How ASCs Can Reduce Anesthesia Subsidy Pressure

Ep. 155: Brian Cohen and Lee Kortmansky – How ASCs Can Reduce Anesthesia Subsidy Pressure

Episode Transcript

[00:00:24] Ryan Cohn: Hi, everyone. Here’s what you can expect on today’s episode. I’m especially excited for this one because we’re tackling one of the biggest issues on everyone’s mind right now, anesthesia subsidies and coverage. And what makes this conversation so valuable is that we didn’t just bring on someone to talk about the problem in theory.

Grant is joined today by Dr. Brian Cohen, a practicing anesthesiologist in South Florida and one of the founding members and administrative chief of Moss Anesthesia Group

Along with one of his partners, Lee Koransky, site administrator at Physicians Outpatient Surgery Center. Together, they walk through what it actually looks like when an ASC and anesthesia group work together to reduce subsidy exposure, improve scheduling, and get more efficient. In Lee’s case, that work helped reduce his center’s anesthesia subsidy from almost half a million dollars in twenty twenty-four to just over a couple hundred thousand dollars the following year.

So we’re talking about nearly three hundred thousand dollars in savings here

That’s why I’m so excited, and I think this episode is gonna be so useful for ASC leaders. Brian and Lee get very practical. They talk about surgeon blocks, OR utilization, case mix, staffing decisions, patient collections, and how to have better conversations with surgeons and anesthesia partners

Then after Grant’s conversation, we’ll spend a few minutes with new data from our brand new twenty twenty-six State of the ASC Industry Report. We’ll look at OR block utilization, cancellation rates, patient collections, and case profitability

And we’ll connect those findings back to the anesthesia challenges that Brian and Lee discussed today. I hope everyone enjoys the episode, and here’s what’s going on this week in surgery centers

[00:02:09] Grant Duncan: Dr. Cohen and Lee, thanks so much for coming on today. To start us out, can you give us each a quick introduction to who you are, your organization, and what your role is?

[00:02:21] Brian Cohen: Sure. I’m Brian Cohen. I’m a practicing anesthesiologist in South Florida. One of the founding members and administrative chief of Moss Anesthesia Group, which includes Miami Anesthesia Services and Moss Anesthesia Consultants.

And we oversee clinical services and management services over about 20 surgery centers here in South Florida.

[00:02:40] Lee Kortmansky: Hi, and I’m Lee Kormanski. I am the site administrator for Physician Outpatient Surgery Center, POSC. We are part of Holy Cross Health System, which is ultimately part of Trinity big health system out in the Midwest.

I have been here a little over two years and I have been running centers for over 14 years in South Florida area

[00:03:01] Grant Duncan: Yeah, excited to jump into this topic with both of you today as we’ll be talking about anesthesia in ASC setting. So let’s start with you, Dr. Cohen. When an ASC is struggling with anesthesia costs, what could be some of the items that’s actually going on beneath the surface?

[00:03:23] Brian Cohen: Yeah the mismatch of anesthesia cost versus revenue is usually exposing something that’s already underlying at the facility and maybe it just hasn’t surfaced yet. So we’ve seen, you know, many of these inefficiencies may be there, but were less imperative to address when margins were good and the dividend checks were, you know, d- being delivered in the mail.

But a- all of these issues like payor mix case type OR gaps end up affecting the bottom line of the ASC just as much as the anesthesia side. But we seem to be that canary in the coal mine right now

[00:04:00] Grant Duncan: Yeah, certainly. And Lee, you’ve made anesthesia coverage a bigger priority for your team. When did you decide, “Hey, this is something I wanna dig into more”?

[00:04:15] Lee Kortmansky: I started in April 2024. Dr. Cohen’s group took over the January, four months before. Literally the– my first day, Dr. Cohen and I started talking. What jumped out at me that day was the $75,000-plus stipends we were paying for anesthesia coverage.

It’s just a nature of the beast. When I started, we didn’t have that, of course. But now it’s right through South Florida and, of course, the country that’s just a matter of fact. You know, to have a center, you need– and then you have anesthesia, you have to have a stipend. We also had people talking the wrong– were saying the wrong things.

They were saying the wrong things at the offices. Saying things like “No, we can’t open a room because it’s– anesthesia won’t allow it,” or putting the onus on anesthesia. That’s not how this works. When you’re in partnership with anesthesia, it’s not driven by anesthesia. It’s driven by the center.

The center is the one that makes the… The center administrator usually is the one who decides, you know, what costs are we gonna allow, what costs we’re not gonna allow. There’s a lot of factors that go into it. But what drove it, that’s we’re spending a lot of money on things that were because we were inefficient

[00:05:20] Grant Duncan: Yeah, I can imagine when you joined new, of course, anytime you join a a new role, there, there can feel like there are hundreds of priorities to focus on.

So what helped you narrow in on, okay, hey, here’s gonna be one of my big rocks? Was it the fact that you were seeing those costs and then the ability to shape how you were working together better?

[00:05:48] Lee Kortmansky: You know what? It’s not only looking at it through the lens of how this is gonna affect anesthesia.

Because when anesthesia is efficient, so is the center, right? Sure. If I’m running an effective center and I’m staffing appropriately, anesthesia staffing, I’m also staffing my own people. So our costs are 100% aligned. So it wasn’t really that I went there going, “Oh my God, I gotta fix this anesthesia issue.”

It was, we have some inefficiencies that are affecting anesthesia. It was actually the opposite. So when we got our own house in order is when we started to see fruits of that labor.

[00:06:28] Grant Duncan: Yeah. Yeah, I’m excited to, to hear more from both of you on what that partnership has looked like. Dr. Cohen when you’re working with an ASC like Lee’s, let’s say you’re coming in fresh, what are some of the early data points or maybe patterns in operations that you’re looking at?

[00:06:48] Brian Cohen: Yeah we try to dig deep into those before we even begin at an ASC, right? Because part of this is about you know, projecting out what reality would be and being sort of honest and transparent about it. So we run these extensive models looking at case types, volumes payor mix and OR utilization hours.

And then that allows us to sort of develop these models that, that estimate costs, but also allows us to try to pick out some opportunities even before we start. I just had a call this morning with a center that operates on two different levels, two different floors of the building, five ORs on each level.

And saw very quickly when I looked at the OR utilization that three out of the five rooms on one of the floors was being utilized thirty-five percent of the time or less. So in my mind, that’s an opportunity. That’s a huge opportunity to start stacking those cases, and now you’ve gone from five ORs to four ORs, which is actually in the anesthesia world, that’s an exponential change because it changes how you staff.

Right. That one change alone, I was able to show that change is a fifty thousand dollar a month subsidy to a seven thousand dollar a month profit, being able to make that one switch. So those are the data points and that we look at even beforehand. And then obviously once we start in an ASC, our whole view kind of changes from 2D to 3D, right?

Because then you start to be able to pick up on some of these more of the intangibles, like the strength of the staff, the physical layout of the place. Those things affect turnover times. They affect, you know, what you can do, how you can do it. But you know, that first and the most– one of the most important factors that, that impact our ability to drive efficiency is typically gonna be all those factors surrounding and put into the surgeon block and how they’re using those blocks.

So, you know, that’s sort of leading up to it and then as we get in and manage it day-to-day.

[00:08:42] Grant Duncan: Yeah, and when you’re doing that upfront contracting, the analysis beforehand how do you suggest anesthesia groups and A- ASCs think about the negotiation or the potential changes? Like you said, like, “Hey, we suggested they change the number of ORs they’re using, at least until they can get case volume up.”

How do you suggest you have that kind of two-way dialogue to build that partnership even before it’s technically a legal contract?

[00:09:15] Brian Cohen: Well, it’s ex- yeah, it’s exactly what you said. It’s two-way dialogue and it’s upfront. And I think one of the most important things that we try to do as a company is this whole ASC world, anesthesia world, healthcare in general is it’s not static.

It’s very dynamic. And so if I’m looking at data from twenty twenty-five and projecting what’s gonna happen in twenty twenty-seven, I mean, come on. We don’t know. So the way we approach it is here’s in black and white sort of our formula and how we approach these things. Number one, from here are our costs, here are our projected collections based on this and here are some of our ideas, right?

And so being able to show them even ahead of time what the impact of those changes could bring to their center is step number one. Step number two then is working with them to implement those, which again, is not always a financial decision. It includes getting the partners on board with maybe shifting their schedules around a little bit, which is not always a- as easy as we think.

So the third piece then is, or second, fourth, wherever I ended up, is how you treat the actual cost as you move forward, right? So whatever numbers we threw out there and we’re gonna put into a contract, that is one possibility. But what we like to do is operate on an actual. So if those s- if that center and those partners are actually taking the initiative to make these changes like, like Lee and his partners did to shift into these models that actually do decrease cost with keeping the same revenue, that should pass back to the center, and that’s how we’ve worked our company a little bit differently i- in collaboration to let the rewards of these changes pass back in savings.

And that’s really been the difference and a game changer in, in encouraging the maintenance of these changes instead of just kind of a, you know, one-time fix.

[00:11:08] Grant Duncan: Right. And, you know, so we’re talking through some of the areas of opportunity in terms of surgeon blocks overall OR utilization, how many ORs you’re even keeping online. Either of you, you know, feel free to chime in. What are some other sometimes issues you see in ASCs maybe from staffing or the scheduling or other utilization things that may drive up those anesthesia costs or subsidy exposures or maybe change the utilization at a center overall?

[00:11:44] Brian Cohen: First of all, I think, you know, what we’ve seen it’s become imperative to have a leader like Lee. And that leader needs to be willing and able to participate in these literally day-to-day operation discussions and decisions. One, one example that I always like that sort of highlights what you’re saying in the fact that we could all be doing what we think is right, but what is actually that translating to is if we look at this from a scheduler’s point of view, right?

And you really have two sets of schedulers that are in play here. You have the surgeon schedulers, and you have the surgery center schedulers. And they have very specific marching orders, put as many cases on as you can, and do what the surgeon wants me to do when he or she wants me to do them.

So, Let’s say a surgeon scheduler sends over cases and says, “I have two cases. A surgeon has to start at 7:00 AM, but he has clinic starting at 9:00, so can only do these two cases.” So the ASC scheduler gets these two cases and slaps them on the schedule because that’s what she’s here to do, is put as many cases on the schedule as possible, and just based on volume.

So if those two cases happen to be Medicare cases, and maybe they happen to be carpal tunnels well, anesthesia, we just essentially dedicated $1,600 to staff that room with a CRNA, and we just collected about $360 for those two cases. Maybe no other surgeon wanted to come at nine o’clock and start more, so that room just sits empty.

So that s- those both sets of schedulers, without oversight and direction, did their jobs, but their actions actually cost the center $1,240 of a loss just in that one room. And if you do that multiple times over a week, over a year, that’s where these costs stack up, and that’s where you know, I’ve seen the value of strong ASC leadership being able to direct some of these in collaboration with the anesthesia team to really create that optimization.

And that’s what cert- without the margins it used to be, this is all about using the minutes that we have and the rooms that we have every day

[00:13:56] Lee Kortmansky: But it’s not like the administrator should be sitting there and thinking only about anesthesia every day. Right.

[00:14:04] Brian Cohen: I know that doctors don’t want that. I

[00:14:04] Lee Kortmansky: mean- I know

we

[00:14:05] Brian Cohen: can talk more about that later. Yeah.

[00:14:07] Lee Kortmansky: Because our efficiencies align so almost perfectly having a center, having… Running the rooms efficiently just by default help anesthesia and your subsidy. But you do wanna run an efficient center just to squeeze out as much as you can for the partnership, right?

That’s, we have a fiduciary responsibility to them. But not every decision that an administrator listening to this is gonna say is driven just by cost, right? And even in Dr. Cohen’s example, let’s say that ophthalmologist is a new ophthalmologist, is… they’re starting you’re wooing them, you want them to start bringing more cases.

You might say, “It’s okay. Come. I don’t want you to have 10 cases, I want you to come for just two. I… You don’t even know where the bathroom is, you know. Come with your two. Figure it out, you know, where there’s lunch, this is the changing room.” Yeah, it wasn’t a great… the room wasn’t great. We didn’t make money in the room, but we’re entertaining a relationship.

It w- that’s not long-term strategy, but that happens, and we’ve done that, you know, with hand surgeons. We do that with new surgeons. We don’t wanna overwhelm them. We don’t wanna say, “No, the minimum is X, Y, Z.” And there are plenty of specialties where two is fine. We make good money on two cases, spine, pain, you know, totals.

There, there’s thir- we get on a list. So it’s not just, you know, have a set number, tell your scheduler, “I only want these two,” and that’s it. If you don’t do it, just say no. It’s a give and take. And every day, the scheduler and I are always talking about, you know, what will work, what, you know, what we can get away with.

You don’t wanna piss off your doctors either. You know, we’re here for the service, especially the ones that come constantly and consistently. Hey, maybe they had seven. Maybe it was gonna be a really good day and they had three cancellations, you know. Do you cancel the room now that the ophthalmologist only has four?

No, you don’t. You don’t do that to somebody, right? But then you have the onesie-twosie that had the one… you see, there’s a lot of go- that goes into this that, that it’s very dynamic. I think you used the word before- Mm-hmm … Dr. Cohen. It’s not just a spreadsheet looking at numbers and going, “Oh, it’s not profitable.

Can’t do it.” Right. ‘Cause you start saying to the doc- you start saying to the surgeons, and this happened at the beginning, “Well, you know, it costs us $2,600 to open a room.” Not that I gotta write a check to Dr. Cohen and say, “Here, you know, please send me somebody.” It’s, these are the costs, these are the revenue, this is the average what it’s gonna cost to have that room operational.

We need to have more revenue than that. They hear it’s gonna cost $2,600 and, oh my God, I can’t believe ASC is so greedy. Why are they sending you a bill? That’s not, you know… Gotta be careful. That’s not what’s going on. They’ll, they don’t care. I mean, th- you w- if I say, no, I want someone there for that room, they’ll send somebody.

That’s not the point. The point is overall, you know, are we doing right by the partnership? So there’s a lot that goes into it.

[00:16:52] Brian Cohen: Yeah. And I think- Yeah … what you see is when you scale this, right? Or whether you’re scaling it from one center to five centers to 20 to 200, or whether you’re scaling it from one day to one week to one month to one year at the same center, there’s There are all of these different factors, and there’s all these different scenarios, and there are different right answers for different reasons.

So what we’ve been able to experiment with over the past 10 years and really work towards and hope to continue to improve over the next 10 years is finding the ways to peel out the predictable factors that are more black and white and present those in a way that are actionable, you know, to the centers, and then while allowing the whole team to take into account those gray factors, the gray zone, and make the decisions.

And as Lee said, our approach has never been and really can never be or should never be here’s what we think is right. No. Here’s what we see, and as a vendor of services to the surgery center, the surgeons, and the patients what would you like us to do based on this information? And that’s really the collaboration that’s started to evolve between anesthesia groups and surgery centers in order to be successful

[00:18:12] Grant Duncan: Yeah. Makes a lot of sense what you’re both saying. It reminds me, we– at HT, we had this tool to be able to predict case profitability before it gets scheduled, and there’s so many conversations that people can have, like you were saying, Lee, where, “Hey, I’m gonna be okay taking some unprofitable cases if it’s going to help for the whole day or for the month or to establish that relationship.”

So it’s really good you’re calling out that you can’t just look at one case or one day on its own. You have to take that holistic perspective and have that back and forth, like you were saying, Dr. Kohn.

[00:18:54] Brian Cohen: Mm-hmm.

[00:18:54] Grant Duncan: So let’s jump back to when you two started working together. When you were digging into the model, Lee, what were some of the insights or aha moments that you came across?

[00:19:05] Lee Kortmansky: Okay. I’m not clinical. I my background is in business. That’s what my degrees are in. So, Dr. Cohen and I connected basically from day one.

So what I needed from him was I needed him to let me know what– ’cause I’m pretty conservative when it comes to patient safety. I need the… I needed him to tell me what models are available and what models he thinks are safe, right? I mean, you could technically have one doctor here and have four rooms running, like one doctor in a day.

Yeah, that’s not– no one’s gonna do that. I’m saying that, of course, tongue in cheek and he’s not gonna do that either. But my point is that there are different models. CMS, you know, mandates, you know, you have a doctor and CRNAs, those ratios and when it’s supervised and things of that nature that, you know, you don’t have if there are MDs.

And that is not something that really occurred to me, like that you can come up with a model, he came up with a model where he says, “Well, you know, it’s actually cheaper if we– if I send you doctors and no CRNAs.” That kind of thing was more of an aha moment because that never really occurred to me because doctors, you know, generally speaking, make more than CRNAs.

That kind of stuff.

[00:20:12] Grant Duncan: That’s a great example

[00:20:13] Lee Kortmansky: Our model is that depending on the specialty we only have MDs here. We won’t have any CRNAs, which is not something that you would be– that’s intuitive, that you would think beforehand.

[00:20:22] Brian Cohen: Yeah. I mean, the, the– there’s two really good examples that come out of that, Lee, is and again this is more of the ability to drill down to not every day is the same at every center, right? So if you have a day, granted you have four operating rooms at your center, but let’s say only two of them are being run, and let’s say it’s not a heavy orthopedic with a lot of blocks type of day.

[00:20:46] Lee Kortmansky: Right.

[00:20:46] Brian Cohen: It is financially less cost to put an MD in one room and an MD in another room instead of an MD supervising two CRNAs. That’s purely you’ve eliminated an entire person. So yes, hourly maybe it is more, but the total cost is less. And is it still an efficient model? Yeah, if you’re not doing 50 blocks in a day.

Is it still a safe model? Sa- safety profile’s the same. So you start weighing those together. And there’s other examples like that, but it all comes back to having the d- drive and reason to look at the detail even of the types of cases and the speed of the cases and the surgeons, you know, for example, rather than just saying two rooms, three rooms.

It’s not all the same. A-and a- and that again is what is needed, that level is needed now in the ASCs because of kind of those loss of margins that we all used to have there.

[00:21:41] Grant Duncan: Right. Yeah, certainly. So we’ve been talking through a number of changes that you two made or you’ve seen done at other ASCs.

Are there other types of changes related to what we’re talking about that you’ve seen that may be worth mentioning for listeners?

[00:22:00] Brian Cohen: Y- yeah, I mean, something that we’ve kind of grown and evolved with over the years is kind of along the same lines of what we were just mentioning with the ability to shift models based on case type. Is that nothing really can be all or nothing or doesn’t need to be all or nothing. And y- that starts to surface more with the types of specialties that are at a center.

You know, ophthalmology is a unique case mix right now and so is GI for two very different reasons. But are two of the most high volume specialties in ASCs right now. So ophthalmology if the majority are being c- done with cat- you know, cataract surgery, and if those cataracts are being done with, you know, maybe a little bit of versed sedation, you can start looking at different types of models that take into account efficiency, safety, CMS compliance, and reimbursement opportunities.

And so for example, I’m not saying– what I’m saying is it doesn’t have to be, is our model CRNA or is our model MD or is it a one to four? There are models in between. And and those can be, you know, again, a little more customized to what needs to be done there because the fact that you’re using a light sedation gives you the opportunity to provide a little more of a zone coverage, like I, I like to call it approach, rather than kind of that man-to-man coverage.

And I’m not talking about zone over patients. I’m talking about zone between MD anesthesiologists or anesthesiologists and CRNAs and how they interact together within the rooms in the center. On the flip side of that is, is GI, which historically has been a very popular field to do all CRNA models with which allows those CRNAs to function under the license of the gastroenterologist.

Which again it works as a necessity in a lot of the more rural areas. It may work in some of the other areas as well. But for those, again, I like to take into account the clinical oversight, and I don’t care if it’s MDs, CRNAs, AAs, anybody, it’s hands, and the ability to have enough hands to provide support for specific cases as they happen.

Upper endoscopy, I’d rather do 50 open heart crashing onto bypass cases than one upper endoscopy because it’s an unprotected airway it’s coughing it’s things that we often see each other, our own peers and colleagues, asking for assistance with and needing help with. So, you know, it– this all comes down to looking at the specialty, looking at the case type, adding that into the mix and being able to do that at scale in a consistent manner with the team that you’re working with there

[00:24:41] Grant Duncan: Yeah, those are great examples. Lee, anything you would add for other changes you’ve seen?

[00:24:47] Lee Kortmansky: Yeah. One of the things a completely different direction that Dr. Cohen went one of the pressures on the ASC is that the doctors love to be flipped. And if you’re not familiar with what flipping is giving one surgeon with enough volume two rooms.

And in the past, that just meant two teams and two anesthesia providers. That was just what it meant. These days though, we kind of cheat, and we can– and as long as anesthesia’s okay with it, and that’s part of it, right, is that we tell anesthesia, “No it’s two rooms, but we only want one of you for these two rooms.”

And I’ll bring in two teams because the cost really is loaded in the anesthesia subsidy. It’s really not in the staffing. Yeah. I mean, there, there is a margin there. We can argue about that another time. So the surgeon feels like they’re flowing faster ’cause they have two rooms, and they have a team setting up the room.

And you’re saving on an anesthesia provider. And I think that’s like a good cheat, especially for somebody that you want to help but don’t wanna invest in the two providers. Right.

[00:25:48] Brian Cohen: Yeah. So that’s more the flop instead of the flip.

[00:25:52] Lee Kortmansky: And my nurse manager told me that word. I haven’t adopted it yet.

[00:25:55] Brian Cohen: I like it. I’m embrace– I’m embracing it.

[00:25:58] Lee Kortmansky: All right.

[00:25:58] Brian Cohen: It makes it clear in my head.

[00:26:00] Grant Duncan: Nice.

[00:26:00] Lee Kortmansky: That’s great. I think NBA or soccer when you say flop, so.

[00:26:03] Grant Duncan: Mm-hmm. Oh, man. So when– Lee, when you were making these changes and improving the ASC is there anything else from the process that you would want others to know or you’d give advice for how they should think about proceeding?

[00:26:19] Lee Kortmansky: Yeah, it could be… Proceed carefully. A- and what I mean by that is, you know, your relationship with the anesthesia is one thing, but you also have a relationship with your staff, your relationship with the management company- Mm-hmm … you have a relationship with the surgeons. And everyone has different needs and wants, and they’re not all gonna be aligned.

I still maintain that the ASC aligns with anesthesia. You know, they make money, you make money. But sometimes you may, you might have surgeons that aren’t partners, that don’t care about your dividends, and just wanna be, you know, in and out, right? They only care about its speed. So they want all the resources on hand-

and they don’t care about the cost associated with it, right? So don’t be talking to them about it’s gonna cost too much money. You know, you better word that differently. You know, and staff like to be there. They don’t wanna be home, you know? So, so be careful how you word it. Be careful how, you know, please don’t lay it at anesthesia’s feet.

Take ownership of it. You know, you’re making these decisions. I’m talking to the an- I’m talking about the administrators that are gonna be listening to this. It’s gonna be your decision. You know, you’re gonna, you’re gonna see the big picture, you’re gonna make a decision. If it’s, we’re the best for the center to align with anesthesia, then you say that.

But don’t say it’s because it’s anesthesia, ’cause then you’re gonna have conflict with anesthesia. You’re gonna have other people having conflict with anesthesia. ‘Cause that’s what we saw when I took over, right? Right, Dr. Conor? Mm-hmm. It was like- Yeah … “Well, anesthesia’s making us do that.” And I’m like, “No, that’s not what happens.”

[00:27:45] Brian Cohen: Yeah.

[00:27:46] Grant Duncan: And ultimately, Lee, to your point, you know, you’re gonna be the one that walks into the board meeting and gives a readout of what’s going on. It’s not gonna be pointing fingers at someone on your team or something else. So empowering yourself or, you know, empowering each administrator to take that that leadership presence is super valuable.

[00:28:07] Lee Kortmansky: Right.

[00:28:08] Brian Cohen: Yeah, and the fact that he’s able to walk into those board meetings and say, he’s not just saying, “Here’s what I decided,” you know? And he’s able to show, “We looked at this, and this, and because of all of these factors, this is what we decided is best for the center.” So it’s a very different approach, and it puts a lot on the plate of the administrators to take into account for literally every case that is being scheduled at the center and every staff that is being hired and booked.

It’s, you know, it’s a lot.

[00:28:36] Grant Duncan: Yeah,

100%. We have fun jobs. Always busy, right? You know, so one aspect that we hear some ASCs focusing on that we haven’t touched on is around patient collections and ensuring that both the ASC can collect on their side, but also sometimes helping anesthesia collect their patient collections. ‘Cause if anesthesia is getting more of their portion, well, again, they’re gonna need less of a subsidy because they’re out-of-pocket less money.

Have you all seen some groups, some ASCs help with the anesthesia collections, whether it’s maybe mentioning, “Hey, you’re gonna be getting multiple bills. They’re not all from us,” or, you know, even having like a terminal or, you know, what have you seen in this regard?

[00:29:28] Brian Cohen: Well, actually we just talked about it recently. And actually Clarity may be a solution that’s sitting at Lee’s center that helps with that. There’s… This has become more complicated but also more simple over the past few years. And it’s the reas- the one reason it’s become more simple, it goes back to everything else we’ve talked about, is our incentives are now aligned so that this is less of us saying, “Hey, we’d like you to do something for us.”

This is, “Hey, let’s– we’d like you to help us do something, you know, with us,” because it everything you said, it helps drive down the subsidy. So the conversation is much easier to have and it’s much easier to get the centers on board with trying to help with collection fees. The execution has been a little bit challenging when you’re dealing with a variety of management companies, health systems compliance and technology challenge that sit within a center or their or the departments.

Whether it’s something as simple as having an additional you know, component there to scan credit cards, who’s gonna do it? Where’s it gonna go? And the exchange of data and information that’s under more scrutiny now, you know, understandably, than it ever has been in the past. So, that’s sort of what has led us back to the conversation of looking at existing internal options that are already built and trying to lean into that a little bit to help capture some of that upfront cost.

‘Cause without getting into the complexities of anesthesia collections just on the patient side alone you know, that, that is something that is very challenging for revenue cycle management companies to deal with because of the unknown or challenge to get full pictures of where the patients sit with their deductibles and et cetera going into procedures as opposed to facilities and surgeon offices.

So anything and everything helps and we’re seeing a lot more collaboration because of that. It’s just finding the right way to get the data exchange of what has to happen or to get internal solutions that are already built in, like Clarity to see if we can sort of streamline that.

[00:31:24] Lee Kortmansky: But to answer your question, we do tell the patients that they will receive multiple bills from multiple people.

We do tell them that. We’ve been telling them that for years actually. But I think Dr. Cohen did a really good job of summing that all up. That it it’s very complex because the management companies, you know, view us separate. You know, anesthesia and the center are separate entities. Sometimes they’re referred to as vendor, which I don’t accept.

They’re not vendors, they’re partners. Cannot do this without them, you know? It’s… we’re in this as a joint venture. We can’t do what we do without our anesthesia partners. But there are people that don’t understand that whole clinical world and how we work together and don’t understand, so they concentrate on the things that Dr.

Cohen’s already mentioned about the compliance and the credit cards and maybe we shouldn’t get involved or we can’t get involved. So it, it is a lot more complex than I think even I thought. So it’s still, it’s a still work in progress to be honest with you

[00:32:24] Grant Duncan: Yeah. Well, there are definitely plenty of complexities in healthcare these days, but hopefully that will get easier over the years.

[00:32:33] Lee Kortmansky: Yeah

[00:32:33] Grant Duncan: Well, this has been extremely insightful. I’m– I know our listeners are gonna love this. Last question for you here, and we do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?

[00:32:47] Lee Kortmansky: Well, that… Didn’t expect that

[00:32:51] Brian Cohen: one. I w- so, I would say the one thing they can do, call their anesthesia partners. Ask for a sit-down meeting, and that request of that meeting is to collaborate and find opportunities for improvement. It’s amazing as we go into new centers and new opportunities, how often the response back is, “Well, this is the first time we’ve really had a lot of this information presented to us.”

So I would encourage them to take advantage, you know, pick the brains and find out how to– f- figure out how to work together.

[00:33:17] Lee Kortmansky: Well, I’m gonna go a different direction because the, you know, talking with anesthesia is obvious because, you know, we have you on the call here, Dr. Cohen. In a week, we’re gonna go live with the forecasting tool with HST.

I would say if you have something like that, because I don’t– I would stand in the guess that there’s many administrators out there in the country that don’t know if their cases are profitable or not. And there’s a misconception that a case is a case, a- and I think that people should spend a lot more time, even if it’s by hand, taking a look to see if the cases that you’re doing are profitable before you do them.

You can move the needle pretty quickly and g- get in the black just by doing that alone

[00:34:01] Grant Duncan: Yeah.

[00:34:02] Brian Cohen: Yeah. Great advice. And we’ve… the collaboration between his, Lee’s team and our team, you know, we went 2024 their center paid almost a half a million dollars in subsidy, and last year just over a couple hundred thousand.

So, all these things we talked about, you know, do translate into cost savings. And managing to do it with keeping all the stakeholders happy as Lee referenced, you know, along the way. So, it is doable. It just takes effort

[00:34:30] Grant Duncan: Yeah, you guys are a great success story. Thanks so much for coming on.

[00:34:35] Brian Cohen: Thank you. Appreciate it

[00:34:43] Ryan Cohn: A lot of ASC leaders are trying to solve anesthesia subsidy and coverage issues right now, but the first place to look may not be the anesthesia contract. It may be the schedule.

And that’s one of the clearest themes that shows up in our 2026 State of the ASC Industry Report, or SOTI as we call it. In our SOTI report, OR block utilization ranges from seventy-one percent in smaller centers to nearly fifty percent in larger centers, and cancellation rates are also hovering around twenty percent

And that matters because empty time on the schedule is not really empty. if anesthesia is staffed and rooms are open and cases are spread inefficiently across the day, the center is still carrying the cost, and the revenue just may not be there to support it.

And that’s where anesthesia subsidies can become a symptom of a much bigger operational issue

one of the most practical places to start is with the scheduling team. Block utilization doesn’t improve just because leadership talks about it in a single meeting. It improves when the people building the schedule understand how blocks work, how open time should be managed, when unused time should be released, and how those decisions affect the entire day as a whole.

That means that scheduler training can actually become a financial lever

If the schedule is tighter, if unused block time is managed earlier, and if cases are stacked more efficiently, the ASC gives anesthesia a better day to staff, and that can directly affect the pressure around coverage and subsidies

That’s what made Lee Kromansky’s example so powerful. His center was paying almost half a million dollars in anesthesia subsidy,

And after working with Dr. Cohen and his team, they were able to save Lee Center nearly three hundred thousand dollars the following year

But the important part is how they got there. It wasn’t just one magic fix. It was better visibility into the schedule, stronger alignment between the ASC and anesthesia group, better conversations around surgeon blocks, and a clearer understanding of which cases were actually working for the center

And that connects to another important point from our SOTI report, which is case profitability. One of the best practices we highlight is understanding whether a case is likely to be profitable before it’s actually performed. And that means looking at staffing hours, supply, implant costs, expected reimbursement, patient responsibility, and how that case fits into the broader day.

Because a case is not just a case. Some cases strengthen the schedule, and others can make the day harder to staff, harder to cover, and harder to make profitable

The same thing applies to patient collections. In our Sotio report, the centers analyzed expected to collect about three hundred and eighty million dollars in patient deposits in twenty twenty-five, but only collected about two hundred and fifty-five million, or roughly about sixty-seven percent. And when collections fall short, revenue becomes less predictable.

And when revenue becomes less predictable, the pressure around coverage, stipends, anesthesia subsidies, it all gets harder to manage.

So if your center is trying to get anesthesia costs under control, start by looking upstream. Look at block utilization, look at cancellations, look at how cases are stacked throughout the day. Look at whether your scheduling team has the training and visibility they need to manage unused block time

look at whether patient collections are matching expectations, and look at whether you understand case profitability before the case is performed. And that’s exactly why we created our 2026 SOTI Report. It gives ASC leaders the benchmarks they need to ask better questions, identify operational gaps, and compare their own performance against what is happening across the industry

You can click the link in the description of this podcast to explore the report yourself. You can either read it online, listen to it in podcast format, or even request a free printed copy. And if this conversation was helpful, please share it with a colleague who is thinking through anesthesia coverage, subsidies, OR utilization, or case profitability at their center.

It’s the number one way to support the podcast, and of course, it helps us get this information in front of other ASC leaders who are looking for it. Thanks as always for listening to This Week in Surgery Centers. We’ll see you next week