Image by Thomas G. from PixabayThe United States is currently experiencing a significant shortage of anesthesiologists, due to an aging workforce, increased demand for surgical procedures and burnout among existing practitioners.
The American Society of Anesthesiologists (ASA) has reported that the percentage of facilities with anesthesia staffing shortages has increased dramatically, from 35% in early 2020 to 78% in late 2022.
Projections indicate that by 2036, the U.S. could face a shortfall of up to 86,000 physicians, with anesthesiologists being a significant portion of this deficit.
“Go to every state in the union right now, and you’re going to see people, feel people, or hear people complaining about anesthesia,” Dr. Arthur Valadie, chief physician with Coastal Orthopedics, told ASC News.
Florida-based Coastal Orthopedics’ 88,000-square-foot Bradenton headquarters is equipped with same-day surgery technology clinical services, physical therapy, administrative offices and MRI facilities, out of which 16 orthopedic specialists operate.
Ambulatory surgery centers (ASCs) are both a part of the problem and the solution; while the shift towards outpatient and minimally invasive surgeries has exacerbated the shortage, there are steps operators can take to work with anesthesia providers to address the deficit.
Enhancing efficiency, offering flexible work arrangements, collaborating with larger hospital systems, and investing in staff well-being are critical steps towards ensuring adequate anesthesia staffing, sources told ASC News.
Causes of the shortage
One primary cause of the shortage is the retirement of many anesthesiologists during the COVID-19 pandemic.
The older population of anesthesia clinicians opted for early retirement during COVID-19, exacerbating the shortage, Dr. Amr Abouleish, a pediatric anesthesiologist and a member of ASA, told ASC News.
“We have an older population of anesthesia clinicians, and coming into COVID-19, people who may have been on the cusp of retiring said, ‘I’m done with this. I’m not going to deal with this pandemic.’ And they left the marketplace,” he said.
In addition to the retirements, there is also a limited number of residency spots for anesthesiologists, constraining the pipeline of new practitioners, he said. The shortage in the U.S. is a supply-demand imbalance affecting all anesthesia clinicians, not just anesthesiologists, he added.
Furthermore, the expansion of ASCs and non-operating room anesthesia (NORA) sites has increased the demand for anesthesia services.
“NORA has grown tremendously,” Abouleish said. “COVID slowed it down for a little bit, but coming out of COVID, it continues to increase. For a full-service hospital, NORA probably accounts for about 25% to 30% of sites. For a children’s hospital, it accounts for almost 50% of the sites they have to cover every day. That demand is growing on top of the operating room demand.”
Then, there’s the operator’s relationship with anesthesiology groups. If an anesthesiology group’s revenue doesn’t cover staffing costs, they may ask ASCs to help cover the difference, Abouleish said.
Therefore, a financially stable anesthesiology group reduces this burden on ASCs. When ASCs employ anesthesiology groups, it’s in their interest to ensure fair contracts with payers.
Historically, providers compensated for low Medicare payments by billing commercial payers at higher out-of-network rates. However, the No Surprises Act (NSA) has capped these out-of-network charges, disrupting this model.
“Hospitals have subsidized anesthesia for quite some time, and now most, if not all, surgery centers have to do the same thing,” Valadie said. “And so that adds an expense burden to a surgery center for a professional service that the payer should be paying for.”
Abouleish echoed these sentiments.
“Because of the way the NSA has been implemented, there is definitely a thumb on the balance scale towards insurance companies,” he said. “Insurance companies have become predatory, saying, ‘You don’t want to be out of network; it’s so bad for you, take a lower rate.’ But if they don’t have a contract, then they’re in a situation where they have to go through the NSA process to recoup the revenue for the care they provided.”
Allowing anesthesiology groups to batch claims by payer, instead of by CPT code, would streamline the process, reduce arbitration costs, and encourage insurance companies to negotiate more equitably, Abouleish said.
“The more we can make it a fair market and fair process, not only will it make it easier for people to recoup the money they’re owed, but it will also force insurance companies to become better at negotiating in a fair manner,” he said.
Potential staffing solutions
Expanding residency programs and CRNA training programs is crucial to addressing the shortage.
There is a need for more residency spots and the involvement of private practice groups in academic training to increase the supply of anesthesiologists, Abouleish said. However, he cautioned that this is a long-term solution that will take years to impact the workforce.
“Even if I doubled [the number of available residency spots] today, you wouldn’t see the effect for four years,” he said. “So, that’s a long-term goal to increase the supply side.”
Offering flexible work arrangements can attract anesthesiologists seeking better work-life balance, Cindy Myers, vice president of ASC operations for NorthStar Anesthesia, told ASC News.
NorthStar employs over 4,000 anesthesiologists and CRNAs and collaborates with more than 300 health care facilities in 26 states.
Myers highlighted the importance of accommodating part-time work preferences to attract and retain anesthesiologists.
“We will work with [clinical staff] and figure out a way to put together a work schedule such that you can continue to be a strong clinician, but you get the work-life balance that they want,” she said.
NorthStar Anesthesia recently announced a partnership with EyeSouth Partners, bringing NorthStar’s anesthesia services to five additional EyeSouth ASCs across Cincinnati, Chicago and Atlanta.
“Currently, across the country, there is a national shortage of anesthesia providers,” Myers said. “Initially, when speaking with EyeSouth, one of their concerns was the stability of anesthesia providers needed for the growth they were anticipating. They needed reassurance about the availability of providers. With us having an already established footprint across the country with hospitals and now surgery centers, it was reassuring for them to know that one of the challenges we would address together was staffing shortages.”
Collaborations between ASCs and larger hospital systems can also help share resources and stabilize staffing, Dr. Michael Burdi, an orthopedic spinal surgeon with Community Orthopedic Medical Group, told ASC News.
Burdi said his ASC partners with a hospital to use its anesthesia group, ensuring a steady supply of anesthesiologists.
“We use the same group we use at the hospital, same anesthesia group, except the only difference is we handpick the anesthesiologists that we have at our surgery center,” he said.
Strategies for ASC operators
ASCs should focus on creating a highly efficient and pleasant work environment to attract anesthesiologists, Burdi said.
Anesthesiologists already prefer working in ASCs due to higher efficiency and fewer bureaucratic hurdles compared to hospitals, he added.
“Anesthesia has been standing in line to work at our surgery center because it’s so efficient, and it’s just a nicer place to work than the hospital,” he said, adding that operators can leverage this preference by maintaining low turnover rates and a smooth operational flow.
Employing part-time or as-needed (PRN) anesthesiologists familiar with the facility can reduce reliance on temporary staff and enhance team cohesion. ASCs could benefit from PRN staff who regularly work part-time, ensuring consistent care without the disruptions, Abouleish said.
“ASCs have some flexibility in the [PRN role], and one of the things we talk about is making the workplace more friendly for those people who may be thinking of going part-time,” he said.
Preventing burnout is critical. Abouleish suggested staffing up to manage high-volume days and providing support for acute pain services to reduce the workload on anesthesiologists.
“One of the challenges is it may cost you a little more, but in the long run, the more you can avoid burnout, the better chance you have of those employees’ longevity of employees and cohesiveness,” he said.
Offering flexible schedules and avoiding restrictive non-compete clauses can attract more anesthesiologists.
While non-compete clauses might deter potential hires, flexible scheduling can appeal to those seeking part-time work, Abouleish said.
“If I come to work at your ASC and you make me sign a non-compete clause that limits my ability to move, then I’m not going to join your group,” he said.
Still, it will take several solutions to address the problem.
Dr. Josh Lumbley, NorthStar’s chief quality officer, pointed out that last year, 70% of MD graduates and only 50% of DO graduates secured anesthesiology residency positions, leaving many aspiring anesthesiologists without training opportunities.
“There’s a big pipeline of folks that want to become anesthesiologists, but the pinch point is available residency spots,” he said.
