“Do we work harder than others?”

“Do we work longer hours than others?”

“Are we as productive as we should be?”



he Medical Group Management Association (MGMA) recently published a cost survey of anesthesia practices. MGMA conducted this survey in collaboration with ASA. Titled Cost Survey for Anesthesia Practices: 2005 Report Based on 2004 Data,¹ it includes 119 groups, almost all of them private practice. This publication has a wealth of information that helps to benchmark financial, business and staffing activities as related to anesthesiology groups. In addition this publication, in combination with the previously published survey² of the Society of Academic Anesthesiology Chairs/Association of Anesthesiology Program Directors (SAAC/AAPD), allows anesthesiology groups to benchmark and compare their clinical productivity with other hospitals and practices.

Prior to these two publications, there was no national survey of anesthesiology groups and hospitals that allowed anesthesiology groups to benchmark their activities. Some previous surveys, including ones from MGMA on physician productivity, have reported productivity measurements as “per FTE,” e.g., ASA units per FTE (FTE = full-time equivalent). Since anesthesia care is provided in a variety of care models, from physician-only groups to medical direction groups, the concurrency (defined as number of operating rooms [O.R.s] covered per anesthesiologist) ranges from 1.0 to 4.0. These differences in concurrency have made “per FTE” measurements unhelpful in benchmarking anesthesiology groups.³ Comparisons using “per O.R.” and “per case” have been shown to be more meaningful.⁴

The new survey by MGMA and the previous article of the SAAC/AAPD survey report data use “per O.R. site” and “per case” and break the data into smaller categories to facilitate group comparisons. The MGMA survey breaks down data by size of group, staffing model and government payer mix. The SAAC/AAPD survey breaks down data by size of hospital, type of hospital and type of surgical staff.

The main goal of this article is to inform ASA members that this data is now available. I will briefly show some examples of how this information can be used. For a detailed discussion of benchmarking clinical group productivity, the reader is referred to the discussion section in the second reference.

Surgical Duration: In hospitals that train surgery residents, the surgical duration per case is expected to be longer than in hospitals with fully trained surgeons. In the SAAC/AAPD survey, the difference is seen when comparing community hospitals and academic medical centers or when comparing a private-practice surgical staff with an academic staff. The MGMA survey finds the median hours per case (hrs/case) for private practice was 1.6 hours. In the SAAC/AAPD survey, the median hrs/case for academic was 2.6 hours. The longer surgical duration results in lower hourly productivity (defined as total ASA units billed per hour of care, tASA/h).⁵ In other words, groups that provide care for slower surgeons will need to work more hours to produce the same number of units as those working with faster surgeons.⁶

Hours (Billed) Per Day: We all have a perception that we work hard. One of the ways to determine if one is working harder than others is to compare if one is working longer hours. Unfortunately it is not possible to determine actual hours worked since turnover time, delays and waiting for patients/surgeons are all nonbillable time. On the other hand, the billable time is comparable. In both survey results, hours billed per O.R. are reported. I prefer to divide the yearly number by 250 days to approximate the hours billed per O.R. per day (h/O.R./d) — a more manageable number to compare. As one may expect, the median h/O.R./d differs among different types of practices and hospitals. Ambulatory surgical centers have the lowest, followed by community hospitals, and the longest is at academic medical centers.² As in all benchmarking, comparing oneself to similar practices/hospitals is more informative than comparing to overall data.

Cases Per O.R.: Despite many obvious limitations to the measurement, one of the most common numbers consultants use to determine if an O.R. is working well is the number of cases performed annually per O.R. (cases/O.R.). For instance some consultants use 1,000 or 1,200 cases per O.R. as the benchmark for an O.R. But is this a reasonable number? The problem is that both h/case and h/O.R./d impact the number of cases/O.R. So simply applying one number for all practices or hospitals can lead to erroneous conclusions and recommendations. If a group wishes to utilize cases/O.R. for its own benchmark, it is now possible to determine the correct benchmark of cases/O.R. for the specific group.

To determine this, the group needs to know two items: 1) the benchmark h/O.R./d that it will use and 2) the group’s own average h/case. The benchmark h/O.R./d should be from similar groups and hospitals. For example the median value for private-practice groups (from the MGMA survey) is 5.5 h/O.R./d and for academic groups (from the SAAC/AAPD survey) is 7.4 hours (equals 1,375 and 1,850 h/O.R./yr, respectively). A group can then divide this benchmark by the group’s h/case. If a private-practice group’s average duration is 1.5 hours, then using the MGMA h/OR/d, the group’s specific benchmark would be 916 cases/O.R./yr. For an academic group with an average duration of 3.0h and using the SAAC/AAPD benchmark, the group’s specific benchmark would be 617 cases/O.R./yr.

Total ASA Units Per FTE: Similar to cases/O.R., consultants have historically used “units/FTE,” and many administrators still wish to use this measurement as a benchmark, despite its limitations. Again, using the new survey results, the group can determine what the correct benchmark is for the specific group. A group must first determine the average concurrency for the group, then multiply this number by the benchmark total ASA units per O.R. (tASA/O.R.) of similar practices/hospitals. For example if an academic group has an average concurrency of 1.6 O.R./faculty, then using SAAC/AAPD median tASA/O.R. for academic medical centers (12,600 tASA/O.R.), the benchmark for the specific group would be 20,160 tASA/FTE. Obviously as concurrency or tASA/O.R. changes, the resultant group-specific tASA/FTE will change. This benchmark is for the group, however, and applying it as an individual benchmark may be incorrect.

The good news is that the data are now available to benchmark clinical productivity of O.R. anesthesia groups. The future looks good as well. All groups should ask their administrators to participate in the 2006 MGMA/ASA survey, which should be sent out soon. All participants in the survey will receive a free copy of the results! The 2006 MGMA survey also will collect data specific to pain management clinics and hopefully have enough data to report.

References:
1. Medical Group Management Association. Cost survey for anesthesia practices: 2005 report based on 2004 data. Englewood, CO: MGMA, 2005.
2. Abouleish AE, Prough DS, Barker SJ, et al. Organizational factors affect comparisons of clinical productivity of academic anesthesiology departments. Anesth Analg. 2003; 96: 802-812.
3. Abouleish AE, Prough DS, Zornow MH, et al. Designing meaningful industry metrics for clinical productivity for anesthesiology departments. Anesth Analg. 2001; 93:309-312.
4. Abouleish AE, Prough DS, Whitten CW, et al. Comparing clinical productivity of anesthesiology groups. Anesthesiology. 2002; 97:608-616.
5. Abouleish AE, Prough DS, Whitten CW, Zornow MH. The effects of surgical case duration and type of surgery on hourly clinical productivity of anesthesiologists. Anesth Analg. 2003; 97:833-838.
6. Abouleish AE. Academic or private-practice groups: You still support surgical training programs. ASA Newsl. 2005; 69(9):10-11.

Amr E. Abouleish, M.D., M.B.A., is Professor, Department of Anesthesiology, University of Texas Medical Branch, Galveston Texas.