Does Your Schooling Actually Matter If You're Not Solving Problems for Surgeons and Patients?

Joe: [00:00:00] Taking off my CRNA hat for a moment, the idea of investing, you know, 12 years into a professional and having them do outpatient endoscopy is like kind of like a giant waste of taxpayer dollars. That's just not a good use of resources. So MD-only care has gone down significantly. All these others, QZ has increased by 15%.

Medical direction or team models has gone up by 30%.

All right, everybody. We're back for another episode of the number one podcast in the anesthesia world- About the rest, Randy Moore. I know. I know. I'm known for my humility. That's what everybody tells me. Humble Joe, that's what my wife calls me. Randy Moore, one of the best thinkers in anesthesia, always a pleasure to have you on, and Andrew Wood-Mansey, new to the show.

Welcome. Welcome, fellas. Welcome. Andrew, how's it going? 

Andrew: Thanks for having me, guys. 

Joe: Yeah. Yeah, absolutely. Now, we've got your fancy bio here, Andrew. Uh, so why don't you get us this... I'm gonna read this, and you can tell us who you really are. [00:01:00] Currently, you're the managing director of Anesthesia Operations Consultants, healthcare consulting firm.

You've got a team of 14. You are only focused in anesthesia, and you are the former director of anesthesia consulting at Surgical Directions, the big firm out of, I think, the mid... I think they're in the northeast or the Midwest, Surgical Directions, Andrew. But just why don't you tell the audience who you are, and, uh, we'll go from there.

Andrew: Yeah. Thanks, Joe. Uh, so hi, Andrew Wood-Mansey, uh, managing director of Anesthesia Operations Consultants. We focus specifically in a- anesthesia, so, um, most of our clients are on the hospital side. We do, uh, support some groups as well, um, but really try to take a holistic view of anesthesia, uh, and come with, uh, suggestions for how groups and hospitals could partner together to help with operations, uh, from peri-op.

Uh, you know, how can they work together, uh, to help improve the reimbursement for the group and help lower the subsidization, uh, for the facility. Uh, before starting, uh, and getting into consulting, I also spent 10 years working, [00:02:00] uh, for TeamHealth and Mednax as well. So thanks for having us, Joe. 

Joe: Yeah, you bet.

What did you do for TeamHealth and Mednax? 

Andrew: I worked in a variety of areas. Um, I was... I started in quality actually for about a year, uh, then, uh, bounced around as the, um, m- more analy- uh, helped develop some of the original analytics- 

Joe: On the analysis side? 

Andrew: Yeah ... uh, on the analysis side, as well as helped with business development for TeamHealth, and then was an internal consultant for Mednax.

Joe: Okay, cool. This past month, VMG, which is one of the largest healthcare consulting companies in the country, do a lot of fair market value evaluations. So for any anesthesiologist and CRNAs listening, if you're complaining about why you can't get a larger subsidy, it's probably VMG's fault. All right? They did not authorize that quote.

But they did come out with a really compelling report, which has been cited numerous times now in Becker's. Let's go over some of the findings, then we'll get some feedback here. Uh, this was from a survey done last year, and they're circulating this amongst their [00:03:00] valuation clients. The most prominent financial challenges expected for 2026 for surgery center leaders, and for those listening, for those who cannot see on the screen, at, at the very top of the charts is anesthesia coverage and cost.

And this is a theme, I went through the whole report- This is a theme that we're seeing everywhere. Operational strategies. The top three most frequently selected anticipated operational bundles are, number one, expenses, right? And then number two is securing anesthesia coverage and the associated cost.

And depending on how you look at that data, that's really the same thing because they, they're only concerned because they're having to pay. And then one more before we start getting some feedback here. Trending topics: anticipated anesthesia models in twenty twenty six. Number one, by a, a fairly wide margin, independent contractor with stipend forty-four, forty-four percent.

Without stipend, thirty-six percent. And then a small, uh, very small part is employment and joint venture. So with all that being [00:04:00] said, we'll start with you, Mr. Moore, Dr. Moore, depending on the context. What are your thoughts here? What are you seeing out there with all the, all the surgery centers? All the surgery centers are listening now, and if North Star is willing to commit to absolutely subsidy-free surgery center care in twenty twenty six, now's the time 

Randy: Well, it's interesting that I was looking at that.

So are you telling me that 36% of ASC administrators anticipate having zero subsidy on anesthesia in the future? Is that what the, is that the- 

Joe: That, that's what the survey said. Yeah, it's interesting. I mean, to, to flip that the other way around, that means 65% of them do, and I imagine that 36% probably includes the pain shops who are, you know, doing 30 cases in one lineup and/or the GI guys who are doing, you know, just cranking out cases with their illegal company model, uh, setup, right?

So, uh, you know, they're not paying a subsidy when they're referring to themselves. Yeah. 

Andrew: Yeah, I was just about to say the same thing, right? Like, uh, you know, I do agree with you, Joe, that, uh, you know, a lot of that is probably your, your quick-turning facilities, right? Like, your, your GI, uh, is not gonna be subsidized and be [00:05:00] running a profit mostly for anesthesia.

Um, ophthalmology, if done correctly without cataracts in the middle of cases, could be done profitably if consolidated, uh, correctly as well as, uh, you know, if you have a high commercial orthopedic center, um, as well. Um, you know, and then obviously, you know, as I'm sure both of you are addressing, right, you know, uh, is your group y- leveraging IDR, um, and the type of model that you're doing in a surgery center as well.

So, um, but yeah, I, I do- Yeah, indeed ... I do kinda struggle with the same things you guys do, right? As a consultant, I try to stay away from, uh, advising surgery centers too much, uh, just 'cause they, they have a hard time wrapping their head around the f- the fact that, um, anesthesia, uh, is not a eat what you kill industry, and they, they usually, um, have a hard time understanding why they should be subsidizing services as well.

Randy: Which is totally understandable if, if... Like, if we zoom out, if we were having this conversation five years ago, it would be, yeah, like 90%, 90-plus percent of [00:06:00] ASCs were, had no subsidy, uh, directionally. And then, you know, the supply-demand imbalance of CRNAs and anesthesiologists hits, COVID hits, and, you know, the, the reimbursement headwinds are only getting stronger.

And it went from a largely unsubsidized business to a almost completely subsidized business al- almost overnight. And so as we look at, like, at North Star, they're-- I mean, this has had a, a really interesting impact on our, our current business, so our legacy contracts that we've had with some ASCs and then some, a lot of inbound business.

And a lot of the inbound business is ASC administrators waking up and finding out that they're, they're going to have to pay a stipend, a subsidy for the first time, and then they don't like that. And, and so there's, there's a lot of contract churn that's happening in the ASC space, some of which makes sense and, and some of it is just the subsidy shock, uh, that's associated with how the economics and anesthesia have placed out, placed out.

And interestingly, I mean, it's, like when we were... I came into North Star in, um, [00:07:00] in the fall, in September of 2021, and that was obviously, we're- 

Joe: Oh, 

Randy: man ... deep within the, you know- That was right in the thick of 

Joe: it. 

Randy: Yeah. And we were, we were navigating through like significant growth. And that growth, what was propelling that growth was, you know, the COVID-related disruptions hitting with the supply-demand issues and, and there's a lot of hospitals looking for alternative anesthesia fighters, providers.

Um, and then that starts to slow down and settle down, and then about 18 months later, the ASC market popped in, in a real way. And, and, again- Yes ... the economics are, are, are driving this in a very real way. 

Joe: We saw the same thing, right? Around COVID, COVID was like this weird moment and everything was changing and then it resettled down, which is probably a good segue from surgery centers to the overall trend of these models, right?

And I, I think this is, uh, for those looking on the screen We see that CRNA-involved cases are going up steadily year over year. Something in Florida, for [00:08:00] instance, from 2010, Andrew, I know you're in Florida. From 2010 to 2024, this is CMS data, CR- CRNA-involved cases went from 70% to about 90%. And just to illustrate the differences between East and West, this is probably a good data set here.

Uh, 2010 CRNA-involved cases were one in four, 24%. Now we're trending towards 50%, so almost doubled in about 14 years. And there's a little blip here which have- being very familiar with the data, I c- I can speak to this a little bit. This little blip correlated with COVID. Randy, you were just talking about this, and this is where C- like QZ just went through the roof, right?

A lot of anesthesiologists stepped back from clinical care, and then it went back down a little bit. The overall trend is up, but, you know, you s- you see those differences. 

Andrew: In terms of the opt-outs, I think the last state to opt out before COVID was in 2013. Um, but during COVID, they had a temporary lift, right, of, of, uh, allowing- Mm-hmm

you to opt out in any state. Yep. And really there [00:09:00] was a, you know, a, a flurry of states that had opted out after that. I think N- North Carolina, you guys are probably a little more tied into specifically to that. I know I'm working in, uh- What, you think we're, 

Joe: you think we're biased? Is that what you're 

Andrew: saying?

Sorry. Uh- Mm-hmm ... I'm working in Colorado as well, and they had a rural healthcare exception, uh, that has recently been, you know, moved to the entire state as well. Um, so I think that's, that's really the big piece of this. But also just a universal, like, uh, acceptance of the safeness of practice, not only of independent practice but also, uh, you know, five and six to one and beyond models as well.

Joe: Randy, what, what are your thoughts seeing this trend towards CRNA-involved... And, and just for the, for the, uh, listeners, this is bundling QZ. We'll, we'll get to breaking out QZ and medical direction, but this is bundling QZ and medical direction. Randy, thoughts? 

Randy: Yeah, this, you know, this is, this is been the trend for many years now, which is the, um, what I often refer to as kind of modernizing the, the, the care team model.

Which is, you know, w- uh, if you don't have [00:10:00] CRNAs, you're, you're looking to bring CRNAs into the model usually for the, the obvious financial and operational reasons. And if you are, you say you have an anesthesia care team model, there's a, there's an increased interest in saying, "Well, hey, how can we move from a Typical one to three, one to four to more of like a zone coverage, uh, u- in using the QZ billing modifier to help facilitate that.

And I, you know, if you look at the data, I mean, I saw data where, you know, the u- utilization of QZ modifier, and for the those of you, your listeners or who may not be super familiar with some of the inside baseball lingo we're using here, just think of QZ modifier as a, as a billing modifier that's used to bill exclusively under the CRNA versus a CRNA versus physician, uh, model.

So it's a signal that there's an increased utilization of CRNAs. Either they've been added to a model or, uh, they're, they, um, the, the practice model at the site has- Mm-hmm ... has moved from a traditional one to three, one to four to something different, right? And so [00:11:00] s- so you see this play out in a very real way, which in, and th- there is just a, a appetite for bringing CRNAs in, and there's an appetite for reevaluating anesthesia care team models and trying to find a more kind of economically sustainable approach.

Joe: You know, what-- Are you guys seeing pushback? 'Cause Andrew, you mentioned one to six, uh, and I'm gonna have thoughts here too, but are you seeing pushback when, you know, hey, we're at one to... And look, depending on the, the compensation, one to four is really the only way to be even remotely close, at least in my models, to economic efficiency.

Like it, and it's not, it's not easy to do. You get to one to five, you get to one to six, and then it's like, okay, that makes a lot more sense. But you know, a lot of anesthesiologists, in trying to characterize their position, uh, and we'll, we'll have them on the show as well, but a lot of anesthesiologists get really uncomfortable with, you know, that one to f- one to five, one to six, one to seven model.

What are you guys seeing out there? As [00:12:00] we see a world in which, you know, look, Florida, nine in 10 cases are done by a CRNA, that means a, an anesthesiologist is floating or some way, and it might be a solo model as well. But what, what are you guys hearing out there? Randy? 

Randy: I mean, it's a, it's a change management problem, so it's like we're all kind of a, a victim of our ex- previous experiences and perspective.

So if I was an anesthesiologist and I trained in a one to three model, uh, and then I practiced, uh, in a one to three or one to four model, then someone comes in and says, "Hey, you, now we're gonna, we're gonna move to a zone coverage model where now it's one to six, one to seven," I, I would probably have concerns if I was that anesthesiologist- Sure

without understanding that when you move from that one to four model to a one to six model, the expectations of your involvement change, too. Mm. And so that is like- And that's hard because if you've been doing, like, you're thinking TEFRA, which are the seven requirements that you need to do to meet medical direction, that becomes, you know, inculcated in your brain.

Joe: Mm. 

Randy: Now you're saying, "Actually, that's not that important." Your role is going to change from being a medically directing [00:13:00] physician to being more of a kind of perioperative consultant of, uh, of some kind, right? And a facilitator of, of throughput. You said that requires a lot of thoughtful communication and change management with the anesthesiologist, also with the CRNAs, and with the surgeons and the administrators.

And so where I see these, these issues where, like, the anesthesiologists get super concerned, they're concerned because they think they have to do everything they're supposed to be doing in a medically directed model- Mm ... but just with more. 

Joe: Mm-hmm. 

Randy: With, with more rooms to, quote unquote, "direct or supervise."

And so that's a failure often of change management and communication, and once you help them understand, well, this, your role is gonna fundamentally change, but it's actually going to be better for you, uh, then, then often you see some success in, in, in the adoption of those models. 

Joe: Andrew, I know you have some-- you've got some really illustrious MDs that you're working with.

I'm sure you work with them, like, you know, people who are employed by the hospital or, or local to the area. What are you seeing on this issue? This is a [00:14:00] recurring theme. It c- comes up in some form or another, you know, i-i-- and o- on every show. What are you seeing out there as far as this zone model, collaborative model, light supervision model?

Andrew: Yeah, so I-I-- You know, I think Randy nailed it, uh, in terms of, uh, how it's working on the physician perspective of taking on that. Um, I think what we're also starting to see, though, is a, a willingness, um, from facilities as well to adapt this model, um, because of the efficiencies they gain, right? Like, the first AM start is no longer, um, being adjusted because the, uh, physician needs to be there at the beginning of the case, right?

Uh, so it's helping them as they're being-- as hospitals are becoming more focused on throughput and, uh, working through that, they're liking this. Even if they stay at four to one and just go to supervision, uh, and allowing the physician not to have to document the seven steps and- Mm-hmm ... like Randy said, being more of a perioperative consultant and being able to focus on the cases that may be a little higher acuity, um, is, is also, uh, yielding a lot of value for the facility as well.

[00:15:00] Um, and I th- I think, you know, just not to dissect too far away, I think it's a shame that, you know, billing constructs are keeping us from moving away what, from what may be most efficient, uh, for hospitals and healthcare sy- uh, systems across the board. 

Joe: Let's u-use the really, really cliche business term.

Let's double-click on that idea. This slide is based on modifiers, right? So it gives us a rux-- very rough approximation, and this confirms what we were seeing in the other slide. CRNAs are in- involved in the majority of cases. MD-only care, solo care. I think the idea of, you know, taking off my CRNA hat for a moment, the idea of investing, you know, 12 years into a professional and having them do outpatient endoscopy is, like, kinda, like, a giant waste of taxpayer dollars.

That's just not a good use of resources. So MD-only care has gone down significantly. All these, all these others, QZ has increased by 15%. Medical direction or team models has gone up by 30%. So but what are you talking [00:16:00] about with this idea around modifiers? 

Andrew: Yeah, I think the construct of modifiers, right, and I, I think I, we had talked about this a bit offline.

Um, you know, I think most of the modifiers, uh, if I remember correctly, was speaking to one of my physician partners, were, were instituted in 2006, 2007, right? We, we live in a different world, right? There's a whole, um, piece of this that's missing where it's, you know, s- you're CRNA only. Does that include, uh, you know, supervision, right?

Where you're fi- you're working in the zone model like Randy alluded to, uh, 'cause that's also being caught by the QZ modifier, right? So, uh, you know, and a complete adjustment to the s- the system, I think, is needed, um, to be able to capture what is and isn't best for hospitals and, and the industry as a whole, right?

And, you know, there are other things to consider, right? Like, I know there's always the CRNA versus CAA construct, right? But, like, you know, currently you can't do a zone model with CAAs even if you're doing four to one, right? So- 

Randy: Yeah, 

Andrew: it's that- By instituting CAAs [00:17:00] into your practice It, it, you're either gonna have to break medical direction or you're not gonna be as efficient as you can be for the OR, which I, I mean, I think is a, uh, a waste of res- resources in, in my opinion.

Joe: You have now been disinvited from the Quad A- ... conference. You will not be speaking at the American Academy of Anesthesiologists Assistants. I mean, but, but, but, you know, somebody asked me what I, what I think of AAs, and I was like, I, they're just not all- they're not, they're not very helpful to us 'cause we- even if we're running a four to one, we're not p- probably not billing it medical direction, right?

It's prob- it's probably 'cause it's a high acuity place, and it's just good to have all of th- that mix of professionals there. 

Andrew: But I think the question becomes as the profession becomes older, right, and you have people that are, like, CAAs that are, you know, 10, 15, 20 years into practice, why do they have to have a physician looking over their shoulder for every item?

And, you know, I think it's just, you know, potentially a bigger question. 

Joe: I know we, we talked about having colleagues of yours on, [00:18:00] but w- when you bring this up, what are your anesthesiologists saying about that? 'Cause that's not the party line, right? I mean, that's not the... You know, I, I put up something on, uh, TikTok or Instagram just yesterday, and I basically said...

I'm trying to summarize my thoughts. I basically said, "Look, supervision i- is gonna be continue to get pulled back, right, from a government point of view." That doesn't really change things on the ground unless it needs to change things on the ground, and people are like, "That's totally unsafe," you know?

"Line up the body bags," right? We've heard that, like, for a million years. What are your anesthesiologists saying? 

Andrew: I mean, most of my anesthesiologists are regional medical directors, right? So they're gonna be thinking the same as, like, a Randy's colleague, right? You know, they're, they're not only doing inner city hospitals, right?

They're also doing rural hospitals. Um, so they're seeing most of this, and they're, they understand what it takes, uh, from the industry perspective. Uh, so, you know, their thought process is not the same as what you would see from Uh, the ASA [00:19:00] and some of what their opinions are, they don't completely disalign with them.

There's some things they agree with, obviously Oh, 

Joe: sure, yeah. Some things they do great 

Andrew: But, uh, in terms of, uh, business, uh, owners, I think they- s- most of them, and it's not just my partners, it's also people that own anesthesia businesses, uh, like you, Joe, um, they have a different, differing opinion on medical direction.

Just put it that way 

Joe: I think the A- and I've said this before on this show so, you know, bear with me, but the ASA's fundamental position is that medical direction is, you know, the gold standard, right? And when you... That's not-- Like, it wouldn't be so bad there, but then it goes further to effectively say that CRNAs and AAs are effectively scribes, for lack of a better term.

That's the fundamental problem, right? It's always gonna set up this tension, and it's, it's an economic like, you know, if this model was here, our economic future would be guaranteed forever and ever. And it's just not reality, and it sets up this fundamental tension. I don't meet a lot of CRNAs who truly [00:20:00] want to practice solo 100% of the time.

You know, they, they just don't, right? Most of us like daytime work or, you know, it's like that's not the point, but nobody likes, you know, the thumb being pressed down on them, and that's where all the tension comes from. So I think if they moved away from that position, this would all just get a lot easier.

The other aspect which in our practice we've had to, you know, talk through quite a bit Especially for people coming from, you know, your heavy northeastern-type practices is, what does that supervision actually look like and how is it defined? Every surgery center, every facility we go into, I say, "How are you defining supervision?"

They say, "We don't define it at all." Uh, of course, that just leaves it open to the government and/or plaintiff lawyers to decide, right? And in other parts of the service sector industry, supervision can be ultra high level, like I'm supervising you on an annual basis, or I'm, you know, really controlling what you do.

I'm controlling your practice. And when we back that, you can keep some sort of oversight. All professionals have oversight in some form or another. It's just a matter of [00:21:00] measuring that locally, and I think that's often what gets missed. 

Andrew: Right. But that's a big problem no one's raising their hand to take on, right?

That goes back to the fact that we haven't changed a construct in, you know, 20 years, right? Like, people don't wanna challenge the system for whatever reason, which doesn't make any sense to me- I do ... as an economics major. I do. I'm in my 40s. 

Joe: I wanna change stuff, 

Andrew: you know? 

Randy: Uh, well, it's interesting. So I think what we're seeing here, like there's, there's a few threads to pull, but the, the thing that I think is connects all of those is what is trying to happen and is that the, you know, healthcare writ large, but I guess the anesthesia ecosystem specifically, is moving, trying to move in a direction where they have economically sustainable practice models, and there's different permutations of this.

But, you know, what you're seeing is the, the, the signal of QZ utilization, the signal of CRNA utilization, the, where you're seeing the all physician practices significantly decrease over time. [00:22:00] All of that is a, a, a byproduct of the hard economics that are occurring relative to providing anesthesia services in a highly subsidized business.

And so if you're on the wrong side of that- So if you are saying what is happening shouldn't happen, then you're probably not effectively advocating for your constituency. So the, like, the, the zero sum, it has to be this one specific construct. And I'm talking about, like, the ASA's position here is, you know, again, I-- from, from completely apolitical perspective, the ASA's position here is, it's, it's almost laughable in that it doesn't reflect what's actually happening in the macro and the micro in anesthesia.

And they're-- And, and I think they're gonna have to adopt, uh, and adapt, I guess, i-into understanding where anesthesia's going, which still is an awesome opportunity for anesthesiologists. I mean, there's like, there's no, there's no world in which we would be talking about artificially limiting the number of anesthesiologists that come into the workplace and/or not using [00:23:00] anesthesiologists.

There's, there's more than enough work. But what I think if I were the ASA, uh, or anyone who really cares about this stuff, I would be thinking about, how do I position myself and my workforce to, uh, to adapt to what is happening because of the, the, the tidal wave of economics that are, that are driving practice model changes?

Joe: Tidal wave is the right word. 

Andrew: Yep. Yeah, I agree. 

Joe: Tidal wave is the-- Like, it's a tsunami. And so I would like to take this moment to officially welcome-- to officially invite Dr. Patrick Ghim, MD, FASA, to the podcast next episode. He's the president of the ASA. He can come on and, and weigh in and, and share his perspective.

But I think I was actually going back and forth with some of the anesthesiologists in our group, um, on some of these issues, and what has occurred to me is twofold, which is If you are relying on the United States government to ensure your value in the marketplace, that's not a good bet, right? The other part is people pay a lot of money to [00:24:00] anesthesiologists, and, uh, this probably will not be popular in CRNA world, but you know, it's just economics.

People pay a lot of money to anesthesiologists because they find value in their service, and that's it, right? Like I- all this whole-- and I know you guys are not on Instagram as much as I am or, uh, or TikTok, but there's this like whole like every third post is, "We did all this schooling, so we should get paid more."

There's dentists on there. "We did all this schooling, so we should get paid more." And I just feel like screaming into the void, "Guys, s- your amount of schooling doesn't really matter." It, it only matters that you're solving the surgeon's problem, and that's it. And if the moment that surgeons can do it without us, they definitely will, right?

'Cause they're just taking risk away. Anyway, I digress. Any other thoughts on these, on these billing trends before we move on to the next topic? 

Randy: The only thing I would throw out- Yeah, please ... and this may be... Yeah, this may be out of scope of the conversation is like the all this QZ billing, uh, conversation that we've had and the trends which are un- undeniable.

The one thing that is, is a bogey and, and it's not [00:25:00] theoretical, it's real, is the reimbursement relative to QZ threats coming- Yeah ... from commercial payers. Uh, and that can, if you, you know, if you sit down and you do the math in certain situations, you know, a fifteen percent or twenty percent delta between what you're gonna pay a CRNA and a QZ model, or in some cases even a medically directed model, they're gonna pay CRNAs less.

That changes sometimes the outcomes of what models should look like. And I think some people are really surprised by that. Uh, and especially in a situation where you have CRNAs are, you know, they're getting, you know, fifteen percent or more less reimbursement in a QZ model and thirty percent or fifty percent of those CRNAs are locum tenens.

Then the, the math- Uh-huh ... starts to swing- Uh-huh ... back towards actually the medical directal-- medical direction model is the smartest thing to do financially. 

Joe: Yes, that, that is true. Uh, locum C- I mean, locum CRNAs just blow the whole model up. I mean, that's brutal, right? 

Andrew: Yeah, I agree. 

Joe: I mean, what, what are you seeing, Andrew, there?

What are you seeing? 

Andrew: Yeah, I mean, I, I would say though that the, the number one [00:26:00] problem, right? And the-- where everyone is just missing the ball on the ASA and the AANA side, and, and not to kinda point fingers at, at either one, right? Is this is like a classic divide and conquer. The real problem we're having is right now as an industry is with insurance companies and regulations, right?

And you know, if there were a unified front, I think that would be better for everybody, right? Like, people are talking about how do I fight for m- for money for myself? Um, and what they don't realize is that, that the hardest part to making that argument with the hospital is the fact that they're subsidizing your services.

If there was a way that anesthesiologists and CRNAs could work together, uh, to fight insurance companies and lower that subsidization, I'm sure people would be more than happy to pay a little more, right? I mean, and that's kind of the number one problem in this in- Mm-hmm ... in this industry, in my opinion, right?

'Cause there is no stopping the low supply situation in the short run. 

Joe: Correct. Yeah, I, you know, so Randy knows this. Andrew, you may not. I'm starting on [00:27:00] the ANA board in, you know, two months or something like that, and I don't know if I'll have a chance to speak with, um, the illustrious Dr. Guillaume or Guillaume.

Forgive me if I'm mispronouncing your name. But I, I try to think about, like, where's the very narrow window of success, and maybe it's in the fact that maybe the United States government shouldn't have anything to do with anesthesia models, and maybe that's where we can unite. I'm serious. Like, why are we letting the government decide these things?

This is crazy. Um, I know they feel like-- I think, obviously, they feel like it protects them, but I don't think it does, like, 'cause I don't think the problem can be solved without them, you know, and as much as- 

Randy: I mean, I- Yeah. I, I co- so I am not a huge, like, deregulate everything libertarian kind of person.

It's all 

Joe: right. I know you're a member of the DSA. It's all right. It's 

Randy: all good. And, and so, like, there is, uh, there's definitely a role, uh, and room for regulation, especially if it's- Yeah, for sure ... like, hey, protecting patient safety, preventing waste, fraud, and abuse. 

Joe: Definitely. 

Randy: Sure. Uh, but if you look at, you know, and, and the, the, the regulations I think you're [00:28:00] referencing, uh, and there's obviously other regulations, and I happen to think that healthcare is actually over-regulated in, in some areas, is, uh, when the regulation gets in the way of what needs to happen from a common sense perspective, then, then we need to look at the regulation.

And, and, you know, w- the, the opt-out is a kind of a good example of, you know, where there's, you know, there is-- there seems to be enough-- there seems to be a mountain of evidence that this is a regulation that doesn't serve anyone's, uh, need, at least from a practical, you know, patient safety, financial operation perspective.

And I think that's an area where, like, I, I could definitely get on board, you know, from a, uh, you know, a deregulation perspective.

Joe: Just yesterday, the state of Vermont, which is now the 26th state plus Guam, so majority of jurisdictions easily now, have removed physician supervision. But yeah, you know, talking about- this is what no anesthesia podcast talks about, but talking about the role of government. [00:29:00] And I don't- obviously, scope of practice is regulated at the state level.

Even that, I am... This is outside of broad strokes, I am somewhat skeptical that 100 elected representatives know enough to effectively regulate scope of practice. And largely they turf it to board of nursing or board of medicine, but, I mean, these things are defined in statute typically, right? So that's the legislature.

And, and I'm not like a, I'm not a diehard Republican, uh, I'm a political independent, but on this issue specifically, trying to talk to libtards is just crazy town. Uh, anyways, so back to the news. So 26 state cuts physician supervision. This is from five hours ago. I just put this up. Uh, you guys are both familiar with this.

This is Medicare Part A. So just for those listening, Medicare Part A reimburses hospitals. That is the federal government's reimbursement of hospitals In those regulations, it requires a physician, which can be a surgeon or an anesthesiologist, to supervise CRNA services, [00:30:00] and it has failed or it has declined to define what level of supervision that is.

This is a one federal regulation that is, uh, within the purview of governors to pull back. So it's unusual in this sense. Uh, what the impact of practice is is a topic of debate in and of itself. But, uh, Andrew, let's start with you. What are your- what are your thoughts? What are you hearing about this? Did you get text messaged yesterday about this, or was it no news?

Andrew: There was no news. Uh, not on, on my front, honest- I haven't worked in Vermont, so it's not- Oh, okay. Okay ... a state I have, uh, much experience in. Um, but obviously, I'm a huge fan of, uh, allowing, uh, you know, free market and opting out, and I, I, you know, I think there's a space for independent practice. So I'm a huge fan of this, and hopefully we get a couple more.

I know Florida was right on the, the doorstep there. Hopefully, uh, we can get that through as well, so. 

Joe: Andrew, you just keep getting disinvited from conferences, man. You're not gonna get invited to the ASA by, uh, by saying that. That's okay. Um, Randy, any, any thoughts? 

Randy: For those of our listeners who aren't super familiar with this, this is kind of the bastard stepchild of what [00:31:00] was trying to happen during the Bush administration, or prior to the Bush administration.

In the 11th hour of the Clinton administration, they had removed this requirement in Medicare conditions of payment. And then when Bush came in, he, you know, he halted, uh, all the rulemaking that hadn't, had not been fully promulgated, and then ended up with this kind of negotiated agreement where they were gonna default to the states.

So here we are, you know, many years later, 26 states have successfully opted out and stayed opted out. Um, and so, you know, it's an interesting experiment. The question I would ask is, like, how does this impact access to care? What data do we have with it? How does this impas- co- impact cost of care? And how does this impact quality of care?

And I think there's a lot of spirited debate around whether the opt-out is, you know, practically changing practice models, whether it's changing economics or whether it's changing, uh, unfavorably patient care. Uh, and you can debate that. There's back and forth between the, you know, the usual suspects on that.[00:32:00] 

I tend to see this as a, uh, a potentially helpful tool in managing the perception barriers associated with changing practice models, right? From, you know, what we talked about, one to three medical direction to one to six zone coverage, uh, those kinds of things. Or even in the ASC, we see a lot of ASCs that are, are either have moved to all CRNA or are thinking about it.

And so, you know, I think about this as a, you know, from a practical perspective, you can have an all CRNA model, you can have a zone coverage one to six model in a state that's not opted out. This just helps make the conversation a little bit easier, and it's a signal like, hey, even, you know, even the state, you know, the governor of the state and, you know, the federal government have created a mechanism by which you can remove this requirement of physician supervision for...

Uh, and so what the practical implications are, I don't actually know. Like, like, what, how is, how is this impacting the, like, the big three things that we care about? Access, cost, and quality of care. 

Joe: Yeah, I'll, I'll, yeah, I'll jump in there. I think, [00:33:00] you know, when I see these regulations being pulled back, I just ask myself, what are the, what are the local leaders going to do about it now?

And this is what I posted yesterday on Instagram. If I were a surgeon, GI doctor, cardiologist, or what have you, I would immed- or, or an anesthesiologist leading a department, I would be immediately sending an email to my compliance department and saying, "How can we update our policies and procedures to remove any perceptions of liability around this supervision rule?"

Because again, you know, from my previous statement, most facilities don't have this defined, right? So now that this is not in place, why have it at all? Uh, only-- And you can still, like we've s- we've talked about, we- there's a fundamental disconnect with a lot of anesthesia leaders because they don't understand the regulatory environment and the clinical environment are two different things, right?

So you can still maintain oversight, even tight oversight, at the local level if that's what you need to do, you know, with the talent that you have, right? And that, that's not unheard [00:34:00] of. But you don't need to keep it in there just because, right? 'Cause ultimately, if you have it there and you're not doing it, that creates a bigger problem.

In Arizona, obviously I know that state well We have one, two, three major groups. Uh, I w- you know, I'll say one of them and I'll- I won't say the other one 'cause they are my competitors and I want- don't want them getting any press. Sorry, Justin, if you're listening. Justin's the, one of the owners there.

He's a good buddy of mine. Um, so there's three major groups, right? So Guide Anesthesia, we are one to Arizona name. There's Summit and then there's Gas. And all taken, these groups probably have about four... Well, they probably have about 50-plus percent of the Phoenix market, and probably one-third, um, you know, depending on how you cut the data, of the entire state.

And when you have groups like that, that really changes things, and that's probably the best example I know of, of there was an, you know, opt-out came into place, and then those groups... And they all, they all have anesthesiol- I'm talking about myself in the third person [00:35:00] here. They all have anesthesiologists as well, and I think that's what people get, what gets lost in the shuffle, right?

It's like anesthesiologists don't go away in this mix. That seems to be the theme of this episode is, like, the changes that are happening with, uh, with all these anesthesia models. Um, I anticipate this will keep going, right? I think we're gonna see '27, '28, maybe a national opt-out in the future just 'cause it doesn't do a lot You know, safety is largely a mechanism of local practitioners, right?

There's no amount of government regulation that's going to prevent a bad actor, right, or an incompetent person. That's my sense of it is, uh, let the, let the local practitioners decide what their scope of practice should be. That sound right, um- 

Andrew: No, yeah 

Joe: I'm, I'm waiting for my, waiting for my invitation to a conference for speaking.

All right? 

Andrew: Yeah. Yeah, I would agree. I mean, I think, you know, I do kind of agree with Randy. You need some guardrails, but I think, uh, they should be very high level, right? And, uh, you know, allow the local group to decide, uh, what is and isn't safe in their opinion, [00:36:00] uh, as long as it's not something ridiculous, uh, right?

Like, as long as someone-- if someone has taken the time to get the license, uh, that we are, uh, nationally accepting for doing care, that should be fine, in my opinion. People should be able to work to top of license anywhere throughout the country. 

Joe: So you know, you know what's interesting? I'm just gonna drop one more thought as we're contemplating things.

One, I keep thinking about this word competency in the sense of, you know how pilots get licensed? Like, they get, they get licensed per pl- uh, this is my layman's version, per plane, right? So rather than, hey, you're an MD, you can do all of these things, you're a CRNA, you can do all of these things, which is really a bad way to do it because we know like, you know, the differential between professionals can be massive, right?

You have some CRNAs who would only do GI. You have some CRNAs who are brilliant, and they're doing all this fancy stuff that I don't personally do. And if we went to a world where it's like, no, you are certified for outpatient anesthesia. You are certified for this segment of regional, this segment of regional, this level of autonomy, and over your career, you [00:37:00] just increase that.

We kind of do it de facto because local people figure it out. That would be a much better way to do it, I think, than a national certification that just, you know, lives on in perpetuity, but I digress. 

Andrew: I think that's a great point, by the way. I do. I, uh, you know, it does exist somewhat on the anesthesiologist side for peds certification, right, trauma, cardiac.

Uh, I know those things exist- You know what? It does- ... in 

Joe: CRNA, but it doesn't- It 

Andrew: doesn't prevent them. Right. 

Joe: Right? That's the thing. Like you're not-- like I could go do, you know, if I c- I can get my delineation privileges, which is super broad, right? And then ultimately it's gonna be whoever runs the board.

And same thing with anesthesiologists, right? I mean, they get their, their DOP. It's super broad. It doesn't prevent them from doing a, a c- anyway, I di- I didn't mean to interrupt you Ra- Andrew. I'm sorry. You finish your point. 

Andrew: No, no, no. I think I agree, though. I, I do agree that, you know, additional steps gives people stuff to work for, right?

And adds a level of comfort across the board, and I do think that would be a, a, a good move, uh, as well, right? 'Cause, you know, we, we've talked about this in the past, right? Like, uh, you know, part of the angst with the QZ is like are we gonna let a [00:38:00] student practice independently? Um, and I think most people, you know, think that may be a little controversial, right?

But if You know, if there was a step to say, hey, you know, five years in you could take another test and then you could practice independently, uh, that may change the conversation completely 

Joe: That has actually been suggested multiple times. I've, so I've seen that a lot over the years. And actually, that competency idea, when we first did our scope, our statute change, where we actually have physician direction in Arizona.

I don't know if you guys know this. So we're required to have the direction of a physician, but we have the surgical, um, surgeon and physician immunity lu- language. So it's this weird legal, uh, state where you have direction, but nobody knows what that means. But we know you can't be liable, so you can't be supervising, so we opted out.

When we were having that conversation, the, a surgeon who was very practical, not unlike the people on this call, basically said, "Look, I had an all CRNA model for many, many years, then I went into a higher acuity practice. And we added an anesthesiologist 'cause, you know, these patients were sick as all get out and blah, blah, blah."

I say, and that's not to say CRNAs don't do... Gosh, it's gonna be quoted somewhere. CRNAs [00:39:00] definitely do. There's sick people everywhere, right? But, you know, based on the local CRNAs, they wanted to add different professionals, and that's fine. But he was the one who brought it up. The license doesn't matter as much as the competency What you did 15 years ago, a sc- a training program that you did 15 years ago, isn't particularly relevant if you're not competent today.

And to your point, Randy, earlier, the competencies that the market will require, I think, humbly, a physician anesthesiologist is likely to change. And that's probably a good segue to our next phase here. I said physician anesthesiologist out of habit, just 'cause that's- I do see that more and more. So this made some news in the interprofessional circles.

No one... You guys probably didn't care about it very much, but we're gonna get your thoughts anyway. The day before, I'm gonna give a little bit longer of a background here just 'cause this is a big issue, uh, the ANA board of directors withdrew a trademark. And follow along with me here. They withdrew a trademark for the name American Association of Nurse [00:40:00] Anesthesiologists.

Now, you may be thinking, if you're listening to the show, I don't know of a group called the American Association of Nurse Anesthesiologists, and that's because that name is not in use. That name doesn't exist. So they effectively, they being the ANA, thought about it 'cause of a conversation I'll just very briefly review.

They filed the trademark. It's not in use. They withdrew it. Subsequent to that withdrawal, the ASA was opposing that trademark. The ASA went on all the media channels, the LinkedIns, the Instagrams, the Facebooks, and said this is a decisive victory for their members. And look, I understand they're, they're trying to, to claim a win.

You know, membership organizations are tough to run. I'm not sure I would characterize it as a decisive victory. But I'm just gonna give a little bit of background and then get reaction here. So first, this issue stems back to industry research. This was leaked on the Internet around 2017, and I remember all this going down.

So this is research from the ASA from 2013. They basically found that a minority of voters [00:41:00] recognize anesthesiologists as physicians. The majority didn't know or thought they were something else, right? So that kind of shook the foundations, I think, of the American Society of Anesthesiologists in terms of identity.

Right? Subsequently, they began to call themselves physician anesthesiologists. In the same industry research that they commissioned from a firm out of Chicago, and this kind of lit the world on fire a little bit during this time, they did research on how to make sure that CRNAs were perceived to be less essential, and the language they used, if you're not seeing it on the screen, is, "This is how we want them to be perceived," which indicates some level of intent to make sure that CRNAs are perceived as less essential and were perceived as more essential.

Uh, fast-forward 13 years or so, now they've been physician anesthesiologists for many years. The AANA, and I don't have anything on the screen for this, but the AANA effectively said, "Look, we..." I'm trying to characterize accurately here. "We recognize the confusion out there. There's dentist anesthesiologists.

There's CAAs, anesthesiologist [00:42:00] assistants, calling themselves anesthetists." Uh, so physician anesthesiologist, still in use today. The American Association of Nurse Anesthetists recognized this term as a complementary term, nurse anesthesiologist. I remember all of this going down. Many, many CRNAs were really against this idea 'cause they're very proud of their title.

When th- however, I think when they saw that, you know, the ASA was doing research on how to make them less essential in the marketplace, they saw that the new anesthetist campaign was very popular at that time from the quad A, from the AAs, that is. All of a sudden there was, "We have to do something." Right?

So that is the entire background. I have some things to say about this 'cause I, I remember all this going down well. Randy, you were... We don't talk about this a lot, but you were the CEO of the AANA at this time. I believe you referred to this, uh, controversy as Brexit at the time. Uh, you know? 

Randy: But- I didn't realize...

Jeez, I'm, uh, I am clever. Yeah. I, I [00:43:00] don't remember saying that, but I'll, I'll, I'll take it. I mean, this is, uh, like I have... Yeah, I definitely have some PTSD from all of this, so. Oh, 

Joe: man. This 

Randy: was a big deal. Uh, so I 

Joe: was- This was a big deal. 

Randy: Yeah, I mean, it's, it's, it's one of the, the bigger things that, you know, as CEO of the AANA, I had to navigate around multiple s- internal stakeholders on this- Oh, man

issue. Yeah. Right. So, uh, and, you know- If you-- I can zoom out for a second. This is- Did you have a 

Joe: therapy bill? Did the ANA cover your therapy bills after all this? This was intense. I remember it 

Randy: going down. Yeah, the, the litigation's still playing out. Yeah. But the, uh, you know, there is the, um... I think this is a interesting, like, kind of human problem, which is a lot of w-what drives human emotion is, like, related to your identity and, and how you think of yourself, and how you're referred in certain ser- in certain situations by certain people.

And so this is tran- you see this as like, this is not uniquely anesthesia. Like, there's, there's interesting-- there's other healthcare-related, you know, conversations around should PAs be- 

Joe: Yes, physician 

Randy: associates ... physician associates or- Mm-hmm ... physician [00:44:00] assistants. And so, like, there's a lot about this that's wrapped up in identity that it's hard to decouple from, you know, like, the psychology versus the practical stuff, right?

So I s- I have seen this, and this is where, you know, I'm-- I, I personally see this as a massive distraction, uh, to what is actually important to, uh, the average day CRNA and anesthesiologist, who gives zero shits. 99.9% of CRNAs and anesthesiologists give zero shits about this. Uh, and this seems a lot to me like political theater, right?

So the ASA is, you know, they, they're now spiking the football. Look how we have caused the A-ANA to stand down, and now the A-ANA, who's made a very practical and defensible, defensive, defensible posit- uh, decision here. The A-ANA's decision to not throw m-more money at this through litigation is a very good decision as, as a fiduciary for the profession and for the organization.

And the ASA is gonna gloat a little bit about it. And, [00:45:00] and, and all, all the while, the key stakeholders, the, you know, the legislators, regulators, administrators in hospitals, health systems, and ASCs, patients could not care less about any of all of this political theater. And I think it was a really smart decision by the A-ANA to say, "You know what?

I don't wanna spend any more money on this because 99% of the people who care in the world don't give a shit." And the ASA can, can continue to say that they did, you know, they've accomplished something. None of their members care. 99% of their members don't care either. And so what I've seen is, like, a lot of, like, emotion around this in a way that doesn't, you know, really mean anything to what CRNAs and anesthesiologists care about.

Andrew: I completely agree. I am not a physician or a CRNA, uh, but I'd find it insulting that they're using our donations to, uh, to spend time on this versus the things that actually affect the industry. So that would, that would be my opinion of it. Um, I understand [00:46:00] there's other political things involved that I may not understand as an actual clinician.

Uh, but I, I do agree. I think it i- it is a waste of both parties' time 

Joe: I think that you're correct to a degree. To some degree, perception drives behavior. I never use the term nurse anesthesiologist initially. I don't walk around saying, "I'm a nurse anesthesiologist." I say, "Joe, I, I'm Joe Rodriguez. I'm a CRNA."

Pronounce it very clearly, so if there's questions around that term, people can ask. I don't say nurse anesthetist because, one, it's hard to say, and two, people don't generally know what the term anesthetist means. They think I'm doing my- their nails or something like that. I say, "Hey, I'm Joe Rodriguez. I'm a CRNA.

I'll be doing your anesthesia today," and I go into the, the patient interview, right? Now, for the savvy or the curious, some will say, "What does that mean?" And I'll say, "It's certified registered nurse anesthetist." And if there's a further contextual conversation to have, I'll talk about different types of anesthesiologists.

That's not a common thing, but it [00:47:00] definitely happens from time to time. So I think it's a helpful tool, especially in the context of if there's a physician anesthesiologist, there's a dentist anesthesiologist, there's a nurse anesthesiologist. That just makes sense, right, from a kind of a lexicon point of view.

But I think the goal is to be clear that there are physicians involved in this specialty, that there are CRNAs who are involved in this specialty, and there's other professions as well. Those are the two main ones. And I think from an internal point of view, it's important to recognize that the specialty of anesthesia is one that is held by multiple professions And that is uncomfortable for some in the industry.

After that, I don't think we need to talk about it a lot, right? Like, uh, but I think it was such an inflammatory issue just- it just became such a huge issue for such a long time. I don't like policing speech, right? I think, I think if you're being clear that you're a member of the nursing profession, that you offer [00:48:00] certain expertise, that is fine.

Um, that is good, in fact. Uh, yeah, like you said, Randy, at the top, at the top of your comments, you said, "Identity is important," and that's where all of this comes from, right? But it doesn't solve economic issues. It solves internal issues. I do think for some CRNAs there is, "Hey, I'm very comfortable effectively operating as an AA," and that's fine.

They can. But there's a large segment of CRNAs who are trying to operate at a high level and feel consistent pushback. And for that segment, and it's, you call it 40% and maybe even upwards of 60% on how they feel, that's where that matters. And I don't think we have to do anything else, though. I think it's fine just as it is.

That is my take on it. I know that's not, like, a super popular one amongst the business people, but yeah, I, I don- I don't know. I'm on both sides of this. You know what I mean? I, I didn't come up at, at our, at guide either. No one, no one texted me right away and say, "Did you, did you hear that, that we won or lost the trademark?"

It was like, nope, just business as usual, you [00:49:00] know? No- 

Randy: nobody cares. N- nobody cares. And, and, and that's like the, the, the challenge with this stuff is that when you get to the board of directors of the AANA or S- ASA, you've now entered into an echo chamber. And what seems like a big deal because someone is running their mouth on s- on Facebook- Right

and there's four other people who are joining in, and then be- then all of a sudden the board starts to get focused on this stuff, is if you, like, really think about it and, and, and, and think it through, is like this is, this is absolutely meaningless conversation. And so the risk here is like any organization, any leadership team is, you know, are we doing the things here as an organization that mean the most to our members?

Mm. And, you know, and that is like driving, uh, you know, the, the economic value of anesthesia relative to anesthesiologists if you're thinking about this from an anesthesiologist perspective or from a CRNA, from a CRNA perspective. And I tend to filter things through that. And if there's [00:50:00] not a practical reason why, uh, something's gonna impact, then it, I, I don't really have a lot of interest in it.

Joe: Yeah, there's not a lot of... I think, I think it was reasonable for members to do something about being mischaracterized in the market. When you see one of the largest and oldest and most well politically fund- or strongest political funded, largest politically funded organizations in the country Trying to figure out how to make you less essential, I think it's okay to respond to that, right?

Like at a, at kind of a philosophical level because Thoughts drive feelings, which drives actions, which drives outcomes. 

Randy: Let me push back real quick. Yeah, yeah, yeah. So you, we, we started this conversation with you showing data how the market is, is moving towards CRNA adoption Right. So you see the utilization of QZ, you see the introduction of CRNAs into models which were all physician.

There's nothing in the data that indicates that CRNAs have been compromised from a market share perspective. In fact, the data demonstrates the exact [00:51:00] opposite. So as we think about these, what I consider kind of the political theater stuff that permeates certain aspects of both organizations, I kind of filter it through, well, CRNA market share has only gone up, and QZ adoption has doubled since two thousand and ten, which is a very good signal of CRNA utilization independent or in a zone coverage model.

And I'm not sure how any organization spending a bunch of money on referring to themselves in a way that they haven't in the past changes that. And I don't feel like because the ASA has spent e- an obscene amount of money on PR, uh, that no one listens to, and, and that you or we, or as an organization needs to spin up a bunch of activity and deprioritize the things that matter the most in order to focus on something that actually doesn't drive CRNA market share.

Joe: I'm gonna-- I can steel man your argument, right? It doesn't drive value for the people that want our services in the sense of, you know, it doesn't [00:52:00] solve patient problems, it doesn't solve surgeon problems, it doesn't solve facility problems. I understand that point of view. It's very utilitarian. The only-- What I would add onto that, and Andrew, we'll come to you with this.

Um, what I would add onto it is, at some point, you have to have an operating framework or a philosophy of who you are. And I do not advise CRNAs to take, like, an ultra-aggressive, like, you know, kinda F other people, right? Like, no. L-like, let's just advocate for a world in which we are professionals. We're professionals who offer services.

There's-- Just like any other professional, there's reasonable oversight in that world. And to some degree, I think the way we talk about ourselves influences the decisions that we make. And that's a really high-level thought, uh, but I don't think it's good for, you know, CRNAs to generally accept permanent second-class citizen status.

And I know the anesthesiologists in our group, and I think broadly speaking, would say, "Well, [00:53:00] that's not what we're going for," right? But again, when a very well-funded organization does those sorts of things, it, it makes you think. It's like, "Oh, wow, how is that gonna play out in ten years?" Uh, so I see, I see both points of view.

I get it. Like, you know, it doesn't create value. Um, and again, all I would say is that it's fine where it is. Don't police speech. Be accurate with your words, and then get back to solving problems because that's what drives the economy, right? No one gets paid because of their title. They get paid for solving problems.

So but it's a different view Obviously. Andrew, g- go ahead. Go ahead, my friend. Yeah, 

Andrew: I would agree, but I would say that the onus is on both professions to, you know, if you go back 10 years ago when all this started, right, like, there was less need for them to push back on some of the, uh, political portions of this, or maybe a little further, further back.

Um, but now them wasting... Both parties wasting their time focusing on these things is kind of a [00:54:00] disjustice to themselves as well, uh, where they should really be working together to try to fix how do they fix reimbursement, right? How do they fix, um, policy, and how do they work together to drive anesthesia forward?

Because both parties are needed moving forward. Uh, now, that's, as an outsider, that's, that's my opinion, right? What really my, my focus is on how do we lower, or how do we keep anesthesia sustainable, uh, from an economics perspective, right? And how do we service clients better? So it's just, just my opinion.

I think that has been a little lost on the, the association level. Leaders like yourself have not lost that, right? I mean, that's why you guys are thriving. Both of your businesses are thriving, but I think that would- I think most business owners would suggest, um, that that should be the path, path forward, so.

Joe: Yeah, I, I, I think you're right, and, and I, I, not only do I think you're right, most business owners, most department leaders who have, like, P&L leadership in some form would fall there. I agree with that point, and I agree with the point. That's where [00:55:00] our focus should be in terms of, you know, generally, I think that the goal of those organizations should be how do we get things out of the way so that our very esteemed members can do what they're really good at, right?

And, and that's it. That should be the goal, create value in their life. Um, this is an issue, uh, but it doesn't have to be. I don't think, you know, we should do the CRNAs. I don't think they should be doing what PAs are doing and trying to change statute in 50 states, right? I mean, I think that's kind of like, like, why?

Uh, and that's where I agree with you, Randy. It's like you're, you're, you're winning everywhere. Like, why waste time on that in that way? Last segment of the show where we just share what is on our mind this week, and actually, uh, we- I've already touched base 'cause I've been making a... I'll start, and we'll flow to you, Andrew, and then you, Randy, can close out.

Uh, I've been sharing on TikTok and Instagram this week, and the feedback has been both unexpected and expected. The expected part is you share, share anything with anesthesia, and the, you know, the normal stuff [00:56:00] comes out, and that's an important debate to have, right? I've already talked on the show many times about the distinction between regulatory environment and clinical environment.

But largely, it's like I, like, we- we've already had that conversation. Can't we talk about something else? And what really occurs to me is how- When I'm sharing these videos, so many young people just want a way to figure out their economic future, and it really makes me think as a country, we have to figure out how to improve the societal contract so that more and more people feel like they're part of this wealth that we're building.

That's one part of my mind, and the other part I've really been thinking about is where America stands in the r- in comparison to the rest of the world. 'Cause ultimately, we s- even though things are hard, you know, comparatively, like milk is really expensive, eggs are really expensive, and by no... You know, like being a CRNA catapults you into the top 5% of earners in this country.

But I still have g- my mom was a nurse and my dad was a teacher growing up, [00:57:00] eventually became a principal. So they were doing better towards the end of my life. But for a large part of my life, like, no, we went to, like, bargain grocery stores Right? That's how we lived, and I still shop that way, and I'm doing better financially than I have in the past, so now I get, like, organic eggs and I really splurge.

So, you know, these two thoughts are in tension all the time for me. In one way, things are better than they've ever been. I think the version of capitalism we have, and I'll end with this, the version of capitalism we have is not a good one. But I am still sold on the idea that for the free enterprise system, when it has good guardrails in place, is still the way to go.

It lifts people out of poverty. It allows people like everybody on this call to go out and create value and be rewarded for that value and have a great life. So that's where I'll end it. Andrew, any thoughts? 

Andrew: Yeah, um, you know, I've been having a lot of, uh, conversations recently, and, and thank you guys for having, uh, me on the podcast, about some of the conversations we're, we've been having today.

Um, and really, uh, you know, I think it's time as an industry for anesthesia specifically, uh, to kind of come together on [00:58:00] all ends, right? So hospital, uh, partners, uh, anesthesiologists, CRNAs, and kind of rethink about how we're looking at the industry and redoing it, um, as a whole. Uh, you know, as throughput becomes the focus of it- of surgery, uh, because surgical backlogs are increasing at a unsustainable rate, um, I think if that doesn't occur, and there aren't changes across the board, um, and the industry isn't unified, we will have to deal with it, whatever those effects are and be doing a disservice, uh, to the people we're trying to provide care for.

So that's been, uh, one of our focuses. I know there's some people taking a look at it. Uh, some people at MedAction as well we talked to will be looking at, um, putting together, um, a panel to kind of look at some of this stuff as well. So I'm hoping that we could, uh, help drive the wave of change here in this.

Joe: Isn't MedAction a digital and anesthesia EMR company? 

Andrew: They are. They have- they've trying to build a software to, [00:59:00] um, help with, uh, coverage, uh, problems. Um, but also as part of that- 

Joe: Coverage like anesthesia coverage or coverage like insurance coverage? 

Andrew: Um, predictive scheduling and stuff like that- Oh, sure, sure, sure

uh, within anesthesia. Uh, and you know, part of what they're trying to take on is, uh, you know, more of like an anesthesia economic forum, and I think that will be Will provide some value, uh, to the overall ecosystem for anesthesia, so 

Joe: Fascinating. Yeah, fascinating. Fascinating. You heard it here first. Yeah.

You heard it here first. All right, cool. We'll be interested to see how it comes out. Randy, final word, my friend. 

Randy: I spend a lot of time thinking about incentives and human behavior and, and one of the things that, you know, in thinking about what I was gonna say today, just how when you see it, you can't stop seeing it, which is like human- our human d- and I'm, I'm just as guilty as anyone else, but human behavior has a tendency to defa- default towards tribalism.

And, uh, I think about myself as an executive in a large anesthesia company, um, my job is in part to [01:00:00] m- m- move people away from zero-sum thinking. And, and so, you know, as a, an executive in a large company, and I have responsibility of, of the clinical strategy of, of the company, which involves all clinicians, is, you know, when trying to snuff out the, the tribalism that can occur at the site level, uh, you know, between CRNAs and anesthesiologists, and instead of- instead build incentives th- that move us from zero-sum to more collaborative, uh, decision-making.

And which sounds very theoretical and sort of easy to do but, you know, it, I- and this is one of the things I've learned a lot is it's the Charlie Munger quote, which is, uh, "Show me the incentive, and I'll show you the outcome." And a huge amount of what I do is trying to figure out what is- what incentives are driving behavior current state, and then what incentives do I need to put in place to change those behaviors?

Uh, and once you start thinking about incentives and acknowledge that incentives drive human behavior, good incentives [01:01:00] and bad incentives, and sometimes you use disincentives, uh, in order to change bad behavior, then it becomes easier to get people off their tribal kind of zero-sum positioning on a variety of different issues.

Joe: Thank you so much, gentlemen. This was really good. All right, everybody, hope you enjoyed the episode today. We have talked about a wh- whole host of things, which I hope you can tell not a lot of people are talking about in our specialty. I want to invite you, if you have feedback for this episode, you can email us, social@abouttherest.com.

We have a website, abouttherest.com. As mentioned during today's episode, I'm on all the social channels, Instagram, TikTok, LinkedIn, Facebook, et cetera. I know many of you have noticed the increase in production quality in recent weeks. You can check out Human Content Podcasts. They produce other healthcare creators that you are familiar with.

So any feedback, please leave it for us. We are interested. I'm your host, Joe Rodriguez. On the show today, Randall Moore and Andrew Woodmansey. Our executive producers are myself, Aron Korney, Rob [01:02:00] Goldman, and Shahnti Brooke. Our editor and engineer is Andrew Sims. Andrew, welcome to the show. Our music is by Omer Ben-Zvi.

To learn about About the Rest's program and ethics policy, submission verification and licensing terms, and our HIPAA release terms, you can go to abouttherest.com or reach us at production@abouttherest.com with any questions, concerns, or fun medical puns. Any life advice you wanna get, you can email us.

About the Rest is a Human Content production. Thanks, everyone. We'll see you next time.