Non-O.R. Anesthesia: Challenge and Opportunity

Summary

Anesthesia groups are increasingly pulled in different directions. Whether contracted or not to do so, group providers are often asked to address patient needs that occur outside of the operating room suite. As most of these services are unplanned, it can add difficulty to the group's ability to optimize and measure utilization.

Anesthesia services fall into three broad categories from a scheduling perspective: surgical anesthesia, obstetric anesthesia and NORA (non-OR anesthesia). The typical ABC client allocates manpower between the operating rooms and the delivery suites and does its best to accommodate requests for services outside the operating room on an ad hoc basis. Sometimes this works and sometimes it does not. Increasingly, the demands of NORA have become a source of considerable frustration to most practices. For many of our clients, increased demands to cover IR, MRI and other procedural interventions on the floor epitomizes scope creep, that ever-more familiar phenomenon of being asked to do more for less.

Definition and Deficiencies

What defines NORA? These are isolated cases scheduled outside the operating room suite. For purposes of this discussion, they include EP, IR, Cath Lab, CT and MRI procedures. Technically, one could also include emergency intubations and blood patches, although the volume of these is usually quite small. Two aspects of NORA define the challenge. First, these services are typically unscheduled or added on during the day and, second, they may occur in a variety of venues. Anesthesia practices are most efficient when they can assign a provider or team of providers to a room for a day but are quite inefficient when isolated cases are added on outside the operating room.

Impact on Utilization

Most of our clients work in operating rooms that are not scheduled at optimum levels of productivity. Ideally, a provider or provider team should generate 50 to 60 billable units per location day. Given a reasonable payer mix, this would generate adequate income to cover the cost of providing the care. The reason that so many practices across the country require subsidies is that they cannot meet this target and the facility must cover the shortfall. The need to also provide resources to cover NORA cases only exacerbates the problem.

As we discuss operating room utilization and manpower requirements with our clients, we are increasingly reminded of the challenge of NORA. To assess the impact of these cases, we performed a review of nine clients from various states over a five-year period. As the table below indicates, the percentage of NORA cases is not huge, but it has been increasing. What the numbers do not necessarily show is just how impactful the NORA cases are on a practice from a manpower and scheduling perspective.

Looking at the Numbers

To put this in perspective, total anesthesia case volumes for this sample of clients increased 6.2 percent over the five-year period. All practices saw a migration from inpatient to outpatient venues, and there was a 4.8 percent increase in the total units billed for endoscopic cases. While some practices saw an increase in total surgical revenue, others did not as their public payer population continued to increase year over year. NORA case volume, by contrast, increased 46 percent for the sample as a whole. Total NORA units billed increased 33 percent and net collections increased eight percent.

Understanding the Uncertainties

NORA tends to be the Wild West of anesthesia practice management—a free-for-all in which anything goes. It should be remembered that, in most cases, the anesthesia group's contract with the hospital does not include any NORA coverage, but only OR coverage. Of course, given the very nature of the service anesthesia providers must deliver, it is hard to say "no" when a request for a NORA case is received. Ideally, these cases would be done later in the day, when the operating rooms are less busy. Some practices are better at this than others. As in so many aspects of practice management, one cannot manage what one does not measure. We have come to realize that this is an increasingly important aspect of the practice to monitor.