1. QWhat are some anesthesia trends/advances
you’re seeing in the ASC setting?
Timothy Beisner, vice president, Anesthesia
Healthcare Partners (AHP): The request for a
dedicated anesthesiologist and/or certified reg-
istered nurse anesthetist (CRNA) to administer
propofol sedation is still “catching on” in many
parts of the country and gaining much more attention for endo-
scopic procedures performed in an ambulatory surgery center
(ASC) setting.
Marc E. Koch, MD, CEO, Somnia Inc.:
Lagging marketplace perception concerning the
non-congruency between ASC and anesthesia
financials. ASC facility fees almost always dwarf
anesthesia professional fees. As a result, a sur-
gery center may turn a profit for a given operating room surgical
volume on a given day but this volume may not provide ample
compensation to support an anesthesiologist working for
market rates. As more and more surgery centers sprout up, the
volume of surgery occurring in any one ASC operating room
is unlikely to keep pace and what may be a compelling and
profitable venture for a surgeon or ASC management company
may not be so for the anesthesia clinician. Over the next five
to 10 years, we predict that anesthesia subsidies will become
more commonplace in the ASC setting.
Dave Simion, vice president of sales, Alpine
Surgical Equipment, Inc.: More ASCs are con-
centrating or adding spine, pain and orthopedic
cases. The ability to perform these cases
increases the profitability to the ASC substan-
tially. Also, the introduction of new ventilation modes within
the anesthesia delivery systems themselves. One in particular
would be PSV mode (pressure support ventilation). Pressure
support is a spontaneous mode of ventilation. The patient initi-
ates the breath and the ventilator delivers support with the
preset pressure. With support from the ventilator, the patient
also regulates the respiratory rate and the tidal volume. This
in turn could allow for quicker recovery time as well as an
increase in the well-being of the patient. Due to this, there
could be a time savings per case, which would allow more cases
to be performed in a single day.
SurgiStrategies spoke with industry leaders to get their perspective
on what is being seen in the anesthesia world related to ASCs the last few years.
Arnaldo Valedon, MD, board member, active
surveyor, AAAHC: A major trend we have seen
in the last 15 years is a greater range of procedures
being performed that were previously exclusively
done in inpatient settings (e.g., anterior cervical
disectomies/fusions, partial knee replacements). As surgical and
anesthesia advances continue, we expect more neurosurgical and
orthopedic procedures to be performed in ASCs.
QWhat other challenges do ASCs face
regarding anesthesia services?
Beisner: Many times an ASC’s procedure rooms are compet-
ingwiththeanesthesianeedsfromacompetingfacility’sprocedure
rooms in the same community supported by the same anesthesia
team. This conflict can sometime leave one of the facilities feel-
ing as a secondary priority of the group; which has prompted
many ASCs to request an exclusive contract. The benefits from
an exclusive contract are sometime overlooked when a center is
researching their anesthesia services. The benefits include less
credentialing work for the ASC’s administration, consistent cov-
erage for the ASCs physicians, an enhanced team feeling for the
entire ASC family and ultimately providing the patients with the
best experience possible, since everyone knows their role when
working in the center, thus improving the patient’s satisfaction.
Koch: Not uncommonly, when surgical volume does not pro-
vide for anesthesia department solvency, anesthesia clinicians
will bill out-of-network to stay afloat. This, however, often taints
the payor relationships ASCs may have worked long and hard
to develop. It will also poison relationships between patients
and surgeons and, even more concerning, relationships between
surgeons and their referral bases. Other times, anesthesia depart-
ments, satiated with robust out-of-network payments, will waive
co-payments and deductibles. Although this mitigates the previ-
ously mentioned acrimony of surgeons and patients, it creates
compliance risks for the anesthesia group, which can negatively
affect the ASC’s reputation. Claims that your anesthesia group
has been charged with UCR fraud will not help with the recruit-
ment of patients or surgeons.
Valedon: The provision of anesthesia services is very region-
specific. Clearly, patient safety guidelines and regulations will
apply nationwide, but the models of delivery can be very different
among states. ASCs must remain continuously vigilant as new
regulations and clinical guidelines are enacted and established
Anesthesia in the Ambulatory World

2. ANESTHESIA IN THE AMBULATORY WORLD
so they can be certain the anesthesia services provided in their
centers are current.
QTell us why you think anesthesiologists play
an important role in the efficiency of an ASC.
Beisner: The anesthesiologist provides another layer of
protection from a malpractice perspective for the physician
performing the procedure, since the anesthesiologist would be
signing the anesthesia record as the “overseeing physician” of the
CRNA, if not performing the procedure themselves.
Koch: The efficiency of an ASC can be dissected down to its
components—preoperative, intraoperative and post-operative. In
each of these areas, an anesthesia company with broad and deep
tenure in the ASC venue can marshal this experience to heighten
efficiency. The ability to improve efficiency extends as far as the
experiences, know-how, and initiative of the anesthesia provider.
Simion: In many cases the anesthesiologists are becoming
partners/owners within the institutions. Because of this they
have a vested interest in the ASC to succeed and prosper. They
help control costs as well as oversee the operating room arena.
An anesthesiologist’s ability to perform certain pain procedures
increases the facility’s revenue stream and allows the ASC the
opportunity to increase profitability. With an anesthesiologist
on board, complex cases can now be handled within the walls of
an ASC. Due to the more complex case load comes the higher-
risk patients. With a higher-risk patient the anesthesiologist can
assess the situation in a timely matter and proceed forward or
even cancel cases. This in turn allows the ASC to be more effi-
cient and cost effective.
Valedon: Having anesthesia providers who understand the
flow and efficient pace of an ASC is key to the success of a center.
It is often the anesthesiologist who leads the pre-operative assess-
ment process for patients, and such process needs to streamlined
to identify “red flags” before the day of surgery. It is imperative
that such red flags are addressed, to the best extent possible,
prior to the day of surgery so there are no surprises on the day of
surgery and the schedule runs smoothly. Patient pre-op assess-
ment by the anesthesiologists also needs to be very streamlined
on the day of surgery in order to ensure both quick and safe turn-
over times between cases. Intraoperative management of patients
from an anesthesia standpoint is also very important in order to
make the surgical schedule run as efficaciously as possible-and
this entails appropriate choices of anesthetics that will allow for
rapid wake-up and recovery.
QWhat are some benefits to providing
anesthesia in an ASC?
Beisner: Depending on the personal goals of the anesthesiol-
ogist and/or CRNA, having the ability to work in an ASC setting
is simply another great option and sometimes very attractive;
since there are rarely any weekend cases performed in an ASC
and the centers are typically not open during holidays, unlike a
majority of hospital settings, where the anesthesiologists and
CRNAs are required to be responsible for a call rotation, work
some weekends and work through many holidays. It is a great
opportunity for those folks seeking this type of schedule.
Koch: Anesthesiologists who favor the ambulatory envi-
ronment fall into several camps. Some prefer the lifestyle…no
weekends, night and call duties. Others might value what might
be considered a more “collegial” environment. Since turnover,
efficiency and teamwork can make or break an ASC, anesthesia
clinicians who consider themselves connoisseurs of this type of
clinical practice gravitate to the ASC.
Valedon: In order to assess the benefits of providing anes-
thesia services in an ASC, the level(s) of anesthesia services
potentially must be discussed. These can range from local/
topical anesthesia to general or regional anesthesia. Generally,
patient comfort and enhanced patient monitoring are benefits of
providing anesthesia services. Ultimately, patient safety needs to
be a goal of all parties involved, but the perioperative experience
can definitely be enhanced when patients are comfortable during
and after a procedure.
QSome advice for those wanting to increase
their anesthesia services in an ASC?
Beisner: As an ASC administrator or owner, use all of the
great resources available online to evaluate the various service
options available to your center; whether it be negotiating cov-
erage with a local group, an individual provider or a national
provider of anesthesia services; you have options and ultimately
make sure that your patients are provided the safest, most effec-
tive and best anesthesia service available.
Koch: An increase in anesthesia service can be viewed
through multiple lenses. If the goal is to have more hands on
deck, coverage models that use anesthesiologists, certified nurse
anesthetists, anesthesia assistant, and nurse practitioners for
anesthesia-related tasking, often permit more coverage for the
same or less cost. If greater service breadth is desired—such as
regional anesthesia, pediatric anesthesia, medical director, or the
like—than recruitment of anesthesia clinicians or a group that
offers these skills is a certain solution. Of course, working with
the current group to have them increase their skill set is always
a wise choice, assuming they are so inclined.
Simion: Make sure the anesthesia group or doctors are famil-
iar with specific ASC anesthesia. By this I mean be familiar with
the types of cases and policies that are implemented on a daily
basis.Thejobresponsibilitiesthatgoalongwiththefreedomofan
ASC might differ greatly from those within the hospital arena.
Valedon: It is often a good idea to visit other ASCs with
similar surgical specialties who use anesthesia services in order
to see the processes involved. Likewise, speaking with admin-
istrators, physicians, and nurses directly involved in providing
such services is also very valuable. Overall, the goal of adding
anesthesia services to an ASC, if and when they are needed, is
to provide for the safe evaluation and treatment of a subset of
surgical patients. Such services should enhance the perioperative
experience of a patient and increase efficiency in the ASC.
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Reproduced with permission from SurgiStrategies, May 2010. For electronic usage only.
Not to be printed in any format. ©2010 Virgo Publishing. All Rights Reserved.