The Impact of Anesthesia Beyond the OR
Demand for anesthesia services has expanded beyond the traditional operating room (OR). Historically, most anesthesiologists were in an operating room setting, where it was common to provide some level of call and work some nights and weekends. With the advances in healthcare, anesthesia services are now also utilized in ambulatory surgery centers (ASCs), physician offices, hospital procedural rooms, and other places beyond ORs. In those settings, anesthesia services are needed only during standard business hours on weekdays, with no nights, no weekends, and no call responsibilities. As providers have more opportunities for standard working hours, it is a greater challenge to find providers willing to staff operating rooms and provide late hours, nights, or weekend coverage.
Flex Coverage
Recognizing the difficulty in securing anesthesia providers in hospital settings, facilities are opting to include in anesthesia agreements the ability to flex up the anesthesia coverage to accommodate potential or anticipated growth in their anesthesia services at some point during the contract term. This could be a potential pitfall if consideration has not been given to the type of staffing necessary for the new site.
Assessing whether an anesthesiologist, a certified registered nurse anesthetist (CRNA), or an anesthesia assistant (AA) is needed for the new site is key in determining the cost of the added coverage. If an anesthesiologist would provide the care directly, consideration should be given to whether a specific specialization is needed, such as cardiac anesthesia or pediatric anesthesia. The same applies if CRNAs are self-directing. If anesthesia is provided under an Anesthesia Care Team (ACT) model where anesthesiologists work with a CRNA or an AA to provide the anesthesia care, it is a bit trickier.
Since an anesthesiologist is needed to supervise a CRNA /AA, there may be a temptation to include the cost of both the additional CRNA/AA, plus a portion of the cost for the anesthesiologist who is needed for supervision of the new site. However, if there is sufficient capacity among the on-site anesthesiologists to provide the supervision, then including anything more than just the additional CRNA’s or AA’s cost for the new site may be overstating the costs of coverage.
It is imperative with the ACT to consider the current staffing complement of anesthesiologists to CRNAs/AAs and the geography of the sites being covered to determine the appropriate cost. ACT requirements limit the number of CRNAs/AAs that an anesthesiologist may supervise at any given time. If the anesthesiologist is supervising the maximum allowed, adding another CRNA/AA would require adding another anesthesiologist as well for supervision. Even if there is capacity for supervising more CRNAs/AAs, there may be geographical issues for supervision if the new site is on a separate floor or a different area of the hospital than the other CRNAs/AAs being supervised.
When capacity or geography indicate a CRNA/AA can be utilized without to need to add anesthesiologist, the cost is significantly less. Conversely, when an additional anesthesiologist is needed for supervision under ACT requirements, it becomes more cost effective to utilize the additional anesthesiologist to provide direct care for that new site rather than pay for the additional anesthesiologist plus the additional CRNA/AA.
It is equally important to consider that this new site would likely require more than just +1 full-time equivalent (FTE) provider. If the new operating room is to be open all year long, more than 1 FTE would be needed to maintain coverage while an individual is on PTO. Not considering that could be understating the costs involved in providing the new site coverage. It could result in the anesthesia providers not having sufficient staffing available when that 1 FTE has time off.
Not clarifying the level of provider coverage needed for the new site could result in unfair compensation for the anesthesia services needed and an inability to provide the desired flexibility to the facility when it is ready to expand its services. Providing this clarification in the agreement terms and aligning the compensation with FMV ensures that anesthesia providers are fairly compensated and secures the ability for the facility to provide those services when they are needed.
Extended Hours
The high demand for anesthesia services has created an escalation in the provider costs for anesthesia services. To manage the rising anesthesia provider costs, many facilities have reduced the number of operating rooms to improve OR utilization and staffing efficiency. These cost-saving efforts have resulted in limited ability to add cases during the normal staffing schedule, resulting in a greater need for extended hours as cases go long or are added. When ORs require anesthesia services beyond standard operating hours, anesthesia providers often expect additional compensation for providing extended coverage. As anesthesia providers take on additional hours, understanding the full financial picture is key to mitigate risks associated with overpayment and maintain regulatory compliance.
There may be a temptation for a coverage arrangement to note that additional or extended hours of coverage by an anesthesiologist or a CRNA/AA would be paid at their hourly rates or even at some premium above the typical standard hourly rates. This seems reasonable and straightforward, but it can be tricky. Extended hours may result in increased patient volume, which can enhance overall revenue. Any additional compensation should consider potential collections generated during those hours to ensure that the financial structure remains viable.
Hypothetical Scenario #1: A surgeon is delayed, and their case starts later in the day than originally planned, keeping anesthesia on site beyond the normal (and agreed upon) coverage hours. The facility is billed $600 for running later than planned. The anesthesia provider does not get any additional revenues since the delay resulted in downtime between cases (since a new case was not added during the downtime). In this scenario, the hourly rate is the only source of additional compensation. If the hourly rate is set appropriately for the resources provided, it should not cause a compliance issue. The total payment to the anesthesia provider would be the same whether it is structured as a revenue guarantee, a cost plus, or a flat subsidy.
