As we travel around the country meeting with our anesthesia clients, we are often asked the same questions. Our clients all want to know how they compare to other clients. Are they working as hard? Are they as productive? Do they have the same challenges? We like to remind these clients that every anesthesia practice is unique, which is true. Each client practice is defined by its volume and type of surgical and obstetric cases, its payer mix and the configuration of providers. Location may also be a significant factor: busy urban and suburban practices bear little resemblance to isolated rural practices. The fact is, though, that any comparison of practices must consider both the general specialty challenges and specific market or practice requirements.
The issue of provider productivity has become especially relevant when anesthesia practices renegotiate their hospital contracts. Administrators like to think that if anesthesia providers were more productive, this would reduce their need for financial support. While this is wishful thinking on the part of hospital administration, the reality is that an anesthesia provider’s productivity is clearly more a function of operating room utilization, than a provider’s desire to perform more cases. Many physician-only practices, especially those in the Midwest and Western United States, have complicated compensation systems that create incentives for anesthesiologists to generate more units. However, most other practices are only as busy as they have to be, to meet the requirements of the facility. It is important to note that in some cases, provider productivity is a result of a philosophical position. Practices often allow members to work at their own discretion. In other words, the design of the group is to allow members to work as much or little as they desire.
We took a sample of 342 anesthesiologists working for ten physician-only practices across the country, to see how many ASA units the average member garnered a year. Conventional wisdom has been that the typical anesthesiologist bills about 10,000 units annually. As the chart below indicates, this still rings true, with the caveat that there are many factors that billable units. The totals include three categories of ASA units: units for surgical time-based cases, units for obstetric cases based on total epidural times and ASA units for flat-fee services such as invasive monitoring, nerve blocks for post-operative pain management and ultrasonic guidance. The only aspect of unit production that has changed much in recent years has been the use of nerve blocks, which has increased the number of flat-fee units billed.
These are average values for the practice as a whole. By definition an average levels out a spread of individual production levels. For most practices the top 20 percent are the most productive. What we found, however, is that in practices which pay providers based on a salary (the lump and divide practices), the spread is much narrower than in those with compensation systems. In fact, looking at one such practice with a particularly unique compensation system, (practice J in the table below) only the top 25 percent of the providers generated 10,000 units.
One of the most significant determinants in provider production levels is obstetrics. Physicians are typically more productive in the operating room than in the delivery suite. For six of the sample practices, obstetric units billed represent between 15 and 20 percent. Obstetric units represent 40 percent for practice F. Practice E is a small facility where unit production is limited by surgical volume. Practice G is actually a large practice where the top ten physicians generate 10,000 units per year, but where other members choose not to work as hard.
It is important to note that there are many ways to count units in anesthesia. While the basic charge calculation includes base value units and time units, other categories of units may also be included such as those ASA units assigned to non-time based services such as invasive monitoring, nerve blocks, ultrasonic guidance and follow-up visits to patients with epidurals. For purposes of this discussion we have included all billable units. For the 2019 data we have annualized the numbers for the first six months of the year.
At least 75 percent of all anesthetics are now provided by careteam practices. So how do these physician-only practice metrics compare to careteam practice metrics? This requires a slightly different metric. We must normalize data by anesthetizing location.
The chart below converts the annual metrics above to daily production metrics. The norm is about 50 units per clinical day, which corresponds to roughly six hours of billable anesthesia time per day. This is a particularly useful reference, because it allows a practice to compare and benchmark productivity per anesthetizing location. A practice that consistently generates 50 billable units per location day may or may not be profitable, due to payer mix and staffing considerations. Those that consistently underperform will find it impossible to remain viable, without financial support from the facility. This data represents averages across all facilities and values which may vary considerably for each location.
Normalizing the data per anesthetizing location makes it much easier to compare practices and benchmark performance. It specifically allows for the comparison of physician-only practices to careteam or CRNA-only practices. As the chart below indicates, physician-only and careteam practices have very comparable levels of productivity.
It should be noted that practices which employ or work with CRNAs often do so because the average yield per provider day will not support a physician-only model. In the chart above, those practices with low average daily unit production levels reflect facilities that are simply not very busy. If the question is are careteam practices more productive than physician-only practices? The answer is it depends.
Despite the perception of hospital administrators that anesthesia providers actually control how hard they work, this is really not the case. The potential opportunity for an individual provider to generate additional or extra units is quite limited. Some providers might perform more nerve blocks with ultrasonic guidance, which would result in some additional units. Others might be more willing to pick up an extra case at the end of the day. Clearly the amount of call an individual is willing to take could have some impact as well. But when we pull the lens back and look at the practice in totality, it is quite clear that with very few exceptions, most providers work about the same.
If you have questions about your provider productivity, feel free to contact your account executive who will be happy to perform the necessary analysis and provide you benchmark data for other similar practices.
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