Courts Hand CRNAs a Win

Randy: [00:00:00] I've spent an enormous amount of my career trying to persuade uninformed people to do the right thing, uh, from a, a advocacy perspective at the state and the national level. 

Joe: I thought you were gonna say your, your marriage. 

Randy: Oh,

no. I thought you were gonna say- Uh, yeah, just kidding. Just kidding, Mrs. Moore. We're totally joking. That's not the case for sure. But I, I 

Joe: think- Don't, don't say ... Just keep moving. Just keep moving. 

Randy: Yeah, yeah. Yeah, we'll have to edit that out.

Joe: We're back with what I like to call the number one podcast in the anesthesia world with our very esteemed guests, Tracy Young. Yes, he does look like the Dos Equis man of anesthesia, and he also dispels out wisdom just like that man. Welcome back, Tracy. And Randall Moore, Randy Moore, chief everything officer over at North Star

A great, great thinker. Seriously, we- we've gotten good responses from the podcast so far. Uh, how are you guys? How you guys [00:01:00] doing? 

Tracy: Great. Doing great. Good to be here. Good to see both of you again. 

Joe: Yeah. Yeah, this has been really fun. I think the-- When I've been talking to people about this podcast, and I basically say, "Hey, we, we may do interviews."

But we're probably going to listen to specific people for a regular time to really get to know them because they are very credible voices. People are like, "Oh, yeah, that makes a lot of sense." And then I say, "It's totally my idea." And I'm, I'm just kidding, it's not, and I stole it from someone else, like all good ideas.

Let's get into the docket here. First on the agenda, more insurance, then we'll flip over to kind of the big news with all this, uh, all these lawsuits going on with the Department of Education. This issue has made a lot of rounds on social media. And then Becker's, and then we'll finish up with just ruminations, what we're thinking about this week.

All right, first things first. So this month, Chris Mays, so she is from my hometown. I'm actually going to a fundraiser, uh, for her this coming weekend. Uh, she is [00:02:00] suing, uh, Multiplan and a number of major health insurance companies, and you guys can see on the screen, for those who are not familiar with insurance companies and all the different tactics they use to not pay healthcare professionals.

This is Multiplan, kind of a aggregator of plans. So they set the prices first. They lowball on every code, and codes are more... For us, we effectively use the primary CPT code, but this applies to the whole industry. Surgery centers, for example, will use multiple CPT codes per case. Then they eliminate competition by making sure everyone is paying the same thing.

Now they are using artificial intelligence to use that data and automatically deny things. And, and look, that's what they want, which is a downward spiral, and clinicians are spread out. It's very hard for them to push back. With that, this is the latest news. Um, Tracy, I'm gonna go to you first. Uh, what are, what are your thoughts when you see the [00:03:00] attorney general of a state suing Multiplan?

Tracy: My initial thought is, great, this is needed, right? It's kinda hard to get into the minutia of this, so maybe what I'll do is explain kind of what's happening in a broader sense, and it all started with the No Surprise Act. The No Surprise Act is a really, really well-intentioned piece of legislation from our federal government.

The intent was to remove patients from getting balance billed. And balance billed is, in, in healthcare, we charge these enormous fees for things, not just in anesthesia, but emergency room, ambulances, you name it. We charge these enormous fees, and we never expect to, to collect those large amounts, right?

It's always written down to either a n- in-network allowable or something that's considered UNC, usual and customary. That was the, the terminology and the language prior to the No Surprise Act. Well, with the No Surprise Act, they said- Oh, well, and the, the problem was people were [00:04:00] balance billing patients.

They would bill them for the difference between what the insurance company would pay and this large extreme amount. They were driving patients into bankruptcy. 

Joe: Yeah, thousands of dollars for an endoscopy, something like that. 

Tracy: Yeah. So it was out of control. There were some unscrupulous characters. And, you know, in typical fashion, instead of going after the unscrupulous people, we create a broad sweeping law that says, "Hey, this is now illegal.

You can't do it." And in so doing, the No Surprise Act, one of the unintended consequences w- it, it gave a lot of leverage to the insurance companies Because, uh, previously you could always, you could always use out-of-network as a negotiating tactic to be able to get fair rates from an insurance company.

Now, if you go out-of-network, the payment that you get from these insurance companies is what's called their median, uh, geographic range of the, of the payments for that type of service. It sounds [00:05:00] normal, it sounds fair, but insurance companies are smart. They figured out ways to drive down their median range to levels that is really, really low and below and, and not sustainable for, for many providers.

So that's really what's at crux here in this lawsuit is the manipulation of some of that data to be able to pay below average rates for the services that's provided. I think that's the overall global thing is like, yeah, I'm, I'm glad the attorney general's taken a stance on this and, and pro-- and fighting back, if you will.

Joe: Yeah. Chris Mays is, uh... I like her a lot on a personal basis. I've never spoken to her personally, but her department has weighed in on a number of issues that I feel strongly about, not related to anesthesia, so hopefully I have a good interaction. Randy, what are your thoughts? We're seeing states fight back.

This is kind of a continued theme. What's your, what's your lens over at, in Chicagoland? 

Randy: Yeah, I mean, it's the, um, this is an interesting intersection of how [00:06:00] reimbursement legislation and policy and then technology kind of intersect. So and, and, and so you, you see like there's this, you know, going back to this multi-plan thing that's happening in Arizona, there's this-- they've created an illusion of negotiation and but on the back end, they're, they're sharing data and they are using technology, including AI, uh, to, um, influence negotiations in, in a way that, again, I'm not a lawyer, I'm not a policy maker, but seems kind of gross and wrong and probably illegal.

So, um, you know, I'm, I'm not surprised. You know, it's like anything else in human nature. Decisions are made often without thinking about the second and third order consequences. And, you know, and when that happens, you know, you follow, you know, show me the incentive, I'll show you the outcome. And so there-- now everyone is incentivized to figure out, okay, what are the workarounds?

And understanding that when these policies were made and when these rules were promulgated, no one really [00:07:00] thought really clearly and deeply around, well, what are the unintended consequences? And in the anesthesia space, you see that, you know, this is playing out in a very real way, uh, whi-which I know we're gonna get into later.

But also, you know, with this, you can see this is a just kind of an issue writ large across the healthcare ecosystem of policies are made- Technology's coming to play. Everyone's trying to squeak out their margin, and it is, uh, you know, it's, it's really tough out there. And you know, you see the states in, you know, getting involved in some of these issues because, uh, the federal government often isn't interested or able to, uh, run at them effectively.

Joe: Indeed. As people who are watching online can probably tell, I'm in a hotel 'cause I'm speaking at, uh, a conference here and I'm on the road. So Randy, you know, you guys both mentioned the No Surprises Act. We've talked about private equity a lot on this show too. Some groups, I'm highlighting one here, or I should say the person who made this slide is highlighting one, are trying to push back in kind of this [00:08:00] conglomerated way, and some are pushing very hard and too far, such that now we're seeing the United States government and state governments, specifically state governments, suing insurance companies.

Now we see insurance companies suing these aggregators of claims like Halo MD. Tracy, you mentioned the No Surprises Act. It seems to me there's exploitive processes going all around, and there's not a lot of ethical players in the industry. And obviously I have you guys-- I asked you guys, and graciously you accepted to be on here 'cause I consider you ethical players who are playing at a large level, but largely, and as far as I can tell, are doing it the right way I don't know the details of these cases, but I see this name Halo MD a lot.

I see the No Surprises Act a lot. 

Randy: Well, I mean, just to pull the thread on Tracy's comment, so zoom out and then we can zoom in. So this is a-- all of this, that's this IDR stuff, this, uh, these lawsuits that are [00:09:00] targeting Halo MD and other parties, this is all second and third order consequences of no surprise billing.

So no surprise billing was passed in the eleventh hour of the first Trump administration. The rules were promulgated and the needle of leverage moved really far over to the commercial payers. And Tracy, I think, did a very good job of describing how their behaviors changed after these rules were promulgated.

They have all this leverage and they're driving down rates. Uh, this has had a seismic impact in the anesthesia community, uh, business community, seismic. I mean, there are firms who are really struggling financially because also as these rates were being driven down, as Tracy mentioned, the federal government is squeezing on reimbursement and the cost of running an anesthesia business exploded because of-- mostly because of the supply-demand imbalance of nurse anesthetists and anesthesiologists.

So this is all playing out at about the same time. What happens? Well, these groups are, or some subset of these groups are pretty smart and they understand now there's an independent dispute resolution process. So [00:10:00] if we don't agree or if a group doesn't agree with what the commercial is, uh, insurance provider is paying, then there's a path where you can have baseball style arbitration from a third party and guess what?

They're winning eighty-five to eighty-eight percent of those, uh, cases and the commercials don't like that. So what the commercials are doing is what exactly what you would expect which is they're, they're suing everyone and their mom trying to figure out like how, how can we stop the flow of IDRs and change the, the win rate.

The challenge is like when the federal government predicted like, well, how many independent dispute resolutions will we have a year? They predicted seventeen thousand a year annually. It's run-- the run rate is five million so- Right ... and they're dropping the independent dispute resolution fee from one fifteen to fifteen dollars So now you're going to have a tidal wave.

If 5 million wasn't a tidal wave, you're gonna have a tidal wave of IDRs coming across. The commercials are [00:11:00] panicking, and so they're suing everybody. That's not appear, appears they've lost every lawsuit, uh, or the lawsuits have been, um, dismissed in court, and the courts are telling you, "This is not actually a court matter.

You have to take this up through the regulation process in the federal government." And so we're now in this situation where anyone who has a sophisticated IDR engine has now established their leverage back with the commercials. And the commercials kind of are stuck, uh, because they don't want to change their indep- their, their NSA approach here because they've won...

They're, they were winning a lot of money by driving down rates. And there's a subset of the anesthesia groups who have the IDR engines to, in, in order to recalibrate, but most of the market doesn't. So now we're in this weird kind of situation where The sophisticated, well-resourced groups, anesthesia groups [00:12:00] are, are, are doing much better from a reimbursement perspective.

And the groups that can't afford to do this, uh, or don't have the kind of strategic sophistication are getting screwed. And I, I don't exactly know how this is gonna play out, uh, but I-- my hunch is you're gonna see more s-separation between the winners and losers in anesthesia based on their ability to deploy IDR.

Joe: Yeah. And I think what I'll add to that is, is the capital associate. Like IDR cases, when you-- if you wanna ar-- Well, there's a couple. If-- Arizona's kind of a big deal with this stuff. Um, if you wanna do that, you just have to be okay with not getting paid from that insurance company for six to eight months.

So it's a major hit on cash flow. I think, I think it actually went from a couple hundred dollars, seven or nine hundred dollars down to one fifteen for the ARP. So costs have gone down a little bit, but not anywhere near where it's gonna make up the difference if you go out of network with Blue Cross Blue Shield.

You're gonna get pummeled or the insurance company or the c-- facility's gonna be filling in the gap, and if you wanna go down that road, then the [00:13:00] Blue Cross Blue Shields of the world are just gonna pressure your facilities. So we, we've seen all these things. It's a mess. 

Tracy: So I think Randy did a really good job of, of kind of explaining how it works.

And what, what I think I'll do is I'll maybe zoom out a little bit and think more about it philosophically in a sense of like what is happening in the marketplace here. And what, what Randy described is it's basically, it's like a tennis match where you volley back and you volley back and forth, right?

So every action has a reaction. Um, maybe another analogy is it's a mousetrap, right? The No Surprise Act created a mousetrap, and they created this IDR process, and then the mice got a lot smarter, right, and started manipulating that. And then the IDR process got simpler and cheaper, and you were able to batch more claims together.

So now, with more and more people partaking in the IDR process, it being cheaper and it being easier, the insurance companies are volleying back, right? They're trying to [00:14:00] create a legal mousetrap to make it more difficult. And all we're seeing is this back and forth and back and forth, this seesaw of what's happening in the marketplace.

And what I would challenge is that, that the IDR process is not unethical in itself. I mean, it was purposely put in there to not have too much leverage on the insurance company side And people, it was difficult and the level of sophisticated, sophistication and the level of capital that was required to partake in it was really, really tough.

You said, you know, four to eight months. I would challenge that and say it's, it's typically almost 12 months before this baseball style arbitration gets seen and heard, and you get a verdict of whether or not you win the arbitration process in the in- uh, independent dispute resolution process. And what's happening, and the reason why these insurance companies are going after Halo MD specifically, is what Randy mentioned.

He said that the, the groups that are doing this require a higher degree of [00:15:00] sophistication because when you do an IDR, it takes a lot more documentation, a lot more legal letters, a lot, a lot of things that go into it besides just having to wait for your capital for almost a year. What Halo MD is doing is they're doing that in-house, and they're outsourcing their services to less sophisticated anesthesia groups and companies so that the masses can now participate in it.

That's why the Blue Crosses, et cetera, et cetera, are suing Halo MD because they are the engine that is allowing this to happen at scale And that's what they don't want to continue to happen. So again, mousetrap, the mice get smarter, they keep trying to manipulate and making the mousetrap bigger and better, and it's just a volleying of back and forth and back and forth.

Joe: There is a large, uh, group here in Phoenix, uh, who is gonna be using Halo MD moving forward. I can't say their name, of course, uh, 'cause it's not public. But when I see one company [00:16:00] regularly in the news for all of these lawsuits, my risk appetite goes way down, and I really begin to think about all the people who depend on our company to make sure we're running things in a reasonable way.

Like, that would just cause me a whole lot of heartache. So i- it'll be interesting to see how it plays out. The other thing which occurs to me is once you're on the radar of these things, you're on the radar, right? Like, give me thirty minutes and a lawyer, I'll find something you're doing illegal. 

Tracy: The IDR process is spelled out in the federal government statutes.

Like, this is nothing illegal about it, nothing even inherently wrong about it. You know, if you j- if you're out of network with Blue Cross and Blue Shield, and you drop a bill, and it's like, "Oh, we're only gonna pay you a hundred and fifty dollars for that anesthetic," and you're like, "Well, hold on a second.

That was a three-hour case. We need to get at least five hundred dollars for that anesthetic," there's a process for that, and it's spelled out clearly. There's nothing immoral, ethical, or illegal about it. It's just a process. And it's like-- [00:17:00] And it's a process that is needed to keep things in check, right? So I think just because the insurance companies don't like it doesn't mean it's illegal.

And the courts have thrown out every case they've made against Halo so far, and they've dismissed it without prejudice. In other words, like, they haven't even really gone to court. They file a lawsuit. Halo says, "Hey, we file a motion to dismiss because we think it's a frivolous lawsuit." And so far, like in the state of California, the judge is like- Mm-hmm

"Yeah, this is stupid," thrown out without prejudice, without even going to court. So just to kinda keep that in mind. 

Joe: Tracy, we were talking off mic. You said you don't-- I actually don't listen to a lot of podcasts either, uh, ironically, since now we're all on one. But this is the type of information, this nuanced, thoughtful information connecting th-these different ideas.

This is what makes it so compelling. In California, they are considering, uh, a PE law, and actually this played out in Arizona as well, where the reimbursement conversation [00:18:00] was segmented in who owns the company. If it's PE, we will exclude them from this protection. And this is not my position, right? I, I actually spoke to a, a lobbyist in DC earlier in the week, and this is an active talking point among big segments of the Democratic Party, apparently.

This is what I'm told, right? And then I saw it play out at the state level, and now I'm hearing that it may happen in California as well. So it's like between the private equity stuff and the IDR stuff, it's just like a really interesting moment. At the risk of sounding biased, I would not want to be in a startup.

Like it was hard fifteen years ago when we got going. Like now it's just, it's wild

All right, let's move on to this next topic: national nursing organizations. This headline, for those listening, it was from a few weeks ago. National nursing organizations file nurse-forward lawsuit against the Department of Education over the professional degree designation. ANA was part of this. [00:19:00] Uh, and then we fast-forward just this week.

This is from the AAPA. This lawsuit went forward. The court found the AAPA and the nurse practitioners and the rest of us are kind of riding all together here. The court found the AAPA and the PA Education Association are likely to succeed on the claim that the department's revised definitions is contrary to law, that implementation of the rule would cause irreparable harm, and that the balance of equities and the public interest favor preliminary relief.

So this is good for all these professionals. This ruling comes six days before the rule was scheduled to take effect on July 1st. Here is the AANP, uh, notice. Uh, as I was putting-- ANA may have a notice as well, I'm not certain. But with that, Tracy, you're, you're speaking here, uh, on your role as yourself, right?

We're all part of these different organizations. Uh, but you also hold a role at the AANA as a, uh, the president-elect, so we'll have your comments [00:20:00] first. Uh, what are your thoughts here? 

Tracy: Yeah, these are great, right? Uh, the, the courts are recognizing what we hoped they would recognize, which is the fact that, you know, at advanced practice nursing and, and even PAs as well, the, the education requirements are expensive.

Um, restricting the loan amounts from federal government loan standpoints is actually gonna hurt a lot of these professions potentially going forward. Um, and it's, it's gonna limit the people who potentially will be able to start entering this profession. I'm thinking first-generation college students, those types of things.

They're gonna have a hard time getting private loans to fill in the gap to, to cover some of these costs. So what's happening is, is with the ANA lawsuit, it's actually being heard next week, so we hope to have an injunction as well too. But at this point, it's almost immaterial 'cause this injunction is for all folks, um, both of the ones that have already come forward.

There's also a lawsuit from over twenty-five states seeking this, a similar injunction. So those of you who are not [00:21:00] lawyers, uh, by day, like myself, that is nowhere near a lawyer, right? What, what does this mean? An injunction just prevents the rule from going into effect while the courts hear the actual case.

So the merits of the case that the courts looked at said the merits are strong enough that we're gonna stop it And we're gonna let the court case play out, and there'll be a decision on whether or not these laws are legal or illegal. So all it's done is put a, a little bit of a brake on what's happening.

It doesn't change anything. It is a win, but it is-- it's, it's a win in a battle. It's not a win in the war, if you will. 

Randy: I'm super, you know, curious, uh, how this is gonna play out. I mean, the... You know, if you zoom out, like, the, the track record of s- of suing the federal government's not awesome. So, you know, as it w- as this makes it through the, the, uh, the legal system and then whatever ultimately happens, I, I care about, um, for sure because I do think this is a, a [00:22:00] wrongheaded...

I don't know if it's illegal or legal in terms of how the D- Department of Education has approached this, but it's, it's, it's strategically wrong to, to do this, you know, based on the fact that healthcare is a four point five trillion dollar business. Uh, we've got a baby boomer generation that is, you know, active, you know, is at the point in time where they're gonna be consuming enormous amounts of healthcare.

I mean, healthcare is probably the only recession-proof business sector that we have. 

Joe: It's not COVID-proof, but we are recession-proof, but 

Randy: yes. That's true. That's true. Uh, so, and it requires an immense amount of labor, uh, including advanced practice providers, and, uh, constraining the-this i-in any way is wrongheaded and, and completely, uh...

I, I actually don't understand what the calculus is behind this. I don't know what the Department of Education is trying to solve a-and why they have targeted advanced practice nurses and, and other advanced practice providers. 

Joe: Yeah, what I'll say is this. There's this thing called Bennett hypothesis. I'm showing my nerdiness, right?

Uh, he was, like, a Republican legislator, I think from the '90s. And, [00:23:00] you know, over the past, like, six months, I've been watching the Instagrams and the TikToks, and most young people on Instagram and TikTok are basically like, "Tuition will never go down. Uh, this is horrible that this is happening." And then I've seen, speaking candidly, like, guys my age and older who are basically like, "No, the government shouldn't be funding these things."

And because the government opened up a giant faucet of funding, all the CFOs of all these universities said, "That's easy money, and I'm gonna get that money into my university because my bonus is paid on how many kids are paying tuition." So Bennett's hypothesis was when that's opened- Tuition rose like crazy, right?

And I think fundamentally that is correct. Like, Bennet is correct. When the Department of Education began funding in this way, you know, it-- tuition rose like crazy. And I think, and I am not-- anyone who knows me knows I am not like an... I don't talk about my politics unless it's one-on-one, [00:24:00] right? That's the only way I talk about politics anymore.

But I think that is a sound idea, right? So let me start there. The other point I would add here, all the Democrats here, and there's the Chrissy Massaras of the world, et cetera, they are correct. This is gonna hurt poor people. Like, this is not good if we want a society where people can have upward mobility.

Uh, so that's why I'm supportive of this. I think as a person who is wary of where my tax dollars are spent, don't hear what I'm not saying CRNAs are a very good bet. That's what I think is lost on this conversation, all these policymakers. It's like, guys, we pass 95% of the time through our boards eventually.

Not everybody passes on the first time. We should be investing in these kids because we're gonna get a lot of tax money from them in the future. So I think it's a little more-- N- like, nobody's talking about that stuff, right? Nobody's talking about Bennett's hypothesis on Instagram. They're, you know, taking pictures of themselves in bathing suits and things like that.

Um, but I'm very supportive of this, the general effort. I am supportive of capping it, but I'm [00:25:00] supportive of CRNAs especially, people who are highly reliable. If the United States government's gonna invest in them, let's make sure the taxpayer gets their money back. 

Randy: Yeah, I mean, there's also, like, if you're gonna s-support or subsidize education, I think it's fine to filter it through a lens of what, what advanced practice or advanced degrees bring terms to the value to the society writ large.

Right? 

Joe: So- Yeah, 

Randy: definitely 

Joe: return on investment, right? 

Randy: Yeah. So, like, this, this, this, you know, take a machete to this and, and then you c- you know, potentially. I think some of-- And I understand why we do it. I think there's a little bit of catastrophization that's going on, which we all do when we're advocating for a specific direction one way or another.

But I think, you know, if you, if you were looking at this through the lens of what, what are the roles that bring the most value, that are most needed in society, I'm, I'm struggling to understand why you would go and, and try to constrain that in the way that was done. And I also think there's a bit of this is- The way it was 

Joe: done is the key.

Randy: Yes. Right. 

Joe: It- The way it was done, [00:26:00] right? If it had been smarter, it, it's not a bad thing, I think, to, to end the open faucet. But Tracy, you're smiling. What, what are your thoughts? 

Tracy: No, I mean, you're, you're saying exactly what I'm thinking, right? And, and exactly what I've said earlier about the No Surprise Act.

It-- a well-intentioned law, right? The goal is to bring down the cost of higher education. It's a good intention. That's what we want. I mean, I, I think as a society, I think that's probably what everyone wants. We wanna make higher education more accessible for people. Where we tend to go wrong legislatively, especially in DC and even in the states at times, is we paint with a broad brush.

We're not very tactical in how we look at it. Uh, it doesn't take a whole lot of, um- of in-depth research to start to realize that CRNAs, they can't work during their three years of education. So one, yet you need at least enough money to be able to live off of, and two, the cost to educate CRNAs is [00:27:00] not the same as it is for other professionals.

It's, it's expensive, right? But we s- we, we really, we paint with a broad brush, and then we make these rules, and we wonder why people get all upset about it, or we pass these laws and we wonder why people get upset about it. Um, ideally, there's, there's gonna be some remedies here where we can start getting a little more specific on what's professional and what's not professional.

One thing that was really, really concerning, and, and it actually made a lot of sense, even though it, it, it infuriated me, during the hearing, the Department of Education, the head of the Department of Education was brought in front of Congress. Some of our allies in Congress, our CRNA allies, really peppered her with some really difficult questions.

And one of her responses, I was like, "Man, she's, she's right," when she said, "To be considered a professional, our view at the Department of Education is that you should not have to be supervised by another [00:28:00] professional." And CRNAs have supervision language in federal statutes. Therefore, are they truly professionals?

She didn't say it quite that eloquently if you go back and watch the video, but that was the gist of her argument. Mm-hmm. And it infuriated me because one, it was logical, and two, it, it needs to be corrected because of the, the old antiquated language that exists in Medicare Part A requiring physician supervision, not anesthesiologist supervision, but physician supervision.

And 90% of the times when CRNAs operate in a much more autonomous and independent practice, that supervision's coming from a surgeon that doesn't know the drugs we give, can't spell them, can't pronounce them, doesn't know the- 

Joe: Come on. Yeah ... 

Tracy: doesn't know the mechanism of actions or whatever. So it's this antiquated, uh, situation that is leading, that is causing us further problems down the road, which is where we are today.

And we need to get it fixed. 

Joe: My new favorite phrase is, [00:29:00] "Don't hear what I'm not saying Because when I say the United States government should have absolutely nothing to do with anesthesia rules and regulations, don't hear what I'm not saying. I, I'm not like some-- I'm not gonna put on the horns and storm the capital or anything crazy like that.

Tracy: States determine scope of practice. States- Yeah ... determine what CRNAs can or can't do. So why do you create a statutes- a statutory law, right? Or promulgate a rule at the federal level that says, "Hey, we're gonna require supervision, but we're gonna let states opt out of it"? Yeah. Just remain silent on it and let states decide anyway, right?

It's like- Say nothing ... it's flipping the paradigm. Yeah- Um- Say nothing. 

Joe: A- and better yet, I, I'd say and, and Randy, if, if I wanna get your thoughts here as well, or we can move on. But increasingly, I'm of the mind that anesthesiologists, CRNAs, surgeons, administrators locally are infinitely more prepared to make model decisions, competency decisions.

Tracy's good at X, Randy's good at Y, [00:30:00] than anyone at the state government. And that last go-round in, uh, at the Arizona-- with the reimbursement bill last year convinced me of that. 'Cause it's like we're teaching them the t- the industry, and then they're trying to regulate it back. 

Randy: I've spent an enormous amount of my career trying to persuade uninformed people to do the right thing, uh, from a, a advocacy perspective at the state and the national level.

Joe: I thought you, I thought you were gonna say your, your marriage. Oh, no. I thought you were gonna say- 

Randy: Uh, yeah. 

Joe: Just kidding. Just kidding, Mrs. Moore. We're totally joking. 

Randy: No, no, that's, that's not the case for sure. But I, I think- 

Joe: Don't, don't-- Just keep moving. Just keep moving. 

Randy: Yeah, yeah. Yeah, we'll have to edit that out.

It's exhausting and it's grueling work and, and there's different perspectives of to what degree should the federal government be involved, and I, I, I may have a slightly different opinion on, on that, maybe a slightly more nuanced opinion. But this is why organizations like the AANA exist, right? This is-- The AANA is, yes, it's a membership organization, but if you like-- This, this is a, you know, like a advocacy-first [00:31:00] organization, and I mean that in a good way.

I mean, it's not a dig. And so, uh, and I would feel this, you know, if I was an anesthesiologist, I'd hopefully feel the same thing about ASA, and if I was a PA or whatever they call each other today, I would feel the same thing about, you know, their organization. 

Joe: Yeah, definitely. 

Randy: And so I think this is a, you know, for those of us who are-- for those of you who are listening in, I think this is like, this is why your national organization and your state organizations require support because they're, they're on the front lines of, of dealing with this stuff.

And, and, and does it-- like, it doesn't have to be, you know, when you look at this legislation that's passed and these rules and how they're, how they're interpreted and implemented, you know, it is-- it, it can be really frustrating because common sense is often lacking when, when, when this is done, and it's done based on what's the lowest common denominator.

Uh, um- Indeed ... and that's really hard to navigate through. 

Joe: I want to, just to, to kind of wrap up the economic fundamentals of this part of the conversation. Uh, as I was [00:32:00] watching this go on on Instagram and TikTok, I'm a mostly an observer there, the re- constant refrain was tuition never goes down. Tuition never goes down, right?

And That's true in terms of outcome. It's not true because it's a law, right? It's not like a law, the, you know, the free enterprise system. So I, and I wanna highlight a few headlines for our listeners, right? This is from May 12th in The Wall Street Journal. The headline, uh, there on the screen is, "There is a fire sale on MBAs.

With m- applications down, more businesses are offering discounts on specialized degrees." Uh, then a few days later in the op-eds, uh, "Why colleges are slashing MBA prices." And this is a, a notable quote, uh, which was, "The MBA always, was always two products sold as one: a signal and a skill upgrade. AI just made the skill upgrade free," right?

That's probably an overstatement, but just for the sake of discussion. So the schools that sold only the skill are in a fire sale, and the schools that sold the signal have more pricing [00:33:00] power than ever. So the Harvards, Stanfords, Wharton, from my original hometown, uh, are all keeping their prices exactly where they are.

But the rest of them, Purdue, uh, school-- University of California Irvine, John Hopkins, they are all giving kinda massive discounts. I think this is really interesting only because the demand isn't there. But for CRNAs, and really all anesthesia professionals of, of whatever sort, like, the demand is through the roof.

Any other comments so as-- before we move on here, gentlemen, on the, uh, on the MBA fire sale? 

Tracy: Can I get a refund for mine? Um, uh- In, in 2008 it was 57,000 bucks. Uh, that was real dollars. Um- 

Joe: Yeah ... 

Tracy: so, um, maybe I could reach out to George Washington University, see if like, you know, "Hey, can I get a little bit of a refund now that it's getting cheaper?"

Yeah. But no, that, that was my only short quip. Sorry, Randy, go ahead. 

Randy: Yeah, I mean, I, again, I, I, I got my MBA from, uh, Southern Illinois University, which is, um, often considered the Harvard of, uh, southern Illinois, so ... And, uh, and the taxpayers paid for that, thank you- Oh ... because of, uh, my [00:34:00] military, uh, service. So I, I think this is a, it's an ROI problem, right?

So if there is a perception by employers and employees that the ROI for $120,000 MBA from a state school is not there, I tend to see this as a, as a natural and healthy culling of the herd. And so, uh, and I, I think it's okay. And, and, you know, I, you know, this is probably a little bit outside of the lane of what you wanted to discuss.

Like, I hire people, and I promote people in my role. I happen to have an MBA. I could care less if one of my candidates have an MBA. Uh, and actually, I don't really care about any of their credentials. And I think, you know, as we get more focused as employers, uh, get more focused on what really makes a good leader, what really makes a good manager, is the MBA part of the equation or not?

I tend to be aggressively ambivalent about that, and I tend to be more focused on, all right, well, what is, what are their str- decision-making skills? What are their communication [00:35:00] skills? Are they, you know, are they, um, are they good at analysis? Are they able to, you know, do the trade-off between short-term and long-term decisions?

None of that, in my opinion, uh, is, is kind of core to what you would see in an MBA curriculum. So I'm not anti-MBA, I have one, but I also am pretty skeptical that, you know, people are-- they're giving all this gravitas to a degree that doesn't really, in my opinion, change leadership or management outcomes. 

Tracy: I would agree with that, Randy.

And I, I said I had one small quip earlier, and I'll add a couple of more. Right? No, it's great. But when, when we, when we think about who we hire in the leadership positions, aptitude, ability, um, emotional intelligence ranks really high on leadership scale. But when we think from a larger picture about the value of the MBA going down, tuition going down, was that a government intervention?

It was not. It was a marketplace intervention, right? Mm-hmm. So the [00:36:00] demand is still there for, for other professions. The cost is still there. And, and it brings it-- it brings us back to philosophically, is a government painting with broad brushes trying to do well-intentioned things the best avenue, or is there marketplace solutions that are often the be- the better avenue?

And I, I would, I would say it's the latter, um, from my philosophical standpoint, the majority of the time. 

Joe: Yeah. You know, generally, I think-- And by the way, Randy, I-- and this is a really great, um, seg- segment, so to speak, about the things which really make anesthesia firms run are the same things which make data firms, law firms, accounting firms run, right?

It's the leadership aspect. Uh, you know, when I think about the role of government, which is something I, 'cause I'm a nerd, I think about more often than I should, the government should do things that only it can do well. Long-term investments in health. No one's gonna ever turn a profit on long-term medical research.

It's just not gonna happen. So we should use our collective efforts to invest in those things because it creates tremendous [00:37:00] societal value, right? And, like, I think that's where Democrats get it right in terms of what are things that we really value. A broadly educated populace, very healthy people, educated professionals which serve our citizens well.

But often, uh, it is a, for smaller problems, so to speak, it's a market-based solution that works more effectively. And that's just-- it's not an ideological position. It's just an observation. All right. Let's go back to specific anesthesia points. Becker's runs this column every few months, and there is a couple quotes which I real- which I thought were worth discussing here.

For those listening, the headline is The Future of the Anesthesiologist-CRNA Relationship. This was also run in the ASA Monitor. Obviously, ASA Monitor was not, uh, endorsing these statements, but they made highlight of the article itself. So let me read a few quotes, then we'll get some reactions. This is from, I'm gonna try to say this correct, Nanette, Nanette Schwan, [00:38:00] MD, professor and vice chair of research at Lehigh Valley Network, uh, close to my original home state.

"Every provider who can deliver safe anesthetic care should be doing so at the top of their license." That sentence in and of itself is probably controversial. Uh, "The staffing model should follow the patient's risk profile, not the profession's political interests. We don't have enough people to argue about who gets to do the work.

We need everyone working." And I would say, well said, Dr. Schwan. Let me go to the next one. Michael Nurra, MD, PhD, professor and co-chair anesthesiology, c- anesthesiology, Cedars-Sinai Medical Center, Los Angeles, not a small institution. "In view of the shortage of anesthesia caregivers, our delivery systems and national societies need to evolve and develop models that match patient care to anesthesia caregiver skills.

Doing so will require less focus on caregiver training pathways and more focus on how competently individuals can provide care for a specific procedure." One more for conversation. L- Leonard Lind, MD, professor emeritus [00:39:00] anesthesiology, University of Cincinnati College of Medicine. "The relationship must evolve.

However, CRNAs appear to be moving towards totally independent practice. I think most are well-trained and can clearly handle most cases. For large traumas, transplants, and cardiothoracic, I am not sure." So we'll leave it there. Uh, Randy, we'll come to you first. Thoughts and reactions about these notable individuals giving these quotes.

Randy: The thing to understand is my experience is like the vast majority of anesthesiologists and CRNAs uh, work together very well when they work together in an anesthesia care team. They're almost always completely aligned on what's the r- what's the right thing for the patient. And rarely is there any discussion of anesthesia politics in the operating room or, or the break room.

Where I think sometimes there's a perception that there's a huge divide is, is because there's, you know, think about this as a bell curve distribution. So, uh, on, you know, on one end, you [00:40:00] know, there, you know, there are folks who, who, who are, you know, aggressively don't care about any of this stuff. The, the hump of the bell curve are folks who are generally aligned on what things should look like.

And then on the far right end are, you know, I would call kind of the militant folks who are very anti-CRNA or very anti-physician. The weird thing is, you know, in the discourse that tends to occur within the associations or on social media, it's the militant group of- 

Joe: Yeah, loudest voice is always heard.

Randy: Yeah, those are the voices that, that get heard. And so I think, again, this goes a little bit towards what we were talking before. Part of this is the market is pushing practice models in this direction, right? So when I say this direction, I mean focusing on, hey, how do I, as an employer, recruit and retain CRNAs?

How do I run my model as efficiently as possible? Often that is creating good culture, good leadership, and strong and attractive scope of practice. It's good for business, it's good for patient outcomes, [00:41:00] uh, and you're seeing More and more of the employers, and that's whether that's hospitals, health systems, or ASCs, move in that direction.

And I think as the physician anesthesiologist community continues to, I think, move in this direction and understand that CRNAs are not out there to replace them, and there's more than enough work, uh, in, out there for all anesthesia providers, I think you're seeing, uh, less and less of this territorial stuff play out.

Uh, does it still play out? Of course. I mean, we-- I mean, we, we, we see this in, in facilities all across the country, but I think m-increasingly, we're seeing a moderation of the-- this, this and, and from a political perspective. 

Tracy: I couldn't agree more, Randy. I-- But I mean, let's, let's think about the courage it took for Dr.

Swan Law-Lawson and Dr. Lynn to, to put that out there in print, right? 'Cause the militant side's gonna really push back against them, and they're gonna-- it's gonna push back pretty hard against them. I mean, I've seen it personally, but what I-- I think I would add a couple of things. You know, one is we [00:42:00] function in medicine with this old hierarchical pyramid where everything is led from the top.

You could maybe even call it patriarchal pyramid, right? Because it's, it's often the physician at the top, and then they dominate and control everything that happens below them. And when they push that model, the patient is rarely mentioned. It's always mentioned, you know- Hmm ... physician-led care, physician-led care.

And what we see the market moving to, and I don't know if they describe it this way, but what we see happening is we're moving into this, this model of collaboration. So it's like a circle with the patient at the center of the circle. And healthcare has gotten so specialized that there are tons of specialists around the patient, and they're collaborating and working together in ways to benefit the patient.

So it's less of this pyramidal, pyramidical, uh, is that a word? Uh, but this hierarchical pyramid of physician at the top controlling and dominating everything. And we're moving to this [00:43:00] more collaborative model with the patient at the center, and that's where we need to be for healthcare, uh, especially as we get more and more specialized.

We need those specialties talking and communicating together. Things like, you know advanced practice nurses who specialized in wound care for patients, and then, you know, s- anesthesia. What are the role we play in the entire episode of care? You know, people don't talk about it a lot, but an episode of care, we're a very, very minor portion of the entire episode of care.

But the decisions we make preoperatively, intraoperatively, and postoperatively can move the needle in large ways on average length of stay, readmit rates, certain different complications that patients can have. And we need to look at our roles in a larger, uh, format and look at the entire episode of care for the value that we bring to the entire, you know, population that we serve and the episode of care that [00:44:00] we serve.

And when we do that, we're changing this dynamic from this pyramid of physician-led and everyone is valued, everyone contributes. And when we do that, a lot of things happen. One, we come-- we become more efficient as a healthcare system. We get better outcomes. And then at, at the individual level, level, we get cultures where we can recruit to and people wanna be involved in.

Um, I recently wrote a Substack, not, not gonna, like, promote it here, but the whole idea was- 

Joe: Promote it. Promote it. No, the whole- Tracey Young and Randall are both on Substack, and you can follow them anytime. But no, you guys, great thoughts. Please continue. 

Tracy: In twenty-six years of doing anesthesia, there are hospitals that are still struggling to staff their anesthesia department throughout all twenty-six years.

They have the same ads out, and when you hear that hospital name or that community name, you're like, "Oh, yeah, they've never-- They've always struggled," right? Whether even in times where the supply and demand where we were over-supplied in CRNAs, those were still hot jobs. [00:45:00] They were still paying more than everywhere else.

They still had six open CRNA spots. And now when we have a-- we don't have enough supply, they're still struggling as well too. So it got me thinking, why is that? Well, it's leadership, it's culture, it's all the things that- Mm-hmm ... I went into, into the Substack into a little more detail, but really it's autonomy, it's respect, and it's this collaborative mindset.

And, you know, so tying it all together, those, those physicians, you know, Dr. Schwab and Lawson and Lynn, they get it. They understand it in, in a larger global context that it's, it's gonna meet the needs of society, it's gonna be more efficient, uh, it's gonna help this, uh, supply crunch that we have when everyone is practicing to their full scope.

Uh, it's just-- It, it's, it's refreshing to see that because we often hear only the militant voices. So it was really nice to see those headlines. 

Joe: You know, when I see these, these quotes, you're, you're correct. I think you're both correct in that, you know, generally we see this push, right? I think what [00:46:00] our profession has made a mistake is saying things like, not profession broadly, but individuals, we're the same.

CRNAs and anesthesiologists are the same. And everybody on here is an advocate in some way for their profession, but I'm very uncomfortable with that statement because I am not a physician. We are not physicians, right? I, I don't have that card, so to speak. And I think we should be speaking about things in terms of overlap, because what that does is it creates a degree of psychological safety For both parties.

And anesthesiologists, and I think these anesthesiologists know it, anesthesiologists are mission-critical to, I think, all of our organizations. There's no doubt about it. These are people who add immense value. They have added immense value to my life, right? Some of these people have inspired me to, to do what I've done because they're just outstanding people who wanna see other people make a big difference.

But their value is not based on [00:47:00] restricting others, right? I, I think that's, like, so much of the ASA value proposition is we are critical for safe care, and these other people will harm you, right? I mean, that's effectively the message that they've been saying, and I, I would advise them humbly, uh, they don't need to listen to me at all, but I would say is the value of an anesthesiologist is not in restricting others.

It's providing their expertise and supporting and complementing and increasing the competencies of everyone around them because they have unique knowledge. That's a very-- They have an unlimited medical license, right? I mean, they, they literally can do anything from a state law point of view. And the only point that I often see missed that I would add here is that in our conversations, in our community, the anesthesia community on the whole, everyone seems to confuse the regulatory world versus the practice world.

A regulatory debate about what rules should be out there is very different than what Randy was talking about earlier. They're two totally separate things, right? Like, [00:48:00] practice-wise, most people work it out. Teams get designed locally, and they kind of adjust to whatever they need regardless of the regulatory environment.

But that's a very different debate than what is effectively regulatory capture in many states, right? The, you know, Las Vegas actually is a great example of regulatory capture. One industry group going to the government, creating all the rules to favor them. They've captured the government. So from my point, I l- I love these quotes, and it's awesome.

I want to add on to that conversation with those points. 

Randy: Yeah, the thing that, you know, strikes, 'cause I, I tend to kind of focus a lot of my time and attention on outcomes. Like, what are the outcomes that we're trying to drive at, at a site level, at a market level, or at an enterprise level? And when I see sites that are doing really well, uh, and the vast majority of our sites are care team, we have some independent CRNA sites for sure, um, but the vast majority of what we do is in, you know, an-anesthesia care team.

When I see sites 

Joe: that are do- Care team, like medical direction care team? 

Randy: Uh, or, or, you know, it doesn't [00:49:00] necessarily have to be medical direction, but there, there are anesthesiologists and CRNAs working together in some capacity. Okay. Okay. Sometimes that's care t- that's, sometimes it's medically directed, sometimes it's QZ, sometimes it's a combination, but there's, there's- Okay

different permutations that we use depending on the sites and all of that. What I see happening invariably, these are sites that are like, we're 95% staffed on CRNAs and physicians. Uh, the administrators are really happy. Um, it's just easy to recruit when there is attrition And, uh, everybody know-- uh, in, in some cases, there's a lot-- there's a line of folks who wanna work there when an, uh, a vacancy occurs.

The thing that I always see there is, A, there is a good physician leader, and there's a good CRNA leader, and they're working together. And they see themselves as a team. And the physicians care about what CRNAs want, and the CRNAs care about what's happening to the physicians. That's, that's always the case.

The other thing is the physicians are actively promoting CRNA competency and [00:50:00] career growth. And so, you know, there is, you know, the-- there is no, "You can't do this because, you know, you, you, you're a CRNA." Right. There's like, "Okay, you're, you're interested in, in, in, in learning how to do this block or do these kinds of cases."

The s- the anesthesiologists are actively promoting that. And the reason why that is, is because the, those anesthesiologists are not operating through a lens of fear They are not concerned they're gonna be replaced. And I think a lot of what's driving this antagonism and this resistance and this is, you know, us versus them, is there's a unstated replacement theory that is- Yes

that's, that is permeating, which is, you know, obviously bullshit. 

Joe: It's not 

Randy: gonna 

Joe: happen. 

Randy: I mean, it's, it's- It's just not gonna- It's just not gonna happen ... it 

Joe: can't. 

Randy: Yeah. It, 

Joe: it, uh- The numbers aren't there. It never happened. 

Randy: And when you create the kind of psychological safety at a site where everyone says, like, "We're all valuable players of the team, it doesn't matter who does this block, it doesn't matter who puts this line in, as long as the patient gets a good outcome," [00:51:00] then all of a sudden it becomes really easy to recruit.

And all of a sudden, it becomes really easy to retain. And all of a sudden, the financial profile of that site changes i- in a very positive way for the client and for the group. 

Joe: Well said. All right. Well, then we are gonna move to our last section, which is ruminations. And one thing that just continually is moving around in my mind is this idea that bad information is everywhere, and I think we see this in American society in general, where we can no longer even...

We can't have a debate about policy, about anything tough in this country, about abortion or any- anything else that's controversial, right? Because we can't even agree on the facts. Okay. So bad infor-- And I'm not trying to associate Becker's with those, those debates at all, but I am saying bad information is everywhere, right?

So this just came into my inbox this morning. Becker's ASC Review states ranked by CNAs by per capita. And I, I intentionally did not include the author, [00:52:00] 'cause I don't wanna cause controversy in that way. But I do wanna highlight that just googling things, like, people need to google competently. You need to get var-- It's old school.

You need to get various sources. If you go to Becker's and say, "How many CNAs, you know, are in the state of Arizona?" It will tell you it's forty-first per capita. There's three hundred and ten CNAs. So immediately thereafter, you guys can see it on the screen, I went to the Board of Nursing, 'cause I know this to be fundamentally untrue.

Certified registered nursing assistant licenses in Arizona are seventeen hundred now, and that has just skyrocketed since I entered the state in two thousand and twelve. So this is in my head constantly. You know, I, I thought about reaching out to... Y- you, you know, you can only correct so much, but that's what's on my mind.

I, I try to pick and choose my battles as far as what I correct. Uh, but I think it's incumbent upon leaders in every organization, right, to try to get their people or their audience, since we live in the age of influencers, the best information, the most full [00:53:00] characterization as possible. So that, that's what's on my mind this week and, and, uh, Tracy, we'll flip it over to you.

Tracy: Yeah. I really didn't have anything prepared, um, but, but I could tell you things that I've been thinking about, and I, I'll use one word: division I've been thinking about division, whether on a grand scale and on a small scale as well too. So if we look at it on a grand scale, you know, the United States is, is divided.

Um, there's, there's political divides, there's religious divides. Like, it doesn't matter what the issue is, there's gonna be a divide on it, and it's gonna go pretty much along party lines. And a perfect example of that is just, um, this week, we, we talked a lot about the student loan issue, and we talked a lot about the, um, the legal cases that are going forward.

Well, there was actually a legislative fix. It was proposed, it went through the insurance committee, made it out of the committee, and went to a full vote. And the full vote lost just this week [00:54:00] forty-three to fifty-two, I believe, a hundred percent along party lines. And I can tell you, in speaking to some of these Republicans, they-- there are a lot that are sympathetic to the cause about nursing should be considered a profession and they should get higher loan caps.

But guess how they voted? They voted along party lines. It's a sign of division. It's a sign of losing our ability to think critically and logically and make good decisions as individuals because we feel like we, we're part of a herd over here or we're part of a herd over here. And then we see it on a small micro level as well too within the ANA.

There's division within the ANA. Randy talked about the bell-shaped curve. We have a bell-shaped curve where there's, there's a certain percentage on this side super, super engaged, and then there's a lot that are moderately to almost apathetically engaged. And then also on both sides of the bell-shaped curve, we have a bunch of loud individuals that disagree with everything of the other [00:55:00] ha-- the other small portion of the bell-shaped curve.

And what that does is it creates an environment where tough decisions are hard to make Because of the loud voices, uh, that you- you're not gonna be able to make everyone happy. And I, I think over the years it's created a, an environment where we start-- we turn all of our arrows in when a decision is made from an organizational standpoint, and we start firing in instead of turning and firing out.

And it's because of that division. It's not a big tent mentality- Hmm ... and there's not a willingness to try new things and potentially failing, right? You grow through failure. And as an organization, we've become so, uh, scared of failure that we haven't really been moving the ball forward as much as we possibly could.

And, and my challenge to, to ANA members is, let's think about a big tent. Let's fire arrows outward. And whenever you're unhappy with something [00:56:00] with the ANA, reach out, ask questions, understand the rationale. And we could do a better job of maybe being more transparent and getting information out. But I, I guess my-- I've been talking now for five minutes when I said I had one word, division, right?

It's division across society. It's division across organizations. And how do we start, um, becoming more united? You know, one, as a country, that- that's a pretty lofty goal. Uh, but, uh- We can do it ... but on a smaller level- We can do it ... as an association. So anyway, that- that's my ruminations of late, and it really stemmed from that vote and the disappointment of, of not one person across party lines to do what maybe they felt really was right or needed to be done.

Joe: The-- I'm gonna swing it back to you here, Randy. The, the prior thinking was all we need, I think this was Joe Manchin out of West Virginia that recently used this quote, which was, "All we need is three good men." Right? We only need three or four people to cross lines, right? And it's this, uh, this aspirational idea of no matter how [00:57:00] divided we are, we just need a few good men.

And that as a society, and we see it play out in our communities, it's like we're, we're... The cycle needs to continue to pass. I'm a big Ray Dalio fan, for those who are interested, right? Wrote this book, Principles for Dealing With a Changing World Order, talks about these cycles. And we need to get through this cycle where it's, "I need to win no matter what."

And we need to get back to a world where, and this is a great segue to Randy, 'cause he's the first person I ever heard say this was, which is rather than my side, it's what's the problem we're trying to solve? Are we trying to solve for a strong association, right? A well-educated populace, making sure people have access to care.

There's lots of ways to solve that. It can be a little right, it can be a little left, but the bottom line is we solve it, right? Uh, so with that said, Randy, your, your thoughts this week. What, what's going on in that, uh, that great big head of yours? And I mean that in the most complimentary way possible. 

Randy: So I mean, some of this I, I think is related, uh, weirdly, is I, I, I spend a lot of time thinking [00:58:00] about incentives.

So thinking about this, you know, incentives versus intentions. And as I, I look at my teams, uh, my organization, my personal life, my family, some of the things we ju- we were just talking about here, it's often when I'm, uh, concerned or upset about where things are going, it's rarely there's a character issue, uh, with the team, with the leader, or with the organization.

There's a design problem, and that design problem is the, the wrong incentives are being rewarded. And so if we, you know, the, what's the Charlie Munger quote? "You show me the incentive, I'll show you the outcome." And I'm sp- I spend an enormous amount of my time trying to design incentives or to eliminate incentives that are problematic.

And you think about whether, you know, there is a million examples of that, you know, in our professional lives and personal lives. You know, you know, even if you look at like the anesthesia business world, you're seeing a lot of companies that are not doing well because the incentives are wrong, [00:59:00] right? And so though the, the current incentive structure, uh, you know, and this is not me beating up on private equity or, or firms that don't have private equity, but like if you're short-term oriented, it's really difficult to be successful.

The problem is the incentives are, are focused on short-term outcomes and- Mm-hmm ... and because it's- Quarterly, quarterly 

Joe: profits, right? 

Randy: Quarterly returns. Quarterly profits, yearly profits, uh- Monthly ... how much did you grow this quarter? What's your EBITDA? Uh, all of those like are important outcomes to be clear, but if they come to the detriment of what the long-term goal is, uh, uh, you know, sustainable, uh, growth, solving important problems for communities around their anesthesia needs, that, that, you know, that is, you know- an area where it's really hard to inflect, but it's incredibly important.

And so as I-- if I look at leaders that aren't performing well, if I look at sites that aren't doing well, I see t- you know, teams that are demonstrating problematic issues, I almost always assume it's an incentive problem, uh, [01:00:00] and figure out, like, how do we create a set of incentives to change the behaviors and the outcomes?

Joe: Any final words from you, Tracy? 

Tracy: Nope. Really enjoyed the conversation today. Um, I, I feel like we got under the surface of some of these things where we see the headlines, and I feel like we were able to really get underneath the headlines and talk about some of the issues in more detail today, which was great.

Joe: I love talking to you guys. Like, this is enjoyable for me, right? And this is the difference between the previous iteration. I am learning, actively learning through the, through the conversation. So thank you very much, gentlemen. We're gonna leave it right there for this week. Thank you. And we'll, we'll take it from there.

Everybody, thank you so much. All right, everybody, hope that was an enjoyable episode. Tracy and Randy both had to run, so I'm doing this closing on my own. I gotta go get ready for this lecture that I'm about to give, uh, at the ASC conference. So thank you for-- We got really, really good feedback on the first two episodes.

People are really enjoying this, uh, this structure which is driving this outcome. Which if you're listening to the show, you can empathize with that statement in terms of what they're hearing from these people, these experts, these great, great [01:01:00] thinkers. I'm enjoying the conversation as well. The full episodes are uploaded every other week on YouTube at About the Rest Pod.

I am your host, Joe Rodriguez. Randy Moore and Tracy Young were gracious enough to be on the show today. Our executive producers are myself, Aron Korney, Rob Goldman, and Shahnti Brooke. The editor and engineer which make these shows sound great, Jason Portizo. And our music is by Omer Ben-Zvi. To learn more about About the Rest's program and disclaimer and ethics policy, submission verification, and licensing terms, HIPAA release terms, you can go to abouttherest.com or reach us-- reach out to us at production@abouttherest.com with any question, concerns, or anything fun you wanna hear about.

About the Rest is a Human content production. Thank you so much to the Human content team, which is making this possible. Immensely, immensely helpful. So healthcare or other related industries, if you're looking for podcast partners​[01:02:00]