The success of the ASC model relies heavily on patient selection, from both a safety and operational efficiency perspective.
But a convergence of factors — from CMS policy to technological advancements and an aging population — has resulted in ASCs managing an increasingly high level of acuity in patients. The anesthesia infrastructure that served the previous era is being stress-tested in new ways.
“Long gone is going to be the 50-year-old total joint,” Adamina Podraza, MD, anesthesiologist and medical director at Deerpath Ambulatory Surgical Center in Morris, Ill., said during a panel at Becker’s Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in Chicago from June 11-13. “You’re going to be doing the 85-year-old total joint at your surgery center.”
That shift, panelists said, is forcing a fundamental rethinking of what anesthesia’s role inside an ASC looks like — not just clinically, but operationally and strategically.
For Dr. Podraza, the change requires integrating anesthesia into preoperative planning in ways that were less necessary before. Patients coming in for procedures they would have once had in a hospital setting require more detailed optimization, family coordination and discharge planning.
“You have to integrate the family. The center has to be aware of limitations in their ability at home, whether they should go home or to an extended care facility, things that they never did before,” she said. “These are the conversations that are happening.”
Moumen Asbahi, MD, corporate chair of surgical services and anesthesia at Chicago-based Insight Health System framed the stakes in operational terms. Anesthesia’s involvement in cancellation reduction and preoperative clearance has always mattered, but with higher-acuity patients, the margin for error shrinks.
“Time is money in the operating room. Everybody who’s looking at the balance sheets understands that,” Dr. Asbahi said. “And so, on top of working through the surgeons to make sure prior auth and patient access and all that is steady, the anesthesia involvement is key.”
The acuity shift is arriving on top of an already strained anesthesia workforce. Panelist Megan Friedman, MD, chair and medical director of Los Angeles-based Pacific Coast Anesthesia said centers that treat anesthesia as a per-case commodity are struggling to retain the providers they need.
“Compensation will get someone in the door, but it’s not going to be what’s going to keep them,” Dr. Friedman said. “What they want in addition to compensation is they want to see that their time and expertise are respected.”
That respect, she said, means involving anesthesia in scheduling, utilization and throughput decisions.
“In the past, prior to this shortage, anesthesia was kind of thought of as a per-case commodity,” Dr. Friedman said. “But centers are starting to realize it’s an infrastructure.”
When asked directly how ASCs can take on more complex cases while working with an array of anesthesia care team models, Dr. Asbahi noted that “[t]here is a gap,” in workforce training.
“Acuity is going to be going up,” he said. “Complicated or difficult patients and difficult management is going to continue to happen.”
His system’s response has been a mixed model: deploying CRNAs, anesthesiologists and certified anesthesiologist assistants depending on location, case type and market conditions — with decisions made at the site level rather than imposed from the top. A CRNA-only endoscopy center operates differently from a hospital running a cardiac service line. Cookie-cutter approaches, he said, fail.
Dr. Podraza, who is also expanding cardiac capability at Deerpath, said the planning horizon for those decisions has to start well before a new service line launches.
“You have to start early to make sure these people are a good fit at our center and that we want to use them later on,” she said. “You can’t just say, ‘We’re going to start a service line’ and say, ‘We’re going to do it Thursday,’ when you know that your group already has that person tied up somewhere else.”
Data, all three panelists agreed, is the connective tissue that makes these partnerships functional.
“Surgeons don’t believe anything unless you have the data,” Dr. Asbahi said. “Having that data is huge and having that open line of communication.”
The challenge ahead, panelists said, is that the assumptions baked into most ASC anesthesia relationships were formed during a different era. Subsidy arrangements, staffing models and partnership expectations all reflect a patient population that is shifting under the industry’s feet.
“To advance the financial and the advancement of your center’s growth, you need to integrate anesthesia to make sure that there is a connection with your input and throughput of all your patients,” Dr. Podraza said. “Otherwise, you’re not going to succeed in this day and age.”