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Spring 2009

The History of Intermountain Anesthesia

Robert Hague, CRNA
Intermountain Anesthesia, P.A., Idaho Falls, Idaho

Picture this: a tyrant anesthesiologist who did not understand the significance of poor customer service and the impact of his ineffective communication, frustrated surgeons whose cases were randomly cancelled at the whim of said anesthesiologist with or without medical justification, and hospital administrators trapped in an exclusive anesthesia contract, who were feeling the pressure to increase surgical volumes and surgeon and patient satisfaction in hopes of avoiding the opening of a competing surgical center. For a sleepy town in the intermountain west, an anesthesia practice was on the brink of a business disaster.

At a small diner across from the local stockyard, an anesthesiologist and a CRNA met to discuss how to save their livelihoods. They identified long term group stability, clinical excellence, and aligned business incentives as the hallmarks of a successful anesthesia enterprise. On the back of a napkin in 1981, the framework was etched to create an innovative anesthesia practice owned by both anesthesiologists and nurse anesthetists. Aided by a young state senator (Idaho state law at the time did not allow incorporation of nurses with physicians) and a business start-up loan from a hospital administrator (sealed with a good faith handshake) Intermountain Anesthesia, PA was created. The initial group consisted of three anesthesiologists and seven nurse anesthetists.

Today, we believe that Intermountain Anesthesia, PA is well positioned for the economic and political constraints facing anesthesia practices. Aligned business incentives and resource utilization are aimed to minimize non-unit producing activities while focusing on surgeon and patient satisfaction. This unique anesthesia care team structure allows for a significantly reduced operating cost per anesthetizing location.

Our current staff of five anesthesiologists and thirteen nurse anesthetists practices in a non-medically directed modality, billing for cases utilizing either AA or QZ codes. Functionally, two anesthesiologists facilitate pre-operative evaluations, manage operative coordination at the OR desk, and resolve issues with recovering patients while two anesthesiologists and ten nurse anesthetists provide services to our twelve anesthetizing locations. Each day as the surgical volume is completed group members leave for the day as operating rooms are closed. This process is completed utilizing an “off list” where the post-call members leave first followed by the call team for the following day, repeating until the call team consisting of one anesthesiologist and three nurse anesthetists remain.

Like most anesthesia corporations, Intermountain Anesthesia elects a President, Vice President, Secretary/ Treasurer, and a Department Chair. Utilizing a board of directors, with equal representation of anesthesiologist and nurse anesthetists, all financial corporate matters, clinical decisions with a fiscal impact, and disciplinary matters are discussed and reviewed. Income goals are evaluated yearly based on industry benchmarks and call burden. The board of directors proposed incomes and operating budget are presented to the entire ownership for approval. Once approved monthly payroll is simply a percentile function of the net monthly collection. This process, coupled with a revenue guarantee arrangement for our services, has enabled the group to very accurately predict incomes.

The future of anesthesia will most assuredly encounter economic and political constraints compounded by production pressures. An increase in government insured patients will have a devastating impact on overall payor mix. Additional pay for performance regulations will likely convert to deductions from reimbursements for failure to meet future performance benchmarks. Increasing costs of employee health, disability, and other benefits threaten recruitment and retention in most anesthesia practices. Surgical services demand is likely to continue to grow as the baby boomers require services while many providers reach the age of retirement. Hospital stipends to support anesthesia practices will likely decrease in frequency and value. All the while anesthesia societies continue to attack each other rather than finding solutions together to shore up gaps in reimbursement. Will your practice consider the innovative, collaborative, leveraged anesthesia care team to help meet those challenges?