In a recent analysis of factors that influence an anesthesia resident's career decisions, investigators found that of the 263 CA-3s from a large tertiary care academic institution over 15 years, 110 (41.8%) went into private practice upon completion of their residency. In contrast, 120 (45.6%) pursued advanced fellowship training, and the rest (12.6%) stayed in academic anesthesiology (J Educ Perioper Med 2018;20:E616). The authors suggest that the low incidence of residents accepting academic positions is somehow related to the fact that many academic posts require fellowship training. Speaking from experience, we believe that the most significant driver of a decision between academic and private practice anesthesiology is economical, or at least, the perception that the financial rewards in private practice anesthesia are significantly greater. We say “perception” because the days when a private practice anesthesiologist in a physician-owned hospital-based group practice could make a large amount of money are disappearing and being replaced by for-profit national practice management corporations. There are perks to this changing landscape in private practice anesthesia as well as some pressures to consider before the leap.

Unlike academic anesthesiology, a large part of the time and energy that goes into being a successful independent private practice anesthesiologist is managing the business of anesthesiology. As most physicians did not pursue medicine as a business interest, the idea of being a business owner often becomes a source of stress and consternation. The pressure of being a small business owner, and all that goes with growing and sustaining a viable business model, has driven some small to medium-sized private practice groups to consolidate with other similarly sized groups, while others have joined a larger health system and the rest consider selling their business to a large practice management company (asamonitor.pub/2UNQgPk). The latter two options function as anesthesia group practices emphasizing management by the participating physicians (e.g., OAG) and those that operate more as management companies emphasizing financial outcomes (e.g., NAPA) (asamonitor.pub/3hDkMEz).

Anesthesiologists have always been at the mercy of surgeons and proceduralists regarding income and lifestyle. As surgeons and proceduralists have abandoned hospital-based practices to establish more lucrative, suburban-based, and ambulatory surgical centers, hospital-based anesthesia groups that had traditionally limited their practice to hospitals were at risk of decreased revenue. As this surgical practice pattern changed, independent private practice anesthesia groups understood that larger organizations with wider geographic footprints would translate literally into greater leverage during negotiations with surgeons, hospitals, and insurance companies. Anesthesia services generate more than $19 billion in revenue annually. That number is likely to grow as the need for surgical procedures increases in parallel with increased life expectancy in baby boomers who are now reaching retirement age (asamonitor.pub/3kgHuEo). To remain competitive in a market that has so much financial incentive, traditional hospital-based independent anesthesia group practices could no longer simply rely on revenues from a single institution to pay salaries and overhead. Those groups that wanted to remain relevant during contract negotiations with hospitals and insurance companies had to build a viable core business infrastructure that supported accurate and timely billing, data transparency, and evidence-based documentation of effective care delivery.

Many forward-thinking private groups opted to reinvest a percentage of their revenues toward building this infrastructure, while others leveraged partnerships with larger private equity-backed partners who already had these systems in place. Whether risks are mitigated by reinvesting salary in growth and remaining independent or through a private equity-based strategic partnership, both have advantages and disadvantages. For instance, reinvesting in your group practice allows stakeholders to remain in complete control of their business. When clinicians value autonomy and flexibility and enjoy running their own business despite the potential for lower wages, this option becomes favorable. For those who value income stability and do not have the in-house expertise or interest in running their own business, partnering with an outside company allows clinicians to focus their time and energy on patient care.

“Private groups, whether independently owned or backed by large corporations, will likely offer higher salaries for the foreseeable future compared with academic anesthesia.”

In many parts of the country, with doctors and nurse anesthetists working at the top of their licenses, how can physician-only anesthesia solo or group practices remain viable? Many practices on the East Coast and parts of the Midwest have moved toward an anesthesia care team-based paradigm. Nationwide, there are more non-physicians – including nurse anesthetists (about 47,000) and anesthesiologist assistants (about 1,700) – than physician anesthesiologists (about 46,000) in the workforce, according to 2015 National Provider Identifier (NPI) data. However, in California, there are about 5,500 physician anesthesiologists and only 1,500 nurse anesthetists. While anesthesiologist assistants can practice in 16 states and the District of Columbia, they cannot yet be licensed in California nor in Minnesota, where we practice. Though some other states, mainly in the western U.S., also have more physicians than nurse anesthetists in the anesthesia workforce, none exceeds California's ratio of more than 3.5 to 1 (asamonitor.pub/3emTEHZ). As financial pressures increase and ASA endorses a model in which a physician anesthesiologist supervises anesthesiologist assistants, residents, or nurse anesthetists in the delivery of anesthesia care, we expect these ratios to shift toward favoring non-physicians to physicians as private groups move toward a team-based approach to care delivery (asamonitor.pub/3hBBkgm).

As of mid-2017, eight practice management companies employed 22% of all anesthesia providers in this country. On May 6, 2020, North American Partners in Anesthesia (NAPA) acquired American Anesthesiology from Mednax, a transaction that put NAPA in control of over 6,000 anesthesia and pain management providers at more than 500 hospitals in 20 states, a far cry from a 20 physician-owned group practice (asamonitor.pub/3kf6Jaa). This is just one transaction exemplifying the astonishing pace of change in the business of health care delivery. As these realities have played out over the last two decades, it became clear that many private practice anesthesiologists once in small hospital-based group practices had opted for strategic partnerships (asamonitor.pub/3hDkMEz). As a result, our current landscape is filled with large physician-led practices and large for-profit national physician corporations that continue to acquire private anesthesia groups or merge to create even more powerful business entities. While the upside of large practice management companies is clear, this upside might not always translate directly to the individual practicing anesthesiologist.

Though we currently work in an academic practice, our past experiences include independent private practice, employment by a private equity-backed national anesthesia provider, and the transition from the former to the latter. In our experience, a medium-sized private anesthesia group working in a private hospital was more operationally efficient when compared with the academic OR. Driven by production pressure from a lean workforce, the expectation of efficiency became central to our business model and even more so as we transitioned under the umbrella of a management company. We believe that efficiency is a mark of a well-run, high-performing OR, but practices must balance this with up-to-date care delivery and patient safety (asamonitor.pub/3r8JW14). Private groups, whether independently owned or backed by large corporations, will likely offer higher salaries for the foreseeable future compared with academic anesthesia. Variability in compensation between private practice anesthesiologists in the U.S. will always depend on the level of training, location, and payer mix. Higher salaries, however, do not come without a cost – namely, more hours worked. To this end, we urge all who consider private practice anesthesia to take into account the total compensation package and not just salary and bonus potentials. The hours worked and the number of rooms carried (case concurrency) will, on average, be higher in private practice, and therefore, calculating an hourly salary instead of an annual salary will be a more objective comparison with academic anesthesiology. Importantly, one must understand how physician income compares with billed fees versus realized revenue (asamonitor.pub/36IPmq1).

In addition to salary, compensation can vary considerably depending on how and when money is distributed (i.e., paid as W-2, 1099, or K-1), how expenses are apportioned, whether health and malpractice insurance is covered and timing of partnership opportunities. Along with higher salaries comes more vacation time. It is not uncommon for private anesthesiologists to have a week of vacation a month. While this may seem like a lot of vacation, especially juxtaposed to the two or three weeks of vacation we get as residents, we often found ourselves resting and recovering from the relentless pace of the very efficiencies that allowed this amount of time off.

A small to medium-sized private practice anesthesia group undoubtedly lends itself to greater control over earning potential, hiring practices, and management of daily resources, particularly in a care team model. We also found that we had more control over compliance and billing, two significant drivers of revenue. Compliance, billing, earning potential, hiring practices, and human resource management are, of course, all integral to running a business and require a core group of anesthesiologists to be intimately involved in the daily business of the practice. This small business model also requires comfort with risk, as salary may fluctuate from one quarter to the next depending on the variability in surgical and procedural caseload, hiring practices, and nurse anesthetist compensation. The pressures to merge with other small groups, entertain an acquisition from a larger corporation, or join a health system is consistently a topic of intense conversation and requires time and energy to manage.

If a private practice group is acquired by a larger corporation, as happened to our group, participation in the daily operational activities of running a business all but disappeared. We were instantly afforded the leverage of being a part of a national organization and could focus on patient care delivery. While our salary decreased, the variability in pay from one month to the next stabilized, and while production pressure did not change much, our vacation time remained unchanged. Many felt the loss of autonomy in care delivery, compliance, hiring, and billing practices. In contrast, others liked focusing on patient care with freedom from the operational challenges that so many small to medium-sized private practice groups face daily. The physicians leading the business concerns of the group gained newfound freedom in their spare time, which was previously often taken up with management tasks.

Contemplating the tectonic shifts in anesthesia practice patterns over the past two decades is likely overwhelming to residents considering a career in private practice anesthesia. In addition to considering the obvious, namely practice location, call schedule, practice stability, family needs, compensation, case type and payer mix, we urge graduating residents to reflect on how practice structure and ownership might influence the culture of the practice. More importantly, consider how that same culture might change in the setting of a merger or acquisition. We point this out not to deter anesthesia residents and fellows from pursuing a career in private practice anesthesia but rather to caution them to examine thoroughly the type of practice they are joining; the devil is so often in the details. It is essential to reflect on one's values carefully and expectations for post-residency practice and lifestyle and match them with the vision and mission of a practice to ensure close alignment.

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Tjorvi E. Perry, MD, MMSc, Chief of Cardiothoracic Anesthesiology, University of Minnesota Medical Center, Minneapolis.

Tjorvi E. Perry, MD, MMSc, Chief of Cardiothoracic Anesthesiology, University of Minnesota Medical Center, Minneapolis.

Andrew L. Wilkey, MD, FASA, Assistant Professor, University of Minnesota, Minneapolis.

Andrew L. Wilkey, MD, FASA, Assistant Professor, University of Minnesota, Minneapolis.