly resourced (better payor mix) hospitals and surgicenters will be able to make up the difference, but hospitals and surgicenters that serve populations with a less favorable payor mix struggle to recruit and retain anesthesia providers.
Absent a correction in Medicare/Medicare-indexed compensation, this problem will persist and likely grow. Because it is administered at the state level, Medicaid is hard to make general statements about, but it is almost certain that these same forces are driving larger numbers of patients to seek care at safety net hospitals.
Sharon Pearce, DNP, CRNA. Former President of the American Association of Nurse Anesthesiology and Current Co-Chair of the Commission for Nurse Reimbursement (North Carolina): One issue in anesthesia that deserves far more attention right now is the lack of enforcement of reimbursement parity for the same anesthesia services, regardless of provider type. Across the country, anesthesia providers deliver identical, medically necessary services at the same level of complexity and responsibility, yet reimbursement often varies without transparency or accountability. We should be paying for the degree of care provided, not the degree of the provider. When the service, risk and outcome are the same, payment disparities cannot be justified.
What is especially concerning is the lack of enforcement to ensure parity where it is required, and the reluctance to hold payors, particularly insurance companies, accountable for these inequities. In today’s healthcare environment, that silence has real consequences. Reimbursement disparities undermine workforce sustainability, limit patient access, strain practice models and ultimately impact care delivery.
If we are serious about fairness, transparency and preserving access to high-quality anesthesia care, reimbursement parity must be part of an open and ongoing conversation, not one that is avoided.
Gregory Rendelman, CRNA. Department of Veterans Affairs (Lancaster, Pa.): I truly feel that decreasing reimbursement for anesthesia services is unwarranted. The fact that we often make it look easy should never translate to “let’s pay them less.” It’s that simple.
Jacob Schaff, MD. Division Chief of Cardiac Anesthesiology at White Plains (N.Y.) Hospital: Anesthesiology is rapidly adopting AI and new technologies, often layered onto fundamentally broken clinical workflows. When handoffs, scheduling, documentation and perioperative coordination aren’t fixed first, technology amplifies inefficiency rather than reducing it. AI should support well-designed workflows, not compensate for fragmented systems, or it risks worsening burnout, cognitive load and patient safety.
Mark Vojtko, APRN, CRNA. Delta Wave Anesthesia: The issue in anesthesia that deserves the most attention right now is staffing. This challenge is largely driven by providers seeking better work-life balance, fewer hours, predictable time off and more time with family and friends. As a result, many have left full-time hospital or ASC roles for locum contracting, drawn by higher pay, schedule control and fewer administrative demands.
This shift creates a double-edged problem. As full-time staff leave, remaining providers face larger workloads, forcing organizations to rely heavily on locums who typically do not want full-time schedules and often work at multiple sites. The result is persistent scheduling challenges, rising burnout, increased turnover and escalating administrative burden, while team consistency and patient outcomes suffer due to variability in protocols, workflows and relationships.
While the solution is complex, it is achievable. Organizations must build a selfless, people-centered culture that values colleagues and fosters buy-in, supported by creative scheduling options such as late starts, half days or rotational models. Compensation alone will not solve the problem. When teams prioritize people and build the right mix of staff, patient care and organizational success follow.
John Westberg, CRNA. St. Clare’s Hospital (Weston, Wis.): Discrimination in pay between CRNAs and MDs for the same services. Very detrimental to either all CRNA groups and the majority rural hospitals.
