Imagine a physician who has been practicing anesthesiology for 20 years. She is skilled, board-certified, well-liked, and respected by her team. She now works more hours than she did 10 years ago, covers more call, cares for sicker patients, and manages an increasing documentation burden. Her take-home pay has not kept pace with inflation, and, in fact, has not changed much in all that time.
This is not a story about one physician. It is a story about the medical profession and the structural forces quietly reshaping it.
If it feels like practicing medicine has gotten harder over the past few years, that’s because it has. Several interconnected forces are bearing down on physicians’ practices simultaneously: the consolidation of health insurance markets, recent federal health care cuts, and a widening gap between the care that physicians provide and what they are paid. Individually, these are not new developments; however, together they are signaling an impending tipping point.
The numbers don’t lie
Let’s examine reimbursement for starters. Inflation-adjusted Medicare payment per anesthesia service declined 20.8 percent between 2000 and 2020 and up to 33 percent for other specialties, according to the American Medical Association (AMA). During that same period, the U.S. population aged 65 and older grew substantially, and is projected to increase by another 55 percent by 2030. Procedural volume is rising. Workforce challenges persist. The math is straightforward: more demand, less revenue per encounter, and a gap that must be absorbed by someone. That someone is usually the physician.
National data show that physician productivity, measured in work relative value units (RVUs) across all specialties, has increased significantly in recent years. As Becker’s reports, providers are working more but are being paid less for their work, and patient demand is up while reimbursement is falling.
In anesthesiology, this translates to higher room concurrency, more urgent cases, sicker patients, longer days, more call, and expanded non-OR anesthesia coverage. As staffing costs rise and reimbursement stagnates, margins compress. Physicians generate more clinical work, but the return per unit of that work keeps shrinking.
When fewer insurers control the room
In many metropolitan markets, one or two insurers now control the majority of commercial contracts, as the AMA has documented. When competition shrinks, negotiating power follows. Reimbursement rates fall. Administrative burdens grow. Independent practice becomes harder to sustain.
For anesthesiologists, the challenge is structural. As facility-based physicians, we rarely control our payer mix and cannot easily walk away from dominant contracts without jeopardizing hospital relationships. What used to be a negotiation has increasingly become an ultimatum: Accept these terms or lose access to the facility. Lower reimbursement then limits investment in staffing, technology, and recruitment, which accelerates the burnout that further weakens physician leverage. It is a cycle, and it feeds itself.
The AMA has documented how insurance consolidation harms both patients and physicians. When competition disappears from insurance markets, the consequences flow downstream, first to physician practices, hospitals, and health care facilities, and eventually to patients in the form of higher premiums, reduced access, longer waits, and care delivered by an exhausted workforce.
Add to that the impact of the recent federal health care and Medicaid cuts. In some areas almost a third of people are covered by Medicare or other federal programs, and almost 50 percent of children are covered by Medicaid or the Children’s Health Insurance Program (CHIP). Many children’s hospitals are disproportionately dependent on Medicaid reimbursement. When this funding shrinks, services, especially those considered less lucrative, will stop. Patients will wait until they are sicker or their condition is emergent before seeking care. Health care facilities and physicians will be faced with providing more uncompensated care with fewer resources. These cuts threaten the stability of pediatric specialty care specifically, and increase health care disparities, burnout, stress, and ethical and political tensions.
What this means for patients
These pressures are not limited to just health care providers. When reimbursement constraints limit resources, practices struggle to hire adequate support staff, update their equipment, or invest in capital resources. OR schedules tighten. Locum personnel fill gaps left by burned-out physicians, disrupting continuity and team cohesion. Independent practices can consolidate or close, reducing local access. Anesthesiologists asked to do more with less are, by definition, doing less per patient.
The connection between physician sustainability and patient safety is not abstract. It is arithmetic.
What a sustainable future looks like
Most physicians did not enter medicine or anesthesiology to negotiate contracts or optimize throughput metrics. We entered it to care for patients, often the most vulnerable patients, in the most high-stakes moments. Sustaining that mission requires financial structures that make it possible.
This means competitive insurance markets that allow genuine negotiation, not the theater of take-it-or-leave-it rate setting. It means reimbursement models that reflect the complexity of modern clinical work, not just volume. It means practice environments that support independent groups, training programs, and the kind of longitudinal commitment that patient safety actually requires.
Burnout is increasing. According to a recent study, anesthesiologists had the highest intention to leave their current job and/or medicine, and had among the highest burnout rates compared to other specialists. Supporting physician sustainability is not a professional interest lobbying point. It is a patient safety matter. When the system fails physicians, patients suffer.
There are several organizations including the AMA and American Society of Anesthesiologists (ASA) that are working hard to support physicians and patients by advocating for improved reimbursement through private insurance, Medicare, and Medicaid; fighting against arbitrary insurance rules designed to make getting needed care more challenging; protecting pediatric and rural services; decreasing health care disparities; and maintaining access to care.
The forces reshaping anesthesiology are structural, interlocking, and accelerating. Understanding them is the first step toward changing them, for physicians, for policymakers, and for the patients who will need us when it matters most.
Rita Agarwal is a double board-certified pediatric anesthesiologist at Stanford University and Lucile Packard Children’s Hospital. Her work focuses on pediatric pain management, neuroanesthesia, medical education, advocacy, mentorship, and sponsorship. She serves as chair of the California Society of Anesthesiologists’ Women in Anesthesiology Committee, is active with the ASA and CSA communications committees, and is one of two hosts of the CSA podcast Vital Times.
Dr. Agarwal is an active member of the Society for Pediatric Anesthesia and the Society for Pediatric Pain Medicine, where she contributes to educational and editorial initiatives. A representative sample of her publications includes work on pediatric sedation safety in Pediatrics, anesthesia for pediatric chest trauma in Seminars in Cardiothoracic and Vascular Anesthesia, airway management in laryngotracheal injuries in children in Paediatric Anaesthesia, opioid use in children during the perioperative period, perioperative management of pediatric patients using medicinal marijuana, dental anesthesia safety, outpatient opioid prescribing guidelines for children and adolescents, and safe and effective pain management in children in American Family Physician. She has also written on workforce trends in pediatric anesthesiology, adverse event disclosure, and perioperative considerations for adolescents and young adults with substance use disorders.
She has completed training in evidence-based coaching and is passionate about advocacy for safer care for children undergoing dental anesthesia and appropriate pain management for pediatric patients, while also supporting physicians through mentorship and coaching. She shares updates through her Stanford profile, on X as @ritaagarwal6, on Instagram as @ragarwal62, and on Bluesky as @momdoc3.bsky.social.
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research, and scientific society with more than 60,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during, and after surgery. ASA members also lead the care of critically ill patients in intensive care units, as well as treat pain in both acute and chronic settings.
For more information on the field of anesthesiology, visit ASA online at asahq.org. To learn more about how anesthesiologists help ensure patient safety, visit asahq.org/madeforthismoment. ASA publishes Anesthesiology, Anesthesiology Open, and ASA Monitor, and stays connected with members and the public on Facebook, X, Instagram, Bluesky, and LinkedIn.
