According to Amr Abouleish, MD, Vice Chair of Faculty Development and Professor of Anesthesiology at University of Texas Medical Branch School of Medicine, productivity measurements are imperative for quantifying the quality and value of anesthesia work being performed. “Leaders want to see an objective measurement of the work you’re doing so they can make data-driven decisions,” Dr. Abouleish said.

The only problem? It’s notoriously complicated to compare productivity across settings, groups, and individuals. With over 30 years of experience in measuring productivity in anesthesia at his institution, Dr. Abouleish discusses the methods behind the measurements.

Productivity in private practice and academic anesthesiology groups is a complicated issue, Dr. Abouleish said. Clinical productivity measurements in each setting vary depending on the size of the group, surgical duration, and billing structure – and that can pose a challenge. For instance, private practices often use productivity measurement as part of a hospital contract to determine how much the facility has to pay for coverage of anesthesia care, something that often isn’t an issue for full-time staff at an academic center.

The challenge with anesthesiology in a private practice is that staffing isn’t necessarily based on a workload – staff sometimes must be available even if there is no expected work, leaving large gaps in the day that skew productivity measurement. Post-COVID, many facilities want to open multiple locations with anesthesia coverage first thing in the morning to attract surgeons, resulting in a full staff for 10 ORs that are stuck there without the workload to fill out the day. This makes productivity management difficult because the determination of how many anesthesiologists are needed each day is then not driven by the number of cases, patients, or surgeries, but by how many sites need coverage each day.

This also allows for several non-anesthesiology-related factors to influence productivity, including the procedures being completed, the speed of surgeons, or the length of patient turnover. For example, if one room has a very fast surgeon doing basic tasks, there may be many billable units completed in a day, whereas another room may have an anesthesiologist covering two or three MRIs with a long turnover that doesn’t make as many units, Dr. Abouleish said. This doesn’t show individual effort – only a need for staffing.

“On an individual level, productivity is typically an internal measurement. In a private practice, productivity determines how money is split among clinicians and can be measured in four ways.”

Some private facilities solve this by measuring on a case by case basis, but in academic centers, leaders must also consider the value of non-clinical activity such as research, education, and administrative work. Private practice groups don’t often have non-OR days, but in academics, there are dedicated days for teaching, supervising, and research. Dr. Abouleish continued: “There are also non-clinical full-time employees, which makes faculty-based billing and productivity measurement in the facility a challenge. Further, academic groups more often include clinical duties not billed with anesthesia units, including coverage of critical care units, acute and chronic pain services, and pre-anesthesia clinics.”

In addition, academic centers have the challenge of longer case durations and limited capacity for procedural volume compared to a private practice. “Longer surgical durations are due to residents learning. In a private practice, the average surgical duration at a hospital is about 90 minutes; in academics, it stretches to 2.5 hours on average. “As a result, there is less hourly productivity, and fewer units can be billed per hour, requiring those in academic centers to work more hours to come up with the same number of units billed per anesthetizing site as a private practice.”

Anesthesiologists working in academic centers are often limited by educational accreditation requirements to work with residents in no more than two rooms at a time. One anesthesiologist working with a resident can cover that resident and only one other person. In a private practice, the staffing ratio is higher, allowing an anesthesiologist to cover three or four rooms at once, supervising and directing care of a nurse anesthesist, anesthesiologist assistant, or resident, for example.

On an individual level, productivity is typically an internal measurement. In a private practice, productivity determines how money is split among clinicians and can be measured in four ways: shift worked, time billed, units billed, and revenue generated. “The ‘shift worked’ says that we’re all going to take the same call, and it doesn’t matter what you’re doing or how many units you bill as long as it all gets done by the end of the day,” Dr. Abouleish said. In this method, all anesthesiologists work the same shifts, take the same calls, and split payment equally. It’s the most simplistic way because so many factors affect how many units are billed that there is no reason to measure individual productivity as long as the work gets done.

In other systems, people get different productivity “points” and payment depending only on the number and timing of shifts worked. Anesthesiologists who come in for a shift get paid for said shift. Though it’s the most common, this system gets more complicated in the productivity method, where individual units are billed. “If one anesthesiologist bills out more units, that physician gets more of the money; for example, if I bill 40% of the group units, I get 40% of the revenue.” This method ignores a patient’s insurance, but the revenue-generated system does not. In this method, the difference between Medicare and private insurance becomes a challenge and even raises ethical concerns. “Medicare pays 28% of what private insurance pays, so I will get paid three to four times more treating a patient with private insurance, even if the cases are identical,” Dr. Abouleish said. “It creates an incentive in the system to not treat patients the same way because of their insurance, which is a huge ethical issue. As clinicians, we take care of patients by giving them the best anesthesiology care regardless of their insurance. We should get compensated equally for the care provided, not because of patient insurance.”