“Thor Wrestling With Age,” by Icelandic sculptor Einar Jonsson (1874-1954). Photo taken in Iceland, July 4, 2021.

“Thor Wrestling With Age,” by Icelandic sculptor Einar Jonsson (1874-1954). Photo taken in Iceland, July 4, 2021.

The expansion of anesthesia services from beyond the OR to include non-operating room anesthesia care, critical care services, subspecialty services (namely, cardiac anesthesiology, pediatric anesthesiology, regional anesthesiology, ambulatory anesthesiology, office-based anesthesia, acute and chronic pain care), and the need for executive leadership in the specialty has resulted in a tremendous new landscape for the practice of anesthesiology. At the same time, large insurance companies controlling the market are constantly looking at ways to minimize health care reimbursement, creating increased challenges for anesthesia caregivers (asamonitor.pub/3hKinqq).

Recently, there has been a shift from productivity to value-based care, including customer satisfaction as assessed by quality metrics and other parameters that make it difficult for academic medical centers to compete with private groups (Anesthesiol Clin 2018;36:321-32). This is even though academic medical centers have contributed to significant scientific advances in anesthesiology during the last century. Such advances have allowed surgical procedures to proceed safely with excellent outcomes. In the year 2010, approximately 50 million procedures requiring anesthesia care were performed in the U.S., with approximately half being done in ambulatory centers because of the tremendous growth in ambulatory and office-based anesthesia. These numbers have significantly increased in conjunction with advances in anesthesiology and surgery. More and more procedures are being shifted from the hospital to ambulatory centers. Office-based procedures employing or contracting with solo anesthesia caregivers have also increased. The use of regional analgesia techniques and the availability of pharmacological agents to minimize postoperative nausea and vomiting have allowed patients to be safely discharged home. Although the number of procedures declined during 2020 because of COVID, complete recovery is expected, along with an increase of 10% or more this year and next year (asamonitor.pub/3ACiPzG). United Health Group, one of the major players in health care, is planning to move more of its members toward ambulatory surgical care, as indicated in a recent sustainability report, which suggests this is being done because of lower cost and the “... same or better quality of care” (asamonitor.pub/3hX32mT).

One of the reasons these actions are possible is because of the high quality of care provided by anesthesia care teams. Currently, there are approximately 50,000 anesthesiologists, the same number of nurse anesthetists, and about 130,000 anesthesiologist assistants in the U.S (asamonitor.pub/3hMGKUO; asamonitor.pub/3hFOcRs; asamonitor.pub/3hX3Acr). This combined highly educated work force has allowed the safe delivery of high-quality anesthesia care in this country. However, anesthesiology leadership needs to be cognizant of the efforts of health care agencies seeking to disrupt the practice of anesthesia services for monetary reasons, as exemplified recently (asamonitor.pub/3qRqvcZ; asamonitor.pub/3AKtNn4). The calculation of anesthesia caregiver productivity is not as simple as looking at the number of cases performed (J Clin Anesth 2021;71:110194; Anesth Analg 2020;131:885-92). It needs to take into consideration case severity, number and type of caregivers involved, location of the care, payer mix and contracting at the facility, and other local issues such as available support from the institution. Benchmarking is another tool used by disrupters and aggregators of anesthesia care in their effort to acquire anesthesia practices. Anesthesia groups need to be aware of this while ensuring that anesthesia care includes not just care of patients in the OR – the landscape, as mentioned, has expanded to provide perioperative care, including extended postoperative pain relief and critical care services and chronic pain management with subspecialty services (Figure).

Figure:

Anesthesiologists have several options to pursue a career. Options include solo practice, small or large group practice either in a hospital or as an ambulatory or office-based anesthesiologist. Small or large groups could be private or be part of an academic entity. Private groups are increasingly becoming equity owned. To meet the increasing demands of solo and group practice, another option is to be a locum-tenens anesthesiologist. Anesthesiologists also have other options as listed above.

Figure:

Anesthesiologists have several options to pursue a career. Options include solo practice, small or large group practice either in a hospital or as an ambulatory or office-based anesthesiologist. Small or large groups could be private or be part of an academic entity. Private groups are increasingly becoming equity owned. To meet the increasing demands of solo and group practice, another option is to be a locum-tenens anesthesiologist. Anesthesiologists also have other options as listed above.

Although the number of solo practitioners providing services in office-based and smaller ambulatory practices is not known, the majority of anesthesiologists are providing care as a group either as a private practice, academic practice, or as an employee of a hospital or other entity. Another group of anesthesiologists and nurse anesthetists work as locum tenens, which is happening more and more to fulfill clinical work force scheduling and other requirements and needs of health care facilities (asamonitor.pub/3qQQNfl). Some individuals enjoy the freedom of locum tenens work and the benefits it provides. One should note that the provision of anesthesia services includes not only clinical care but several non-patient care-related elements, namely: revenue cycle management, accounting, tax preparation, payroll, practice management services, including bookkeeping and billing, and compliance services while providing cost-competitive care with enhanced quality and patient satisfaction. In addition, anesthesia groups must be actively involved at the executive level for the negotiation of contracts, ensuring patient safety, and actively bonding with surgical and local leadership teams to convince decision-makers on the significant value and role of anesthesia caregivers (Figure). A weakness in group leadership has led entrepreneurs to recognize vulnerability and profitability aspects of anesthesia services. Many such entrepreneurs have established equity-based companies resulting in mergers and acquisitions of anesthesia groups (asamonitor.pub/2TGzkKA). Equity groups capitalize by centralizing the non-clinical aspects of anesthesia practice to increase shareholder value while ensuring up-to-date administrative, compliance, and legal requirements. In response, academic programs for physicians and nurse specialists have expanded the available traditional advanced training programs to include the administrative and leadership aspects of training (asamonitor.pub/3jLdyQx). This has been done to meet the demand for value-based care while maintaining competency, as reflected in newer regional anesthesia and acute pain fellowships and advanced training in ambulatory and non-operating room anesthesia for physicians. Several institutions are also offering and promoting joint programs in health administration and business administration so that groups may appoint such anesthesiologists to help manage and lead the group and review all aspects of any prospective mergers or acquisitions. Mergers and acquisitions are no simple matter for anesthesiology groups and require scrutiny and evaluation. Items requiring appraisal include risk pooling, price bargaining, benefits of diversification, and stability of the merger. Not all mergers and acquisitions are successful and can further disrupt individuals and anesthesia services in institutions. Anesthesiologists may also seek other non-traditional opportunities to pursue their careers (Figure). Anesthesiology societies and academic institutions are currently strongly promoting research and education to advance the specialty and ensure the availability of the predicted need in the future of anesthesia people power. Thus, the future of anesthesia is bright for anesthesiologists, nurse anesthetists, and anesthesiologist assistants (Adv Anesth 2019;37:111-26). This issue of the ASA Monitor has invited experts to address the current and future landscape of anesthesiology practice and provide details of some of the issues discussed. Their articles provide valuable information for budding and current anesthesia caregivers and hopefully can help prepare them in their career paths by allowing them to look before leaping!

“...anesthesiology leadership needs to be cognizant of the efforts of health care agencies seeking to disrupt the practice of anesthesia services for monetary reasons, as exemplified recently.”

Kumar G. Belani, MBBS, MS, FACA, FAAP, SAMBA-F, Pediatric Anesthesiologist-In-Chief, University of Minnesota Health Fairview-Masonic Children's Hospital, Minneapolis, and Professor of Anesthesiology, Medicine & Pediatrics, University of Minnesota Medical School.

Kumar G. Belani, MBBS, MS, FACA, FAAP, SAMBA-F, Pediatric Anesthesiologist-In-Chief, University of Minnesota Health Fairview-Masonic Children's Hospital, Minneapolis, and Professor of Anesthesiology, Medicine & Pediatrics, University of Minnesota Medical School.