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Needs Assessment for Business Strategies of Anesthesiology Groups' Practices

Scurlock, Corey MD, MBA*,†; Dexter, Franklin MD, PhD; Reich, David L. MD*; Galati, Maria MBA*

doi: 10.1213/ANE.0b013e31821c36bd
Economics, Education, and Policy: Special Article

Progress has been made in understanding strategic decision making influencing anesthesia groups' operating room business practices. However, there has been little analysis of the remaining gaps in our knowledge. We performed a needs assessment to identify unsolved problems in anesthesia business strategy based on Porter's Five Forces Analysis. The methodology was a narrative literature review. We found little previous investigation for 2 of the 5 forces (threat of new entrants and bargaining power of suppliers), modest understanding for 1 force (threat of substitute products or services), and substantial understanding for 2 forces (bargaining power of customers and jockeying for position among current competitors). Additional research in strategic decisions influencing anesthesia groups should focus on the threat of new entrants, bargaining power of suppliers, and the threat of substitute products or services.

Published ahead of print April 13, 2011 Supplemental Digital Content is available in the text.

From the Departments of *Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York; and Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Conflict of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Corey Scurlock, MD, MBA, Departments of Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1010, New York, NY 10029. Address e-mail to

Accepted March 18, 2011

Published ahead of print April 13, 2011

Progress has been made in understanding strategic decision making influencing anesthesia groups' operating room (OR) business practices. However, there has been little analysis of the remaining residual gaps in our knowledge. In part, this is because there has been no simple way of categorizing issues in strategic decision making for anesthesia group practices. In the sole previous study, qualitative research methods were used to study how one hospital took advantage of knowledge of its similarity to peer facilities that were previously unrecognized.1 In this special article, we present a needs assessment for unsolved problems in anesthesia business strategy, our “industry,” based on Porter's Five Forces Analysis (Fig. 1).

Figure 1

Figure 1

In 1979, Porter described 5 competitive forces that shape strategy within any industry2:

  • Threat of new entrants,
  • Bargaining power of suppliers,
  • Bargaining power of customers,
  • Jockeying for position among current competitors, and
  • Threat of substitute products or services.

We use Porter's Five Forces and their subcomponents to organize prior economic research in anesthesia relevant to strategic decision making. We show a need for additional research to guide anesthesia groups for 2 of the listed forces: threat of new entrants and bargaining power of suppliers (e.g., academic training programs). In contrast, groups can apply developed tools for 2 other forces: bargaining power of customers and jockeying for position among current competitors. We show also some modest understanding of the threat of substitute products or services.

Relevant strategic decisions differ among countries and health systems, whereas the strategic questions for OR anesthesia are largely similar. This article likely is useful only for markets with anesthesia groups competing and functioning as decision-making entities that are distinct from their hospitals. However, the needs assessment itself should be valid among differing countries and health care systems.

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Some anesthesia groups can be replaced by a different group. This makes them susceptible to competition from outside participants. An example of this force is a large anesthesia group making a proposal to hospital administrators to provide anesthesia services at their facility in place of a smaller incumbent group. Logically, incumbent groups should be vigilant to the presence of forces delivering new entrants and the barriers to entry that prevent them from entering the market. Two barriers to entry that are relevant to anesthesia practices include economies of scale and product differentiation.

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Barrier to Entry: Economies of Scale

Anesthesiology groups with a large local market share3,4 may possess economies of scale. They may have more bargaining power in contract negotiations with payers and in negotiating for employee benefits, malpractice insurance, and other administrative services related to billing and collection. These groups may also have advantages in recruitment and retention of anesthesia providers seeking the security and stability that a dominant group in a marketplace provides. Such economies of scale would favor the merger and acquisition of smaller private groups to form larger anesthesiology groups. However, we are unaware of epidemiological studies investigating the relationship between anesthesia groups' market concentration and reimbursement per American Society of Anesthesiologists' Relative Value Unit. Similarly, we are unaware of work relating the market position of a group to its bargaining power in contract negotiations with suppliers, such as billing companies.

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Barrier to Entry: Product Differentiation

Product differentiation may benefit anesthesia groups that focus on concepts of marketing and branding to distinguish themselves from other groups. Consider a hypothetical anesthesia group that has an exclusive practice at a pediatric hospital. The group expands progressively by offering pediatric anesthesia services at other facilities. This hypothetical group is using product differentiation as a competitive advantage. The same could apply for cardiac anesthesia, office-based anesthesia, etc. We are unaware of research on the percentage of anesthetics nationwide delivered by such specialty groups of anesthesia providers. We are likewise unaware of the percentage of anesthetics delivered by groups that deliberately provide all types of anesthesia services, including board-certified critical care, echocardiography, pain management, etc.

There are other attributes to Porter's barriers to entry, including access to distribution channels, capital requirements, learning curve advantage, and regulatory policy. However, it is our impression that each is either negligible or influenced by other competitive forces in Porter's taxonomy. For example, the distribution channel for anesthesia is principally through surgeons and surgeons' practices, and is considered below in the section that reviews the power of customers.

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Porter described a powerful supplier as one that has a unique product that is important to the industry. Suppliers that are concentrated in a specific market can wield great power. For anesthesiology groups, the suppliers are the training programs that produce anesthesia providers. Academic groups that have residency and fellowship training programs may act as powerful suppliers by enticing graduates not originally from the region5 to accept employment to staff their own facilities. However, private groups may negate this supplier power by offering higher salaries. Whether this results in reduced power of academic practices is unknown.

Heterogeneity of suppliers among markets may influence their power. For example, many training programs are concentrated in the northeastern United States. New York State had 14% of the total available anesthesiology residency positions in the United States in 2006.6,a Whether training programs in New York consequently have greater power is unknown.

Summarizing the preceding results, additional research is needed for 2 of Porter's competitive forces, the Threat of New Entrants and the Power of Suppliers, if groups are to consider such forces in their strategic decisions.

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Although the ultimate consumer is the patient, anesthesia groups have multiple customers, including surgeons who refer patients, facilities that contract with the group, payers with whom the group contracts, and employer and governmental entities that underwrite insurance benefits. According to Porter, a customer is powerful if it purchases in large volumes, is more concentrated than the entity it purchases from, or has the threat of “vertical integration.” An example of vertical integration would be a hospital hiring its own anesthesiologists.

Anesthesia practices can be managed nationally, but their clinical practices are local. The economic power of customers depends partly on the availability of other nearby facilities, to which surgeons can refer patients. This can be assessed by analyzing the following:

  1. Do anesthesia groups in the primary market area care for patients undergoing the same types of procedures?
  2. Do substantive numbers of patients leave the primary market area to undergo the procedures elsewhere?

These questions can be answered from publically available data using similarity1,3,6,7 and competition analyses.4

Nonprofit hospitals and their outpatient facilities generally behave to increase the number of procedures performed.8 This can adversely affect an anesthesia group's profitability if the hospital increases the number of procedures with a payer mix that is disadvantageous to the group.9 The influence of the hospital (as a “customer”) on the anesthesia group depends on the alignment (or lack thereof) between growth and profit.10 For strategic decisions, knowledge of the customer's (hospital's or ambulatory surgery center's) views of the profitability of service lines is important in negotiating an agreement that balances these incentives when they are misaligned.11 Financial support agreements are often written to align incentives.11

In contrast to inpatient surgery,12,13 for outpatient surgery, patients and surgeons sometimes consider the service being provided to be both the procedure and when it is performed.14,15 For example, patients undergoing cataract surgery considered the service not to be cataract surgery per se, but cataract surgery on the morning chosen by the patient.15 Providing this enhanced service creates an opportunity for competing anesthesia groups to gain competitive advantage. Survey methodologies to learn patient perspectives have been developed for use by groups.1215

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This force refers to internal rivalries within the industry or profession. As viewed by Porter, competition within an industry is high when competitors are numerous, switching costs are low, and services lack differentiation. Competition among the anesthesia groups within a region influences each group. For purposes of strategic decision making, competition between 2 nearby groups is equivalent to competition between facilities, when one group practices at the first facility and the second group practices at the second facility.

Strategies that influence surgical procedure growth have been investigated. In outpatient surgery, the bottleneck to increasing the workload is the surgeons' productivity.16 An extensive primary care network does not increase the amount of surgery.16 Repeat experience with an anesthesia group or surgical facility has little impact on anesthesia workload.16 The process of referral of patients to individual surgeons also has minimal effect on anesthesia group or facility workload.17,18 However, when surgeons own ambulatory surgery centers and/or hospitals, the amount of surgery performed in the local population increases.1921 Although perhaps counterproductive from a societal perspective, surgery and thus anesthesia services grow in tandem when surgeons have a financial interest in the health care facility.

Because opening outpatient facilities causes net declines in hospitals' outpatient surgery workloads,22,23 anesthesia groups maintain their own workload by remaining associated with the surgeons as they open such facilities. The balancing factor is that adding anesthetizing locations can reduce an anesthesia group's productivity, because the principal predictor of group productivity is having full ORs.24 Optimal thresholds and criteria for choosing when to open another OR are well described.23,25 For example, the 80% upper prediction bound for future weekly workload can be calculated quarterly, and another OR opened when it exceeds 8 hours.23,25

Growth can be measured as either caseload or workload.16,23,26,27 Sensitivity of growth by specialty to the addition of surgeons can be forecast from publically available data.2629 Sensitivity of forecasts to market visibility can be presented graphically or in tabular form,30 and the sensitivity to data from individual hospitals examined in tabular form.31 Growth per se may not be beneficial to a for-profit group, but the means of combining forecasts of growth with its economic impacts are well developed.28,3134 Limited open hospital beds can restrict a hospital-based group's growth. Research on how to include that hospital bed data in a group's analyses has also been developed.31,3538 Using data regarding surgeons' most common procedures may be sufficient to guide decision making.39

The profitability of the group can be enhanced by using technology to optimize staffing.40,41 Less than 1 year of OR information system, anesthesia information management system, or anesthesia billing data are sufficient.4244 Achievable reductions in costs typically exceed 10%.45 Psychological biases account for lack of implementation.46 Staffing optimization can also be done for evenings,44 weekends,47,48 and holidays.49

Technology can also increase group profitability by providing advantages for hiring and retention of providers. Staff scheduling can be optimized based on minimizing cost,50,51 meeting work hour rules,51 and reducing unexpected late work.51,52 Compensation can be mission based and increased when salient, as compared with being based solely on workload.53,54 Professional charge capture can be increased55,56 and billing costs reduced.57 The proper use of technology for cost reduction provides competitive advantages.

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Substitute services can reduce profitability of all anesthesia groups in a region by diverting customers to a different product or service. Some substitute products for anesthesiology groups are registered nurse–administered sedation (e.g., for colonoscopy) and minimally invasive procedures replacing surgery (e.g., percutaneous coronary interventions).

Substitution is expected over the long term. Research, use of standards, improved monitoring technology, and anesthetic drugs with larger therapeutic windows have improved the safety of anesthesia care, with the paradoxical effect of making anesthesiologist-delivered care less valuable. Anesthesiologists are expensive, far more than the typical maximum societal cost per quality-adjusted life year from use of monitored anesthesia care.58 In addition, there is marked heterogeneity in frequency of anesthesia providers administering monitored anesthesia care (e.g., in Ontario, approximately 50% of colonoscopies at low-volume community hospitals are performed with monitored anesthesia care versus <5% at major academic hospitals).59,b

In the short term, groups' major risks are from substantial and sudden reductions in profit caused by payers' decisions to reduce or curtail payments to anesthesia providers for providing monitored anesthesia care for some procedures based on the cost58 and observed heterogeneity.60,b Changes would likely start with adults, as the addition of registered nurse sedation teams for pediatric patients resulted in more IV sedation (as opposed to no sedation or enteral sedation), rather than reducing the number of cases performed by anesthesia providers.60 The risk of reduced payments by payers for adults is important, because monitored anesthesia care accounts for >25% of anesthetics nationwide.b

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For this report, we used Porter's taxonomy of 5 forces to perform a needs assessment to understand the benefit, or lack thereof, of existing research on anesthesia groups' strategic decision making. Our objective was to identify gaps in knowledge that may influence anesthesia groups that operate in competitive environments. We found little to no research for 2 of the 5 forces (threat of new entrants and bargaining power of suppliers), modest research for 1 force (threat of substitute products or services), and substantial understanding for 2 forces (bargaining power of customers and jockeying for position among current competitors).

Our report is limited by being a narrative review. We assumed that the absence or paucity of publications related to a Porter's Force indicated a need for research in the area. It is not likely that our conclusions could be compromised by missing a small number of applicable publications. When presented with articles categorized according to Porter's forces, it seems obvious what is known versus what is unknown.

The reason there are few studies for the threat of new entrants and bargaining power of suppliers may be that researchers in academic anesthesia departments have been focused on those forces that influence their group's practices. An academic group is unlikely to be displaced by another anesthesia group and has a steady supply of new trainees. The group is more likely to specialize in physiologically complex anesthesia, not monitored anesthesia care, reducing the threat of substitution.60,b Thus, it is expected that the 2 forces with limited research are those least applicable to academic anesthesia practices. We believe that the value of categorizing research using the taxonomy proposed by Porter is that it enhances our understanding of the gaps in the knowledge of factors influencing strategic planning in anesthesia practice.

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Franklin Dexter is the Statistical Editor and Section Editor for Economics, Education, and Policy for the Journal. This manuscript was handled by Steve Shafer, Editor-in-Chief, and Dr. Dexter was not involved in any way with the editorial process or decision.

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Name: Corey Scurlock, MD, MBA.

Contribution: Dr. Scurlock participated in study design, conduct of study, data analysis, and manuscript presentation.

Attestation: This author approved the final manuscript.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Franklin Dexter, MD, PhD.

Contribution: Dr. Dexter participated in study design, conduct of study, data analysis, and manuscript presentation.

Attestation: This author approved the final manuscript.

Conflicts of Interest: The University of Iowa performs statistical analysis for hospitals, anesthesia groups, and companies, including some of those described in the article. Dr. Dexter receives no funds personally other than his salary from the University, including no travel expenses or honoraria from any source, and has tenure with no incentive program.

Name: David L. Reich, MD.

Contribution: Dr. Reich participated in study design and manuscript presentation.

Attestation: This author approved the final manuscript.

Conflicts of Interest: This author has no conflicts of interest to declare.

Name: Maria Galati, MBA.

Contribution: Ms. Galati participated in study design and manuscript presentation.

Attestation: This author approved the final manuscript.

Conflicts of Interest: This author has no conflicts of interest to declare.

a Grogono AW. NRMP Anesthesiology Match Results for States 2006. Available at: Accessed February 24, 2010.
Cited Here...

b Daugherty L, Fonseca R, Kumar KB, Michaud PC. An Analysis of the Labor Markets for Anesthesiology. RAND Technical Report, 2010:30–34. Available at: Accessed July 9, 2010.
Cited Here...

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