Tony Mira, President and CEO
Putting Your Anesthesiology Practice on Wheels
Shawn Michael DeRemer, MD and Gregg M. White, CRNA, MS
Anesthesia Associates Northwest, LLC (AANW), Portland, OR
Health care delivery has gradually shifted from in-hospital to outpatient settings, most recently to physicians’ offices. In fact, in 2009 the number of office-based procedures in the United States numbered 12 million. Nevertheless, though outpatient surgery may be more convenient and financially beneficial for both doctors and patients, many physicians are not taking advantage of the full realm of possible procedures that could be offered in an office setting.
In 2010, we decided to expand our own anesthesia management and staffing services business by helping physicians expand their practices. Our idea was to bring the surgical suite to physicians’ offices via a fully equipped van that would deliver all necessary resources — and also foster a “culture of safety.”
WHAT WE NEEDED
We went to task outfitting a slick- looking van with everything a physician might need to ensure efficiency and safety during the delivery of anesthesia for office-based surgery. After months of labor pains, the AANW mobile anesthesia van service was born in January 2011.
The process of purchasing and equipping a van started by identifying our requirements, choosing a vehicle manufacturer and comparison-shopping for vans. We also worked closely with vendors to get the best deal on equipment. In addition to monitoring equipment, oxygen, supplies and drugs, we bought battery back-ups to cover power outages. We also drew up a safety checklist and maintenance schedules for the van and equipment. Lastly, we procured a parking space, with special lights and camera surveillance, outside our business office.
Altogether the start-up costs totaled well beyond the six-figure mark.
WHAT WE PROVIDE
Sticker shock aside, we ended up with a sleek Mercedes Sprinter van with state- of-the-art anesthesia equipment. The intent is to bring all-inclusive anesthesia resources/equipment/supplies, along with pharmaceuticals and anesthesia clinicians. This eliminates all financial and many of the legal burdens on the surgeon/physician. Additionally, the surgeon can do what he does best. Instead of monitoring the patient before, during and after receiving anesthesia, the doctor can concentrate on the procedure at hand.
We work flexibly with our client medical practices to provide a staffing model that suits their needs — whether an MD-only model, a CRNA-only model, or a combination of the two. Our Quality Assurance/Safety Director and our Director of Practice Management collaborate with the medical team to ensure best business and safety practices and provide recommendations when needed.
Some of our regular clients have blocked days where they schedule and then notify us of the cases. Others call to check for availability and we coordinate times with their offices. Paperwork is faxed over and folders are prepared, which our anesthesia providers collect the day of the procedure for transport.
Appointments are confirmed one business day prior to the scheduled time. We arrive approximately one hour prior to the procedure to set up and do intake with the patient, including pre-anesthesia evaluation, vital signs, answering questions, etc. The average case time is one to two hours, and we remain with the patient until he/she is fully recovered (approximately 20 to 25 minutes).
All equipment and supplies are removed and returned to the office for documentation and are cleaned and checked for the next scheduled case.
All mobile cases are billed by time to the physician’s office. The physician collects from the patient. If the patient has insurance they can submit the invoice
Highly publicized fatalities such as the death of Kanye West’s mother have drawn attention to the safety of office-based procedures, which are unregulated in all but 23 states. Moreover, a vast majority of medical practices lack accreditation by one of the major accrediting agencies (AAAHC, AAAASF, JCAHO). With or without an anesthesia care team such as the one we provide, safety is a critical issue we knew we had to address.
With this in mind, we collaborate with office-based practices to create a “culture of safety.” (We use a safety checklist similar to the one developed by the Institute for Safety in Office-Based Surgery, which appears on page 8 of this issue of the Communiqué.)
The safety checklist gives our clients details on what to expect and familiarizes them with our specialized anesthesia service, including perioperative management; complications and recovery; medications and sedation. We assess the facility itself to ensure it is up to par and help with patient and procedure selection. Before surgery we also contact the patient by phone to answer questions and further assess suitability.
Monitoring during the recovery period is perhaps the most important service we provide. One study showed that 46% of adverse office-based incidents leading to an ASA claim were deemed preventable by better monitoring—e.g., by pulse oximetry in the postoperative setting. (Source: Domino KB. Office- based anesthesia: lessons learned from the Closed Claims Project. ASA Newsletter 2001;65(6):9-11, 15)
WHOM WE WORK WITH
When we launched our mobile service, the majority of our cases were at small dental/endodontic offices and orthopedic practices. Today, we are working with all types of practices (ophthalmologists, podiatrists, dermatologists, endoscopists, cosmetic and plastic surgeons, and others), and we are called on to provide anesthesia for a wide variety of office-based procedures, including hysteroscopies, LEEP procedures and sterilization, cone biopsy, endometrial ablations, etc.
In developing the marketing materials for our mobile services, we focused on several messages and how these messages can be translated to the patient, including:
- We’re there so the doctor can do what he does best. Few patients really warm up to the thought that their surgeon is multi-tasking during an operation. The presence of an anesthesia clinician allows the doctor to do the procedure in the office and make himself or herself look good at the same time. It also enables the surgeons to focus on what they do best.
- More revenue for the doctor; less cost for the patient. In today’s economy, all of us are trying to find ways to increase revenue. This is one way a doctor or dentist can do so while also saving the patient and/or insurance company money. (By the way, cost containment for the patient is a significant, though often overlooked, benefit. Many patients pay 20% of medical costs out of pocket, and many procedures (dental, cosmetic) aren’t covered by insurance at all. Eliminating the hospital facility fee greatly reduces the patient’s bill.)
- The advantages of our mobile service also centers on convenience and efficiency, both for the surgeon and for the patient. By using our services, the surgeon has the potential to see patients in between procedures. There’s no time wasted driving offsite to a hospital or surgical facility. And, patients enjoy the safety and convenience of a hospital in a familiar office setting with experienced board certified anesthesiologists or AANA-certified nurse anesthetists by their side.
- Up-to-date equipment and knowledge benefits everyone. In the past two years anesthesia has evolved; huge technological advances have been made. Surgeons can’t be expected to keep up. Those practices that have purchased anesthesiology equipment often have an outdated, hodge-podge solution that won’t meet the needs of all patients and all procedures. A mobile anesthesia service like ours mitigates all these factors.
From a service provider’s perspective, under-utilization is the biggest risk and a lesson we quickly learned. Our van is in service an average of 3.5 days a week (with an average of 2 cases per day), which means it is parked in our garage at our facility, not earning any revenue for the rest of the week.
To ensure the van doesn’t break down on the way to a procedure, we purchased full service maintenance contracts from the van manufacturer, and we follow preventive maintenance cycles to minimize wear and tear and reduce the risk of breakdowns.
In addition to the up-front costs of establishing a mobile anesthesia service, a provider has to bear the ongoing costs of doing business. Vehicle maintenance and equipment refurbishing costs are a major expense, and there are other ongoing costs that are unique to a mobile service. For example, we need medical and equipment-related insurance, as well as insurance on the vehicle, both for the van and the contents inside.
Though it’s too early to project profitability, the mobile anesthesia service has grown steadily since its inception in January 2011. It has expanded our customer base into places we never could have serviced had we maintained only our outsourced labor services.
Even with less than maximum utilization, the bottom line in terms of community response and customer satisfaction has been positive for us. Doctors and patients alike appreciate the convenience of having the equipment and technical staff come to them. It has given us a leg up on competition and an image that is helpful in branding ourselves.
In summary, there is definitely a market and need for mobile services such as ours, but start-up costs are high and profitability won’t be immediate. Nonetheless, we believe this is an opportunity to be in on the ground floor of an industry that is just beginning to take shape.