John Ansorge is CFO of Somnia Anesthesia Services. Mr. Ansorge joined Somnia in 2010. He has more than 20 years experience in hospital finance, most recently holding the position of interim CFO for Stamford (Conn.) Health System, a 305-bed teaching hospital affiliated with Columbia University Medical School. He has also held the post of CFO at Lincoln Park Hospital in Chicago and Ephraim McDowell Regional Medical Center in Kentucky.
Q: The provision of anesthesia is often viewed as a "black box" by the hospital C-suite and stakeholders, such as the board of directors. What are your thoughts on this?
John Ansorge: I've always characterized anesthesia services as a black box. From a revenue generating perspective, anesthesia can either be a hospital's best friend or its worst enemy. Many administrators and many C-suite executives tread very carefully when it comes to the relationships between anesthesia providers and surgeons. They realize that the central revenue generator that the OR represents is what really makes the facility a hospital rather than a hotel. If an OR is working, let it work. If it's not working, you have to be very careful about going across the "blue line" [like in hockey]. Not only do you suffer the penalty in political capital, you may end up upsetting that black box all together.
In a hospital, there is a sterile line that you do not cross unless you're in scrubs, you have shoe covers on, and you have permission to actually go across the line. In a lot of hospitals it's a red line, sometimes it's a yellow line, but it's like that blue line. You don't cross that line unless you have permission.
As my career and hospital management responsibilities grew, my focus became less about the complexity of cases and more about ensuring we were optimizing capacities and throughput in the hospital's ORs. We wanted to take great care in making sure that as soon as the patient was in the room, a good relationship developed with hospital staff, working to quickly and effectively utilize the room, ultimately turning it around for the next patient. One of the critical questions we asked was: Who actually starts the procedure? Since the anesthesiologist has to anesthetize the patient, how quickly can the anesthesiologist get the surgeon to the next patient? That depends on how fast the surgeon is.
Q: As a CFO who has spent a large part of your career in acute care, what do you see as some of the greatest concerns and challenges for a person in this position?
JA: I think hospitals have gone full circle, from generating data for performance improvement to generating data for cost control, and hopefully you can marry those two together. Sometimes focusing on cost-control issues can lead to short-sightedness, which may also result in not patient-friendly decisions either. I think many people shy away from those types of discussions, which creates challenges.
If hospitals can become more efficient and increase capacity, the surgeons, anesthesiologists and the hospital all tend to benefit. For hospitals struggling to do this, it often means fewer paying patients, with some bypassing the facility altogether for an ambulatory surgery center, for example. When facilities look at long-term capabilities and objectives, they want to see greater capacity without necessarily having to expend a lot of bricks and mortar, which are prohibitively expensive. Poor efficiency hinders the ability to maximize capacity. The key is to think differently about the solutions to these challenges.
Q: Why do you think hospitals and CFOs struggle to work effectively with their anesthesiologists?
JA: From a historical perspective, anesthesia is one of those [at least] semi-subsidized work forces, and it's difficult to get the case volume needed to get away from the subsidy. When you think about a radiology group, from an imaging perspective, you see a lot of community hospitals talking about investing in a new PET CT or open MRI and promoting it on a billboard to help drive the patient selection process. When it comes to surgery, it's much more limiting. If a hospital has enough political capital to be able to work directly with physicians, they may be able to effect some change internally. Then again, they may start backing away from it because it's kind of like the black box concept: You're happy when if it works and you don't want to shake it because it may stop working.
The big feather in anyone's cap on either side of the table is when the subsidy is removed and everyone is able to function independently. That's a win-win. Through the partnerships with Somnia, we have worked with facilities to create the necessary capacity, where there's enough volume to support the model, and the facility is able to take care of its patient population. We're seeing that at several facilities. Those are the encouraging signs from the financial perspective.
But I think many hospitals never get to that point as they have broken processes. They employ the wrong mix of anesthesiologists and CRNAs, creating such an imbalance in costs that they're never going to get out of the hole. They may think they only have a problem with scheduling. They think they're going to fix scheduling and get more cases in, but the cases are costing three times as much and providers aren't getting paid for them. Guess what? Scheduling isn't going to be the fix. It's got to be managing the costs of the entire model. Not many facilities have the political capital to fight that battle.
Q: How can hospitals and CFOs elicit positive change?
JA: It's not just about documentation and checking the boxes here and there. It's behavior. Anesthesia is, to a certain extent, a very nameless, faceless service. However, the outcomes, the risks we take are tremendous. The C-suite needs to see them not as a faceless issue. It is a patient care issue and there are so many interpersonal interactions during a very high-stress time. If [CFOs] can provide a level of confidence in their physicians' behavior, it definitely helps eliminate that level of stress.
This applies to the anesthesiologist as well. Anesthesiologists need to be able to forge relationships with a variety of surgeons. They're going to come into contact with various specialists (thoracic, orthopedists, etc.) and each of these [surgeons] has their own approach. Some work like carpenters, some work like microsurgeons. They treat people differently. The ability to be flexible and accommodate each surgeon's style in the anesthesiologist role is critical.
Q: What would be your advice to C-suite decision-makers?
JA: If they don't know their entire anesthesiology team on a first name basis, they need to introduce themselves. They also need to become familiar with the data — from the payor mix, to the number of cases, to the number of procedures. It's not just a black box where everything works and everything's fine. They need to familiarize themselves with all of the outputs of that black box and make sure that the right team is in place for the management of anesthesia.
The churn of hospital leadership is shortening. It used to be 5-10 years for a CEO, now its 3-5 years. Some CFOs only hold their position for 18 months. That's not a lot of time to become familiar, so people start basing their decisions on previous experiences, but it's critical to gain the familiarity of really what goes on in their specific ORs. Administrators and C-suite members tread very lightly, but they still need to be recording and understanding the dynamics between all of the different types of patients they may see and the physicians who may work in their ORs.
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