Office Hours: Anesthesia Stipends Rising: Are Anesthesiologists and CRNAs the Cause? Insourcing, GI Self-Dealing

Joe: [00:00:00] There was a lot of talk about this two, three years ago. There's just too much friction in the process, too much friction in the market. And what I tell anesthesia groups is if you cannot do it better than a hospital or a surgery center, there's no reason for you to exist

All right, everybody. So if you haven't figured it out, we broke this Office Hours episode up into two episodes. We had a lot of good questions. There's a lot of information to get out there and try to communicate it to you in an effective way. So now you're about to hear the second half of our original Office Hours episode.

I hope it's enjoyable. Davrin asked a bunch of questions. Davrin Davis from Nevada: How do different facilities pay for anesthesia, and what proportion of facilities in specific regions are paying stipends for anesthesia? Oh, this is everywhere. So how do different facilities pay for anesthesia? Let's start there.

Okay, there's two different buckets to think of, and I've written on this in the past, so I'm happy to share it with you here as well. There's two different types of anesthesia stipends. It's either flat or [00:01:00] dynamic. That's it. There's-- You can only put them in... In, in my view, in my paradigm, my way of looking at things is really only those two ways to understand it.

Flat is whether it's daily, monthly, or annual. You basically say, "Hey, we're gonna do nine thousand cases a year. That's gonna generate this amount of money. You need this amount, twenty, thirty percent of program revenue to cover the rest, so you can have an operating margin for all this financial risk, uh, but also so you can pay everyone and not go out of business.

Here's a number That's it. Flat s- flat subsidy. You live and die with the, the, the volume of the cases, and you've gotta work your tail off to make sure your commercial contracts are actually in place, to make sure you're lowering your overhead, you're not spending money inappropriately, all these sorts of things.

Now, on the other side, and this goes back to Logan's question about this 80/20 aspect, right? There's this world of dynamic. There's a lot of different names for it, but the principle is it all changes. Month to month, the number will change, whether it's cost plus or revenue [00:02:00] threshold or revenue guarantee or net revenue guarantee.

Different regions come up with different names, but the distilled principle is that it's dynamic. It changes month to month. And there's all these mechanisms that either side will put into place. "Well, hey, if you don't have... You know, we said we'd get 9,000 cases, but we're only getting 8,500, so we'll do our job on revenue cycle management.

We'll t- we'll absorb some of the risk there. But if you- your volume goes lower, then you've gotta kick in more." There's all these different mechanisms, and as varied as the human mind is or as varied as lawyers and financial folks can come up with the models, that's how varied you see them, right? So they are all over the place.

I, I've worked with, uh, some of the surgery center companies on analyzing some of their contracts, and I see these things that people come up with, and I'm like, "Holy mackerel," right? And generally, the, the key word in this-- The, the, the risk in the flat part is relatively easy to understand. The key word for the dynamic part is who absorbs the risk?

And there's a couple big risks with anesthesia contract. Number one, what happens when expenses go up, right? And that can be overhead expenses. Everything is [00:03:00] getting more expensive right now, okay? Or it can be payroll expenses, clinical payroll expenses. What happens if the RCM company doesn't do their job?

What happens if grandma does not pay her bill, right? Sometimes people don't pay their bills. Who's gonna absorb that risk? And it might not happen, matter if it happens once, but it matters if it happens over the course of a larger contract or a lo- longer relationship. You have-- So you have your... And then, you know, the final aspect, one of the downsides of the revenue guarantee for a facility is that ultimately, if you get a really good deal, the f- the anesthesia group is not very interested in doing their due diligence either on RCM, because it doesn't matter, 'cause the facility's gonna fill the gap.

And again, there's ways to mitigate that. Or on the commercial contracting, you're, you know, why spend so much time, limited time, on commercial contracting when the facility's gonna fill the gap? And that's why you see a lot of giant subsidies exploding and, you know, facilities react and they go in-house and all this sort of thing.

Uh, all right, let's keep moving here. What goes into determining the cost of the stipend and how [00:04:00] competitive is the bidding? How competitive? Very Very competitive. Uh, it is, uh, what I'll say is there's two separate markets, right? So there's the individual market, which, you know, it's effectively, it's-- the financial aspect is relatively low risk.

Most people get paid. I've seen some situations where people don't get paid, but generally most people get paid, right? But on the contract market, it is much more competitive, and there's much more risk involved. So like these giant private equity companies, having interacted with them, and I'm speaking broadly here, they are very motivated to grow.

They're very-- like, they hire people where it's their only job is to meet a certain amount of quota of growth of contracts. So they get very competitive on the bidding. So very-- I'm really emphasizing this, I've experienced it lately. And then what goes into determining what that stipend is, is generally you make a proposal, whether it's flat or dynamic.

You explain the different variables, you mitigate some of those risks, whether it's RCM or [00:05:00] expense or so on, and then you come up with a number. And how that number gets paid, usually there's a true up in some form or reconciliation, right? We collected more, we didn't collect as much. Maybe they, they fill in a little more up to a certain degree, all those sorts of things.

And then when you're talking about the comparison between hospitals and surgery centers and eye centers, what's happened in the last two years especially, maybe in the last year especially, surgery centers and eye centers all of a sudden are having to pay more. And as you might expect, you know, the bigger centers have those more complex agreements where you're mitigating much more sophisticated, a lot more eyes, a lot more professionals are laying their eyes on that contract.

There's a lot more at stake, right? So for a, um, a lot more at stake at the organizational level. Now, I'm not referring to clinical patient care. For an eye center, you might just say, "Look, we're doing X amount of cases per day, and I'm looking at my individual provider market, and, you know, they're making X amount of dollars, and I can only generate about half that.

I need you to make up the difference, so let's just call it even," and, you know, it's a couple hundred bucks a day, five hundred, seven hundred bucks a day, whatever it is. [00:06:00] There's a lot of variables there. So that's how it works in different areas as well. And to your question here, Davren, is that happening all-- in all markets, stipends?

Yes, it is happening everywhere right now to one degree or another. Definitely happening with surgery centers. I think Vegas is probably one of the last holdouts with some of that, some of the western cities, but it's, it's definitely happening everywhere. This is a big part of what we're seeing All the time.

All the time. Uh, and then your comment here, I can see this being a huge barrier for low volume centers. Yes, definitely. Yes, definitely. It is forcing people to consolidate their volume and schedule vertically rather than making it what we call-- used to call the surgeon's playground. And, you know, you, you have two cases each in three rooms, and you're all done by ten AM.

Those days are coming to an end or have ended, right? And that's why we've seen a lot of contract churn in recent years. Uh, any thoughts on whether this, I assume you mean, uh, subsidy here, Davrin, uh, is gonna be the new norm for the foreseeable future? Yes, it's probably going to be the norm in some form for the foreseeable future until something [00:07:00] changes that doesn't...

We don't see any changes there. Explore the rise of in-house anesthesia and the slow demise of anesthesia providers strictly following the surgeon from a hospital to hospital. So just by way of background, in many Western cities, uh, there is a follow the surgeon model. This was present in Phoenix when I got there in two thousand and twelve.

Still present in Vegas to some degree, present elsewhere throughout the West. This is slowly going away. But Phoenix has largely gotten away from this outside a few handful of groups that still practice in this way. And then so that's the follow the surgeon model. And then, you know, okay, we have a few...

The hospital has a few options. Surgery center has a few options. Are you gonna go in-house or are you gonna go external, right? And there's pluses and minuses with both. So with the in-house model, effectively what the, the value proposition there or the bet they are making is, we can do this better than an anesthesia group can.

And what I tell anesthesia groups is, if you cannot do it better than a hospital or surgery center, there's no reason for you to exist. So you need to do it better [00:08:00] than they can. That's like I hire, uh, landscapers or a plumber or a neurosurgeon, it doesn't matter, uh, because I believe they can do it better than I will be able to do it for myself, right?

And that's whether it's working on my body or my home, they're the experts, and I trust them to do it. Now, at some point, if it's easy to do or it's super expensive, I'm gonna look around and I'm gonna try to figure out how I can internalize those. I'm gonna fix the plumbing issue myself. It's the same principle.

Now, in-house is hard, however, and you know, there's a lot of talk about this two, three years ago. Oh, they were gonna in-house the entire system, insource the entire system. Yeah. Uh, there's just too much friction in the process, too much friction in the market, and it really comes down to this, Davrin Success requires focus, okay?

And what I mean by that is whatever an organization chooses to do, whether it's anesthesia or running a surgery center or running a hospital or j- running a surgical practice, you're gonna have to be focused because of all those competitive dynamics we spoke about earlier in the [00:09:00] episode. So if you can figure out how to focus on more than one thing at one time and go deeper and deeper and deeper in that industry and become an expert in that industry, you definitely should.

Good for you. Most people can't, right? And there's also the data, right? When you look at anesthesia consulting companies generally will say there-- the delta between a insourced anesthesia service and an external service is about twenty to thirty percent when taking into account both expenses, number one, and revenue generation ability.

And that's for very practical reasons, as you might imagine. The first is on the revenue generation. If I'm an anesthesia group and I have to pay my bills and pay everyone and make payroll every two weeks, I need to make sure I am generating enough revenue. And I will be deeply motivated to make that happen because I have personal guarantees, and if I can't do it, then I'm probably gonna have to be putting money in the bank account.

And I have done that over the years. We have done that over the years. So I'm gonna be more interested than a surgery center in generating anesthesia revenue. And that's because generally when you're talking [00:10:00] about facility surgeon anesthesia, it's a backwards pyramid. Facility fee, surgeon fee, anesthesia fee, again, generally.

So if, uh, my fee is down here, I'm gonna be very motivated to focus on it even though it's the smallest one. But if I'm managing all three and I have an in-house revenue cycle company or an external revenue cycle company and they are rewarded based on how much they collect, well, they're gonna focus on the big one because that's where they make most of their money.

And as it turns out, everyone enjoys making money, and that's okay. That's normal. But it sets up this situation where anesthesia groups tend to be better on the revenue generation side. The other side of it is, is expense management, right? So fundamentally, the surgery center or the hospital does not know the anesthesia market as well.

And you can hire third-party consultants, but they're always behind, right? They just don't have a pulse. They're not one of our br- one of the brethren, right? They're not an anesthesia provider, an anesthesia clinician. They just don't know what it's like. So they come up with these compensation models That don't always fit what we need [00:11:00] as an anesthesia community.

That's part one. The other part is when you're part of this giant conglomerate, again, it goes back to this idea of focus, you just can't remember everything, right? When you're dealing with, you know, multi-billion dollar budgets and your anesthesia budget has been leaking out all this unproductive time, maybe the salaries are the same, right?

But fundamentally, you're not running the p- department in an efficient way, and you have all this paid time where no one's doing any cases, no one's paying any attention. So eventually, some new executive is gonna come in and be like, "Oh my gosh, I'm really focused on this. I need to lower this cost." And it's a three to five-year cycle, and eventually they call up a group and say, "We need an RFP," right?

That is, that is the general cycle. And then you do that RFP, and if the anesthesia group does a great job, and they prove and communicate that they're doing a great job, and they're doing a great job for all the stakeholders, right? The members of the group, the patients, the surgeons, the facility, guess what?

You can keep that contract for a very long time until they get a little too comfortable and then that, you know, some new executive comes in and says, "I feel like I'm paying a lot of money," and then the cycle all [00:12:00] begins again. They go in-house or they give it to someone else. It's all on a cycle just like the rest of the economy.

That was a long answer, Davrin. I hope it was helpful. All right. Uh, yes, I, I see your comment here. We used to have a lot of independent, independent anesthesia providers in Vegas that would cover just one surgeon. That's all shifted in-house. And yes, I think in-house is gonna be the way to go, especially knowing the economics of things.

Okay, Davrin, another question. "I've been curious about a deeper dive into the legality of how some GI docs try to pay anesthesia providers separately and bill anesthesia services for themselves." I'm gonna tell you a story, Davrin. Our group, we acquired a practice, a struggling practice. They owed their providers upwards of a million dollars.

Really something, right? Strong relationships, unfortunately, the person running the, the practice just, uh, they didn't adapt to this new environment. They got in a lot of trouble, and we came in and we, we helped, we helped renegotiate all this sort of thing. And one of the things I noticed, I was like, "Oh, you're staffing this GI center and you're, uh, you're asking this ortho center, both surgery centers, for this giant subsidy."

I'm trying to remember. It was like seven hundred thousand for two rooms or something like that. [00:13:00] This giant subsidy, and meanwhile, this GI center, you're doing all these cases, but you're not making any money. What, what's up with that? And I look and I was like, "Oh, they're not billing for the cases." So I talked to the GI center and I said, "Hey," um, you know, "we're helping out this group.

They're having a lot of financial trouble," right? "They're getting a lot of pressure from ortho world with this big subsidy that they're being charged," and I was pretty forthright about it. And, uh, so ultimately, we, we need to start billing for these cases 'cause y- this is a really, really busy center, right?

And we need to be profitable here so we can avoid taking so much money over here. That- that's generally how it should work. And he was like, "Yeah, no problem. But what's in it for me?" And I was like Uh, great service, great services in it for you. And I was like, "By the way, uh, do you own the company that's billing for anesthesia?"

And he kinda wriggled, you know, did a little of this, and, uh, he was like, uh, you know, basically, yes. And I was like, "You know, this is, this is referring to yourself, right? This is, this is a [00:14:00] self-referral. You are, you're dipping your toe on both ends. You are finan- deeply financially motivated to refer cases to yourself, cases that could be going elsewhere and maybe should be going elsewhere, but you, now you have a financial motivation."

I said it differently at the time. There's a reason the federal government doesn't like that. Referrals, generally according to the federal government, the CMS, should be made based on the clinical need, not simply on money, right? And there's this whole thing called the company model, right? Effectively where GI docs do this, and they do this all the time, and it is super illegal, right?

And this... Look, I'm not a lawyer, but this, this is, it's pretty straightforward. Uh, Fort Myers doctor agrees to pay more than one point seven million to resolve allegations of fraud. This is Dr. Jonathan Deitsch. This was in Fort Myers, Florida, and he had a company where he paid the CRNAs ten ninety-nine, and y- he was doing urine drug testing, all, all these sorts of things.

And then one thing they found was they're cran- this was a pain shop. They're cranking all these cases, right? And [00:15:00] he owns that company, and he owns the pain company, and he owns the drug testing company, and I'm using this for example specifically. And guess what? Uh, I don't think he's able to practice anymore, and he had to pay all that money for fraud, right?

And the reason I bring that up is because this is kinda like cheating on your taxes. It's not a problem until it is, until the lawyers find it, and then they find everything else. Okay, there's other examples. Tenant to pay sixty-six million dollars to settle the FCA suit involv- involving company model of anesthesia services.

That was from 2019. Uh, that was, um, an article from Mark Weiss, a well-known, uh, anesthesia lawyer. Paul D. Weir, John Morgan, CarePlus Management anesthesia entities pay seven point two million to resolve kickback and false claim allegations. So again, other examples of things where the folks do things that are illegal all the time.

I spoke to an anesthesia group recently, uh, and they were involved in sort of this rate renting thing that wasn't set up in a compliant way. And they were like, "Well, the-- we're doing it with this big [00:16:00] company, and their lawyers approved it, so it must be okay." And I was like, "No." Not okay. Uh, just because law, some lawyers approved it doesn't mean it's okay.

What really is gonna matter is what a judge says in the future. And you can pay a lawyer to, you know, they're gonna figure out some way to wiggle around it and give you some little gray area, but at the end of the day, the only thing that's gonna matter is what a judge says and how a judge rules. And they are not gonna be, uh, these are serious people, right?

And we see this in the broader political environment, judges making unexpected decisions, maybe not aligned with what the general political body would assume. You better have your stuff in order if you get audited and/or a lawyer has to dig through all your things. And this all relates back to these GI docs doing these things.

So it's illegal, it happens, and, uh, we don't participate

All right, Davren. Why is provider discrimination provision not being enforced on commercial payers? Why are private insurers getting away with cutting CRNA reimbursement to eighty-five percent? The [00:17:00] takeaway here, Davren, is this idea of enforcement. Enforcement and pain, okay? So let's take the enforcement first, right?

The, uh, CRNA professional association, the Z-AANA, sued the federal government on this issue to try to get them to enforce the laws on the books, right? And I don't know the details of that case. I do know that part of the discussion was, are you actually experiencing financial pain? Like, in the real world, is this really causing an issue?

Now, again, this is part of the issue with having the government, whether it's state or federal, weigh in on these things that they really don't understand, right? And this is not s- that's not some anti-government position. The, the, the truth is if, you know, the anti-government people are gonna hear, "Oh, he's anti-government," and the, the expertise people, which is generally associated with more on the left or more on big cities, are gonna hear out, you know, he's for expertise.

I, I get confused all the time. I'm a registered independent by, uh, by default, by design The reason they're getting away with it is there's no enforcement mechanism [00:18:00] currently, number one. And number two, the market has adjusted, unfortunately. It's a very messy environment. It's difficult to prove, right, in a highly obvious way to non-anesthesia eyes or non-clinical or non-healthcare eyes that patient access is going down because of this.

Now, if you're deep in the industry, it might be obvious, right? But that's the way our system is set up, we have to prove that to an outside party, and that can be difficult to do, and that's why we're in the situation we're in. But ultimately, people are adjusting, right? I mean, Davin, you know Guide. We're-- We've decided, look, we can't wait for those sorts of things.

We've gotta grow, we've gotta diversify, and we've gotta get into other places to make our negotiating position as strong as possible. And we need to be fairly well-capitalized so that when somebody says they're not gonna pay us for six months, we're gonna be okay, and we're, we're gonna be able to pay our bills without hesitation.

So, and that's what we've done for over ten years. That was not meant to sound like an advertisement, but that is my personal position. All right. Can we get this law enforced without a legislative change? I don't know, Davin. Probably not, [00:19:00] right? It's probably gonna need a statutory change. And just for those listening, statutory authority is generally the most powerful, right?

In a state, especially on healthcare issues. There is this idea of federal supremacy, but on many issues s- the statute is the most powerful thing because statute controls regulation, it controls DOPs, it controls clinical practice if it gets that specific. And it usually doesn't, but it always influences things.

So to answer your question, probably not. Let's move on to clinical site barriers. Is the ANA working on a statement to combat clinical site barriers? I need to stop right there and say I do not speak for the ANA. I'm involved there. I'm a member, an elected member of their board, but I do not speak for the organization itself.

This is only my opinion. What is the ANA doing to stop those clinical site barriers creeping up? From the ASA statement, uh, student nurse anesthetists and CMS regulations. So I am familiar with this document, and I didn't wanna share the name on this one just to be, uh, sensitive, to be smart But effectively, this document says, allowing a student enrolled in a nurse anesthesia graduate [00:20:00] program to administer anesthesia in a hospital setting without the continuous physical presence of a qualified and credentialed anesthesiologist or anesthetist violates federal regulations in most circumstances.

Okay? So let's stop there. And what I will preface this with, Anonymous, is I am aware of this issue, and I'm gonna give you my take. I have not-- I'm not a lawyer. I've not done an ultra deep dive on this. This is my initial take, okay? The AANA and the ASA are trade associations. Their job is to advocate for their members.

Okay? So alwa-- they always have to keep that in mind. Now, ideally, you do that in a smart way, right? With... You advocate for your members. You go to states, you go to regulatory bodies and say, "Hey, we can improve your situation, and our members can add value," right? But another way that trade organizations do this at a general level is by this idea of regulatory capture, right?

So they try to control the regulatory framework to benefit their members backwards, right? Instead of saying, "Hey, our members provide value," we're now just gonna control the rules so we can get [00:21:00] value to our members. So it's kinda backwards in that way. Okay? So I share that so you can look through that paradigm when you're looking at these documents.

But let's dive a little bit deeper into the language Let's focus on the word presence. Now, I don't know if continuous phys-- how continuous physical presence is defined. I do know for TEFRA guidelines, medical direction, right, continuous presence, and there's many statutory and regulatory examples where continual presence is quite broadly defined.

You could-it could generally defined as in the operating room suite or in the building, in something like that. Now, I'm not saying that, you know, SRNAs or nurse anesthesia residents, wh-whatever term you're using, all need to be practicing in this way. I am saying when I see this document, and then I also contrast that with the knowledge that I have that CMS has regularly authorized, uh, CRNAs to supervise SRNAs or NARs at a one-to-two ratio and be billed and be reimbursed for one hundred percent of the service, that stands to reason it-- one can only conclude, [00:22:00] right, that physical presence is not defined as one hundred percent in the room all the time.

Otherwise, it would be principally inconsistent with their other document that they, that came out well over 15 years ago, and that has not changed since that time, authorizing CRNAs to supervise their learners, to use the generic term, at a one-to-two ratio, because invariably you're gonna have to pop back and forth between both rooms.

So I see this document, right? And sometimes, you know, we've spoken during this episode about this idea of prima facie logic, and I see this document, and when you look continuous physical presence, the people who don't, aren't familiar with these legal docu- these legal definitions might think they have to be in the room all the time.

That's the, that's the first look definition. But when you go deeper, you're like, "Okay, what does that really mean? Where is that defined? How, uh, does continuous physical presence mean they can be across the room? Do they have to be directly behind them?" Right? Like, r-ready to reach in at any time. Can they be outside the room?

Can they be down the hallway as long as they can immediately respond to an emergency which would [00:23:00] align to the TEFRA guidelines? What I see in a practical way is that ideological people can use these guidelines to ex- to create the environment that they want, where they have all power and control Right?

And ultimately, if y- what I would say for people who are advocating, and you notice I have not said MDs or CRNAs here, okay? For people who are advocating for a world in which CRNAs, anesthesiologists, everyone can use all of their skills, talents, and abilities to take care of people, which is what we should be doing, okay?

If you live in that world, you see this document, you say, "I wanna comply with this, with CMS," of course, you gotta comply with the law, but let's do it in a way that maximizes safety, that maximizes value for the patient, value for everyone that's involved here. Or you can look at it in a way that says, "Let's do this in a way that makes sure I'm in control."

Right? And I think that's what you're experiencing, and there's only two ways to deal with that in my experience. Number one, it's if you're [00:24:00] really dedicated to that place, you stay, you navigate it, you massage the, the messaging, you, you have the meetings, you do all the stakeholder building, all the credibility building, all that sort of thing.

But if you're working with a truly ideological person, I use that word specifically, like they are rigid in their ideology and they're not practical about it, then you just need to move on, and ultimately your values are not aligned. And that goes back to that, uh, that answer with Kevin, right? Are your values aligned?

Right? And I speak in these, these principled ideas, 'cause the truth is, CRNAs and anesthesiologists at the local level, they come in all shapes and sizes, all different skill level, talent level, all that sort of thing. But when you see this document and you're s- experiencing someone saying, "No, we can't train your SRNAs or your NARs because of this document," what you're really experiencing is a power flex, and you've gotta decide, "Do I wanna navigate that power flex or do I just wanna take my services elsewhere?"

One or the other. That's, that's my take. All right, Bijal. Your question: How is AI changing the future of anesthesia and the business models [00:25:00] of anesthesia? Bijal Charchuveti, hopefully I'm saying that name correctly. Don't wanna be that guy who mispronounces the name. I-- This is changing at a very basic level, Bijal.

This is changing judgment, execution, and accountability. That's going back to that 80/20 rule we talked about earlier in the episode, except it's probably more like 95/5. So let me explain. Most people are gonna use this in some way where they either disconnect mentally, right? They become a more lazy person.

Or they get 60, 70% of a way on an issue, and that takes away from the value proposition of a knowledge professional, whether it's an anesthesiologist or a CRNA or a neurosurgeon or a business owner or whatever, right? That knowledge work is now becoming less hidden because it's generally available, okay?

And that's out in the broad level. Now, what does that mean? That means that people who are a... So all the people at the f- the 5%, they are using these tools as well So the gap between those two things is becoming much larger. So people [00:26:00] have access to this information. They can sometimes do stuff with it, but most people won't, right?

So the people who control the frame that which- in which they interact with these large language models, the framework, the paradigm, the questions that they actually ask. To give you a specific example, I was speaking with our compliance lawyer about this, and she said, "Hey, this is really gonna cut into my hours," right?

Like this, I n- I need to change what I'm doing here. And I said two things. Number one, now you can pick up more clients to diversify your client base, right? Because you can do more work faster. And the other aspect of it is, look, I can get 60, 70% of the way on any given issue just by being a critical thinker or something I'm wondering about, right?

But real expertise, real judgment n- and being accountable for results in an org- organization, I'm not gonna be able to do that. I don't even know the questions to ask. And the people who do are gonna go that much deeper because they're already further ahead than the general population. So the point is, people who have judgment [00:27:00] and expertise and operational ability, they are going to do very well, right?

Because they're gonna use this tool to supercharge themselves, and that's what we're seeing in the business models of anesthesia. All of these professionals are using this to supercharge their abilities. And then the other half of it, right, the 60, 70% of the audience, if they're not using it to supercharge themselves and be a thought partner, effectively you can become more lazy because of this, so you get further behind, right?

And this connects to the larger economic moment we're living through, but that is my answer on what AI is doing to this industry. All right. Keep us abreast of the latest economic market trends regarding anesthesia, salient points and new practice poli- This is a broad one. You know, we're gonna save this for w- in a couple weeks we're gonna do an episode.

We're gonna get everybody back on the show. We're gonna review 2026, and we're gonna make 20-- uh, one episode. In another episode we're gonna make predictions for 2027. So I'm gonna save this one. And the last one is, how do you talk a business-like guide into doing a pre-conference workshop on TEE, [00:28:00] uh, or potentially doing a live stream during a podcast?

And Brian, we should definitely talk. Uh, the podcast is growing. This is a great, this is a good way to end, actually. Uh, there's, I think, a hunger You know, everything comes into balance, right? So, you know, we're all on our phones, and all of a sudden we're hungry for in-person stuff. We're lonely, and we wanna see people.

So you see this surge back into the analog, and we see these conferences growing. And that- we've seen that on anesthesia conferences, but we're seeing it broadly as well. Third spaces are popping back up because we need them, right? And the- and the same way, the conversations on the internet, a lot of them are junk.

And eventually people figure that out, right? So we say, "How do we get credible conversations?" And we scrutinize these people, we can ask them hard questions, and they give us reasonable answers. And if you wanna do that live, we should definitely talk. I think our goal is to highlight those voices on a regular basis and h- to hear from more than just me, although we'll do these office hours from time to time, and probably get some interviews back in 2027 as well.

All right, we just wrapped the second half [00:29:00] of our Office Hours episode. This was super fun. Get to connect a lot of just concepts that people don't connect normally, right? We talked about power, and we talked about politics, and we talked about anesthesia dynamics and anesthesia economics. I really enjoyed it.

Thank you so much for submitting the questions. If you want to reach out to us, many of the people, you can reach out to me directly if you know me. Uh, but if you wanna reach out to the podcast, you can email us. There's many ways, social@abouttherest.com. You can visit our website, abouttherest.com. Uh, you can reach out to me on my socials, on the c- the podcast socials, on the Human content socials as well, if you're interested in starting a podcast.

Great company to work with, Human content Pods. So thank you for everyone, for all the feedback. You're listening, we do try to incorporate that, uh, into the show directly. I would be remiss if I didn't mention YouTube, where I'm getting a lot of views apparently, which is new to me. Uh, I am your host, @joerodrigues.

Our other executive producers are Aron Korney, Rob Goldman, and Shahnti Brooke. Andrew Sims is our editor and engineer. Thank you, Andrew, [00:30:00] for all the work you do, even though we've never met, as well as Omer Ben-Zvi, who I have also not met, but I am also thankful for your work. To learn about all of our disclaimers, ethics, submission verification, licensing, and HIPAA release terms, all those important things, you can reach out to us at production@abouttherest.com.

About the Rest is a Human content production. Have a great week, everyone. Thank you so much for listening.

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