UnitedHealthcare $5.5B Profit, Another State Opts Out, and Why MIPS Is Dead

Randy: [00:00:00] Joe, have you ever attempted to talk to a patient about smoking abstinence? 

Joe: No. I actually talked to an anesthesiologist who was like, he's very earnest and, uh, like very, he's almost a voice guy. He's like, "You know, it's a, it's an important question to ask, and now I ask it in my preoperative interviews."

And I was like, "I'm a bad person. I never, ever do that." I 

Randy: mean, in, in, in the history of humankind, has anyone ever been talked out of smoking right before they have a procedure? Like, "Oh, shit, I hadn't really thought about that until the CRNA or anesthesiologist mentioned it. Maybe I should stop smoking."

Joe: Welcome back to the number one podcast in anesthesia world, at least the one that talks about business and policy and performance issues. Randy Moore and Gerry Keeling, hi. How you guys doing? It's great to see you guys. How you doing today, 

Gary: Tim? 

Joe: Hey there. Yeah. Great. Hey, Randy. Every, every day is a great day, man.

Every day is a great day. It's not the [00:01:00] Middle Ages. I don't live in the Middle East. Gerry, you're looking good, man. Did you just get done with a client call? 

Gary: I did. I, I had a call this morning, and you know, I'm a CPA by trade, so you know, we, we kind of are magnetic towards, uh, ties. I went right up against it, so I figured you wouldn't mind me trying to impress you today wearing a tie.

Joe: Of course not. Can you tell us who the client was? Can you... Do you wanna share? 

Gary: Oh, I'm not allowed to do that. 

Joe: Not yet? Not until you sign them? 

Gary: Exactly. 

Joe: Okay. Exactly right. Well, I'm your, I'm like your number one... I'm the best former client you've ever had. 

Gary: Uh, 

Joe: that's good. You know, I just, I, uh, just, you know, I keep ringing your, your, uh, your bell.

And, uh, Randy, what's going on with you, man? How, how's Chicago? 

Randy: Uh, it's currently, uh, smoky. Uh, there's, uh- Yeah, sorry about that ... the wildfires in Canada and Minnesota have created what I think is probably a toxic environment out there. So we're, uh, we're trying to minimize our outside activity. So between the, the, uh, the, the lettuce diarrhea and, uh, [00:02:00] the, uh-

and the smog- Oh my gosh ... it's been an interesting, uh, time here in the Chicagoland area. Uh, not that I've had- Yeah ... the lettuce diarrhea, but, uh- ... actively trying to 

Joe: avoid 

Randy: both. Yeah. 

Joe: Yes. I am glad you have not had it. I'm glad. Yeah. It's a great time to avoid salad. 

Gary: Yeah, Pittsburgh's in, in the, in the smoke as well, so it's, it's even going that far down south.

So we have the same issues here. 

Joe: It's, uh, yeah, scary times. But, well, hopefully, uh, hopefully it clears up soon for you guys. But let's get into the docket here. Always good to catch up a little bit. And we're all, we're all gonna see each other in a few weeks in Boston. That'll be fun, too. Uh, when we get more sophisticated, we'll do a live show.

But let's get into the docket here today. Plenty of anesthesia news to talk about. First up on the docket is the state of Ohio. And on the screen, for those watching at home, is a woman named Kelly Dieter, who is the state representative from Huron County, population 55,000. Uh, so she is from... That's from way [00:03:00] north Ohio, and there's a picture up there with Vivek Ramaswamy, the likely governor of Ohio, who's coming in, and current governor is, uh, DeWine.

So just a little bit of context on this issue. Uh, Representative Dieter, who is a C- CRNA by training and background, uh, passed or authored House Bill 52, which, uh, changed the word supervision to collaboration still, or I think, I think it's just collaboration, and, uh, changed the statute in the state of Ohio.

And then subsequent, about a year later, Governor Mike DeWine, who I learned through a little bit of interesting background, he was actually a senator, I believe, previously. The fact-checkers will be, uh, will be commenting on this. He was a senator who actually tried to implement federal supervision and, and federal statute many years ago.

So it's an, this is an interesting position. But Ohio is now the 27th opt-out state, so that is official. Now, Vermont was just last week. And first for reaction, what do you think, Randy? Is this, is this gonna change... [00:04:00] You guys are in Ohio, right? 

Randy: Yeah, North Star is. I, yes. 

Joe: Yeah. 

Randy: Yes. We have, we have a, a, a pretty sizable footprint.

Joe: What, what's your initial reaction, uh, with this change in Ohio? And I know we talked about this last week, but it bears repeating, so let's, uh, let's get into it a little bit. 

Randy: Yeah, I mean, I think it's really interesting where you see two states opt out in a 24 to 48-hour period. Um, I, I don't know that there's, uh, any necessary, like, correlation there to, to, to talk about other than it's, you know, probably a bad day at ASA headquarters.

Um- So- 

Gary: Yeah ... 

Randy: uh, I think practically speaking, I, I think it's, it's again, it's kind of, it's a good signal of that... I would think about this as how is healthcare trying to position itself around increasing productivity and access to care? I think that those are probably the issues they're trying to solve, and opt-out is one of the mechanisms.

As we, as we talked about before, opt-out, you know, there's some question around how much does it actually improve access, how much does it ac- actually [00:05:00] improve cost of care, and what are the quality impli- implications, which I think most of those questions or all of those questions are probably gonna be definitively unanswerable, uh, just based on the way things play out in anesthesia.

I do think, um, it is an in- intriguing pattern. Uh, and I, I think, you know, the, the more that we are talking about opt-outs, the more I tend to think about this as a managing the perception of stakeholder solution. So meaning- 

Gary: Mm-hmm ... 

Randy: how, how do surgeons and hospital 

Gary: administrators- Yeah, yeah. What do you mean by 

Randy: that?

Yeah. So how- Mm-hmm ... how do, how do they... I, I think specifically around liability Uh, so if you're working in a CRNA-only model, and to be clear, uh, I'm gonna conflate some issues here, um, because this is how it's conflated in the real world. I mean, you know, we're talking about Medicare reimbursement policy versus r- um, commercial reimbursement versus practice models versus state.

I mean, it gets complicated very quickly. And so, uh, you know, [00:06:00] sometimes I get confused, honestly, in terms of how this all intersects. But I, I would say that a lot of what opt-out is, is an attempt to manage the perception of liability by the surgeon and the hospital administrator because when you see in federal statute or re- or reimbursement policy a requirement for, quote-unquote, "physician supervision"- 

Gary: Mm-hmm

Randy: that, I think that is a bit of an obstacle. Uh, and I think this is, you know, an- another attempt to, to do that. Now, whether that practically changes access to care or cost of care, who knows? Uh, and, and there's a, there, there's a bunch of debate, and there's conflicting data, uh, coming from the usual suspects on this.

But I- Mm-hmm ... I do think it's intriguing. What I'd like to see or what I am curious to see is, are we going to see more states fall in line? Like, what, what was unique about the Vermont situation rel- you know, versus the Ohio situation? Is this a signal of, uh, like a broader pattern of change in these states- Mm-hmm

that [00:07:00] are, uh, looking for ways to increase access and decrease cost of care, especially in rural and underserved areas within the state? 

Joe: Yeah. It's the impact is-- We'll, we'll, we'll get into the impact a little bit in a little bit. But Gerry, Gerry, what are your thoughts here? You've been watching this happen.

You've been watching this happen since, you know, the Clinton years, right? When it, when it was Clinton first and then Bush, right? And for any of you, uh, Gen Xers or Gen Zers that are listening, Bill Clinton was a president. Uh, yes. Yeah, William, William Jefferson Clinton was a president of the United States.

We gotta go way back. What do you think, Gerry? What are your thoughts here? 

Gary: Yeah, I think this is the s- the sign of the times, right? I think the tide is moving that direction. And again, it's all due to the shortage, right? So, and I think, you know, Randy probably gives some of these folks too much credit is these legislatures and government, they don't know, they don't understand it deep enough, and they hear, "Well, Vermont passed a bill and, uh, allowed an opt-out state, so why don't we do it as [00:08:00] well?"

All they're hearing is, "We can't get anesthesia providers, and, uh, we're having a problem in our state." So it's an, a, a quick switch to flip And they feel like this is gonna be a quick fix to the problem when, when it really isn't. I mean, the, the, the, the s- the workforce is shrinking and anesthetizing locations are increasing.

So y- you know, you're really just, um, you know, you're, you're put- your finger in the dam here by allowing these opt-out states to occur, but you're still gonna have the same issues. So I think it's just an easy, an easy thing to pass, and they, they move on. So I would expect more and more states will continue to go the same route that Vermont and Ohio are.

Joe: Yeah. It's interesting. Couple thoughts. Um, I worked with... Full, full disclosure, I mean, I-- Let me start with two observations. First of all, anesthesiologists are never ever going away . Like, like they are [00:09:00] mission-critical to this system, and I think that bears stating because this often generates a lot of my team versus your team type stuff.

The other thought I had with this is, as more states have opted out, anesthesiologist demand, or to use the preferred nomenclature, physician anesthesiologist, okay, uh, anesthesiologist demand has gone up. So there-- I mean, I'm not saying it's causal. I am saying it correlates, and I am saying that when I look at the commentary online, you know, there's a, there's a mild undertone of financial concern, like, "Am I going to be still relevant?"

And what I want to observe is that the demand and value of anesthesiologists is inherently not dependent on federal regulation or state law And that's like we spend so much time on this stuff and the ASA opposes it, ANA proposes it. It's-- doesn't fix local issues, right? I'm not saying I, [00:10:00] I do think it should happen.

Uh, and I did work with the Ducey administration on this issue. Um, while at the same time, you know, in our practice, we have MD-only models and medical direction models. But it does, I think, Randy, to echo your two points just a little bit differently, I think it does make it easier to create higher value within the anesthesia model.

And I think the other point that bears repeating here is all anesthesia models have to be local, right? There-- like there's no world in which, you know, the ASA or the federal government or whomever is gonna really determine or should determine the model. You know, that's my point. I, I mean, I hope we see more of this only because, uh, the more...

And I'm not, I'm not an anti-government person. I feel like I, I should be saying that now. I'm in my forties and I pay a lot of taxes. I just genuinely don't feel like the federal government shouldn't be involved in these things at all, or the state government. I told Kelly this and she said, "You sound like a f-far-right crazy libertarian."

And I was like, "Oh, oh, that's not, that's not my goal." In either case, yeah, I think we'll see more of this. It wasn't [00:11:00] easy when we did it in Arizona. It was fiercely contested, but I generally feel like anesthesiologists as a society are not using-- I don't think, you know, humbly, I would suggest it's not a good use of their time So we'll see.

We'll see what happens with, uh, with opt-out. Uh, I don't know of any others. I'm, I'm on all the text threads, you know, people talking about this stuff. I don't know of any others, but any other commenta- commentary there, gentlemen? Since we just, we just talked about this last week too. 

Gary: I, I, I'm back to the business side of things.

It's just the supply and demand, right? Is, is the m- the demand is so high and the demand or the supply is, is not going to meet the demand, I think people will try anything, right? I mean, we'll, you know, we'll go opt-out states, we'll do whatever because at some point there needs to be catch-up in providers in the market to in order to, to get this crisis to go away.

But I don't think-- I think we're gonna have this discussion for years. It's-- we're years away from getting caught up with supply. 

Joe: You know, [00:12:00] my feel is we're on the back half of this shortage, and I know-- Like people are like, "Oh, that's because you, you know, your, your company makes money." And I'm like, "That's not how the service sector economy works."

Like if our margins are too high, our contracts get bid out and our margins go down. Like that's how the market works. So it's not a I'm gonna make more money thing. Um, but I feel like we're on the back half of this. And also, you know, Randy, feel free to weigh in on this, but when these opt-out things occur, I think it makes it a little bit easier in the minds of, I don't know, I'm speaking from a lot from anesthesiologist point of view today, but in the minds of anesthesiologists, it makes it a little bit easier to instead of being one to three or one to four, to be one to five, which is a, you know, 20% increase depending on how you measure, 25% increase in coverage that day, right?

I was just speaking to an anesthesiologist towards the end of his career, very casual, w- far away from the halls of medicine. Great, you know, it's not an uncommon scenario. He does all the blocks, he does all the pre-ops. Sometimes he goes up to one to five, but the CRNAs are quite [00:13:00] good, so when he can't fill in, they do the pre-op.

It actually works quite well, right? So, but I think it just makes it a little bit easier to do that and I think that's where the world should go 'cause that's a world where it's like let's maximize value for the patient and safety for the patient. Let's not listen to a dictate from a trade association or the federal government.

Clearly my bias around local control is really coming out here. Randy, go ahead. 

Randy: Yeah, I think it's-- The way I tend to think about this, like the opt-out in my experience, and so caveat, that's what my experience is It doesn't really factor into the calculus that we have, um, internally within my company or our company a- and, uh, the conversations we have with healthcare stakeholders.

When we talk about what you're talking about, like what's like, "Hey, can we take a different look at the practice model? Can we move from a one to three, one to four model of medical direction to something that is more what we just..." I think we use the term zone coverage. 

Joe: The last- Zone, z- zone, supervisory, collaborative.

Randy: Yeah, yeah. 

Joe: It's all kind of the... Yeah. Mm-hmm. 

Randy: And I, and I, and those [00:14:00] conversations happen irrespective of whether or not it's an opt-out or non-opt-out state. It's, it doesn't have a lot of influence. Where I think around the edges it may have some influence, uh, is sites that are all CRNA or thinking about moving to all CRNA.

Yeah. And, and, and in those sites, and I think that's a pretty small percentage of sites that, um, where they would say op- you know, whether a state has been opted out or not would be kind of deterministic of what model they go to. So I think we're really talking around the edges of sites and, uh, and practice models versus like I don't see this changing in a material way anything that's gonna happen in O- Ohio or Vermont, um, maybe around the edges in a few facilities.

Uh, now if you zoom out, maybe that's a different answer. Maybe if you look at- Yeah ... over, across 25-year time horizon, and nobody does that- Right ... in healthcare. Healthcare w- we typically think in five months. Uh, so- 

Joe: Mm-hmm ... 

Randy: if, if you think of [00:15:00] maybe, maybe, but who's gonna measure that? And who's gonna, you know...

And, and so I, I think there is a little bit of this, which is I agree directionally stupid rules should be removed and seems as though this is a, a, you know, a reasonable solution there. But I don't know, you know, how that's going to... I guess I'm a little bit on the skeptical side in terms of- Sure ... whether this is gonna result in a significant sea change of, of- CRNA or physician utilization 

Joe: Real quick on, on this topic of, you know, does it, does it really change things?

And this is, uh, cool that we're getting this deep and really talking about it in a, in a nuanced way. Arizona's kind of an outlier, right? But it's instructive because there's so much-- There's, you know, again, I, I mentioned this before, three major groups all doing QZ billing, all have anesthesiologists, right?

Uh, Gas probably has the most 'cause they do the most hospitals. But if I answer the question, you know, if this happened in all 50 states, would it make a difference? I think the answer is probably. I think you are correct. It would be the, you know, it's obviously rural sites, it's [00:16:00] underserved sites. But then I answer another question, would the role of anesthesiologists diminish?

No. Like, it, it wouldn't. It would e- it likely expand. And I do-- And I'll, though I'll-- And Gary, I'll move to you here. I, I will say one of the other big mistakes we make in anesthesia is it seems like policy debates are centered around the concept of all providers are the same, all CRNAs are the same, and all anesthe- anesthesiologists are the same.

There are vast differences in talent levels. There's a gulf between high-performance, uh, anesthesia clinicians and, you know, moderately low performance. In where I grew up, where we used this, uh, model We all had to be high performance. And that could-- Like we had, I'm gonna speak really plainly here, we had folks come from the East Coast who had never, CRNAs who had never pushed their own drugs, and they didn't last.

They, they couldn't operate in our practice. And we have a mixed MD CRNA practice. So I add that n- level of nuance around the local idea. Go ahead, Gary. I'm sorry. 

Gary: Yeah, I think honestly, I, I agree with [00:17:00] Randy. This is more like background noise, right? It's, it's on the fringes, but I do not think we're on the down slope of the shortage.

I think it's gonna stay as bad or get worse. And from a macro perspective, you see these health systems are becoming mega systems, right? And what they're trying to do to stay relevant and continue to grab the right patient mix, they're building micro hospitals, right? I have a house in Florida and I have a house in Pittsburgh, and there is-- it looks like the Starship Enterprise near my house in, in, in Pittsburgh.

It is this micro hospital that is- Is it 

Joe: the Starship Enterprise or is it the, uh, the Death Star? 

Gary: It is- Is it like a, more of a- But it's incredible ... more of an empire type 

Joe: of- 

Gary: Right? I feel like I'm going to the Ritz Carlton to get- Oh, 

Joe: that's cool. 

Gary: That's cool ... uh, my colonoscopy, right? And, uh, and they're doing the same thing all around Florida.

So you're gonna keep ha- If, if you increase the supply, there's gonna continue to be more anesthetizing sites, which is going to keep the shortage going. And until these [00:18:00] mega-- Because what's gonna eventually happen is you're gonna have these mega health systems, right? They're gonna cross state lines, you're gonna have huge health systems, which I think is already happening.

And it's gonna continue to, to force this shortage. You're gonna need to figure out a way, and again, I'm, I'm an anti-government guy as well, but you're gonna need to figure out how to- I 

Joe: said I'm not anti-government. I'm just, I'm just pro li- I like, I like my governments as small as possible. 

Gary: But you're gonna have to open up these residencies, and you're gonna have to open the pipe to get more supply in the marketplace, and anything that goes through these regulatory, uh, organizations take forever.

So it's, that's really, that's what's gonna have to happen to change, in my opinion. There, there needs to be more residency spots for MDs to get more anesthesiologists into the marketplace. Uh- More CRNAs schools are gonna have to be cranking out, out providers. But I think we're in such a short fall of staff, i- even if you open up the pipes [00:19:00] as much as you can, it's still gonna take years to get caught up because you keep having micro hospitals open up.

And, you know- Oh, sure ... I like going to a micro hospital More anesthetizing 

Joe: sites. 

Gary: Yeah. More sites. I, I like going there. It's a lot easier, right? I don't have to- 

Joe: Of course ... 

Gary: pay for parking. I don't have to drive into the city. You know, I pull up 10 minutes before and I go into the, the, into the hospital. So it's, it's gonna be bad for several years, I, I, I think so.

Joe: Uh, I, my perspective there is based upon, you know, um, you know, Phoenix is the fifth biggest metro in the country, and we're pretty active there and connected in the market there. So I mean, we had to stop hiring, uh, new grads because we had so many people have moved here. So it's a, it's a different market.

Florida's, I think, you know, still short, right? Many, many people have moved there as well. But I, I think that's, you know, again, it comes down to local groups

The consolidation point's probably a good segue here because this week, uh, moving on to issue number two here, this is, uh, [00:20:00] certainly I'm sure Coronis, uh, Gerry, you guys, I saw your email come out on this, this week. CMS proposes a decrease to anesthesia payments in twenty twenty-seven, making a s- also making some changes to MIPS reporting.

Let's kinda bottom line it here for the audience. Conversion factor is going down. Most, um, the alternative people reading on the screen will see the word or the acronym APM, that's alternative payment model. Most groups are not in those, at least as far as I know. Conversion factor is down one point three eight percent.

You add that onto inflation of, you know, say, two percent. Now we're looking at, you know, three, maybe even four percent decrease relative with anesthesia conversion factor, which is somewhere between, for most groups, you know, somewhere between forty to seventy, even eighty percent of the mix of the patients that are coming through.

Then the quality program is also changing, and, uh, Gerry, we'll come to you first here. The PON combination therapy is out. You know, we've-- apparently everyone's getting enough PO- [00:21:00] PONV treatment, and they're adding measures around patient-reported experience with anesthesia and intraoperative hypotension.

All right, so the big news is that anesthesia conversion factor is going down once again. 

Gary: It's like Groundhog Day. Every year it's the same thing, right? So, uh, the good news for the, the industry, though, is when you're talking about twenty dollars, right, uh, two percent increase in twenty dollars or two percent decrease in twenty dollars, it doesn't really move the needle very much.

Uh, it doesn't really factor into budgets, et cetera. So the whole industry is still relying on commercial carriers, right? As for the MIPS, you, you do know they upped the threshold several years ago, so most providers don't even participate anymore, right? It is-- I've done an analysis recently of, uh, you know, fifty providers.

One Did enough cases that he has to report to 

MIPS 

Joe: Just for the sake of the audience, just can you give the, you know, the, the quick rundown? What, what's MIPS, [00:22:00] the quality reporting, the whole thing? 

Gary: Okay. Yeah. MIPS was created several years ago, and what a lot of people don't realize, it's only for Medicare patients which are straight Medicare.

Meaning- Hmm ... if it is, uh, Blue Cross Medicare Advantage, that doesn't count, right? So there's a very small percentage of patients that are just straight Medicare nowadays. And the original threshold, I believe it was $30,000 a year, maybe it's $35,000 a year, in Medicare allowances, which means if you see a patient as a CRNA billing QZ, that's 200 bucks, right?

$200 of an allowed payment. And to get to 35,000, you're just dividing 200 into 35,000. So people like you and Randy, you would qualify that you'd have to be participating in MIPS Years later, they upped it to 90,000 because the, the, I assume Medicare realized that you're not gonna [00:23:00] really save money on anesthesia, right?

If, if, if my mother needs to get a g- her gallbladder removed, anesthesia's not really an option, right? They're not gonna say, "Mrs. Keeling, here, bite on this bullet and you'll be fine," or, "Here, drink a shot of whiskey and you'll be fine." So th- there's, there's no way to cut costs on the anesthesia side, so they upped the threshold to, for reporting, and now you throw in Medicare HMOs that don't qu- count- 

Joe: Right

Gary: nine- I, I, I know very few providers now that even participate in MIPS. I mean- That's 

Joe: fascinating ... 

Gary: some groups will do it as a group because the upside for a group is that's something you can market. You can say, "Hey, we are, uh, a quality provider according to Medicare." And when they go to pursue new contracts, they can hang a little feather in their hat with that.

But in general, it's, it's really becoming a non-factor. This- 

Joe: That's- ... 

Gary: this annual cut in the MIPS, it's, it's doesn't really matter much anymore. 

Joe: Yeah. Randy, what do you think? Cut again. 

Randy: Yeah. I mean, there's, [00:24:00] there's two different things that are I think happening here. One is that the valuation of anesthesia services has been flawed since its conception.

Uh, and then there is the, you know, Congress every year has to kick the can down the road on draconian cuts. So those, the 2.5% cut is for '26 is gonna sunset unless Congress does something. So that's gonna impact- Mm-hmm ... not just anesthesia but, you know, across the board physician and advanced practice provider reimbursement is, it- that's, that's a real challenge.

And that's, that's, and, and it's, there's, you know, I think probably some decent amount of speculation that there will be another legislative fix which would result in kicking the can down the road a little bit down the, uh, on that. The other thing is, you know, we're, we're talking about this also in the context of value-based care.

Like the, like anesthesia's role in value-based care as conceived by CMS is profoundly [00:25:00] stupid. I mean, if, if you look at- ... value-based care models- Yeah ... are for longitudinal patient care episodes. Yeah. So primary care physicians- Yeah ... internal medicines, card, you know, cardio- Uh, cardiologists, et cetera. The way that we interface with a, with a patient is two hours plus a little bit of PACU time, right?

And so they're trying to squeeze a round peg into a square hole, and then, you know, like these MIPS measures were always a joke. The evolution of this program is gonna continue to be a joke because we don't fit into that model. And, and- Exactly ... uh, 'cause... So yeah, so we're, we are proceduralists. We are involved in, in, in the care of a patient in a very limited window.

And yes, they'll say, "Well, there's decisions that I make in the operating room that have impact on 30-day mor- mortality and morbidity." Okay. Okay, that's fine. But how are you qua- how are you identifying and quantifying those? Which is why, you know, they're moving towards intraoperative hypotension. I am still highly skeptical.

Uh, I, I don't think value-based care [00:26:00] MIPS in, in the context of anesthesia has moved the needle on patient outcomes one bit. Uh, I, and I, I, I am equally skeptical of what the next evolution of what this is gonna be. This is a check the box exercise in order to prevent your reimbursement from being impacted if you are, you know, meet those criteria.

So if we were really thinking about, uh, like how do we position anesthesia, uh, in a way that helps healthcare, it is around, I think, operational efficiency. That, that's what I would put our butts on the line, which is how, you know, throughput throughout the operating room, first time starts, all of that stuff.

That doesn't necessarily directly impact pa- impact patient care, but it does impact financial Uh, performance and if we keep- Right. And 

Joe: ul- ultimately, you know, those, those two things are, are intimately connected, right? You, you perform better on the finances, you make better use of taxpayer dollars, more patients get care, and the care is generally pretty good.

But I mean, basically, you're, you're saying that the MIPS [00:27:00] program has, you know, effectively no impact. I would, I would tend to agree. Are you, are you suggesting we just, you know, not use it and we get, we get rid of it? Is that the- 

Randy: I think in the context of anesthesia, I think it's just, it's profoundly misguided.

Okay. And I think that they're like, "Well, we gotta do something for anesthesia. Let's do this." And- Yeah ... and this is what they've done. But I don't think any serious person, uh, and I don't consider myself a particularly serious person when it comes to like, you know, you know, being a, a- 

Joe: Life? 

Randy: Almost anything, including like quality outcomes in anesthesia.

But I think any- Yeah ... remotely serious person, if, if you ask them, ha- have, has the MIPS program in the context of anesthesia had an impact on patient care or patient outcomes, they would laugh. They would say, "Absolutely not." This is a check the box exercise that was conceived by the federal government because they're like, "Oh shit, what about anesthesia?"

Gary: Well, it's funny, Randy, you're on the right track there. So, uh, the company I work for, we created our own registry, right? Because these companies came out and everyone was running around that, "Oh my goodness, MIPS is coming." And these [00:28:00] companies grew out of nowhere, and they would charge you $800 a year to gather your information or more.

The ASA was charging, I believe, uh, free for, for, um, members, and it was 1,500 for CRNAs. So we just built our own registry, and we include it in our fees. But what it's migrated to, it is a, uh, customizable quality- pasture mechanism for our clients now, right? So you can say, "I wanna track on-time starts. I wanna track, uh, patient nausea," et cetera, et cetera.

And we allow y- we, I mean, it's just internally reported now. So we keep our own registry, we can report back to you, you can report back to your facility- So you, 

Joe: you replaced ePreOp effectively, right? Isn't that the b- the company- Yes ... that a lot of companies were using, ePreOp? 

Gary: Correct. 

Joe: Yeah. 

Gary: Correct. 

Joe: Mm-hmm.

Gary: Correct. Yeah. And, and when the threshold went up, the, the need for, for that service really disappeared, right? Because, you know, most people don't qualify anymore, so why do you wanna bother gathering it? Our registry, though, would [00:29:00] be collecting dust if we didn't figure out another way to use it. So we offer that we'll track whatever you want us to track for you- Right

and we'll report it back to you. You can report it back to the hospital. And with subsidies nowadays, everybody's getting a subsidy. The hospital wants to hang their hat on that subsidy some way, right? We want you to track this, this, this, and this. We do it. We report it back to the group who reports it back to the hospital.

But, I mean, you would need someone like of, of Randy's training or his experience- Mm ... to get a job with the government to explain what do we really need to gather for anesthesia. And, uh, you know, I don't know if anyone out there wants that job, but I think, you know, you could go to work for Medicare and, uh, you know, get something done that way, but I don't know if anyone wants that job because it sounds kinda boring.

Joe: And my take here is that, you know, number one, Gary, your point on does this really matter? And no, it doesn't because so many groups have some sort of, you know, guarantee of their [00:30:00] threshold, their revenue, et cetera. So reimbursement goes down, it just shifts more pressure payer to subsidies to, uh, the commercial end.

The other thing this goes back to is that it just gets increasingly as the differential, again, I, I as the, uh, the relative newcomer, I think, compared to, to you guys. I think I'm a little bit earlier, not much, but a little. Um, what this does, I think, is just, it makes it harder and harder for startup groups to get rolling, right?

Because they are now increasingly dependent on subsidies as well. When I started, uh, what was then AZAS, we lived off fee-for-service for many, many years in many, many scenarios, and it wasn't until around 2020, uh, maybe '21, '22, like everything went subsidized effectively except for a few rare, uh, ultra-high volume facilities.

And then even in those we had to, you know, make sure they weren't doing a, an, an illegal company model, but I digress. Um, but the, the, the point I'm making is as- 

Gary: They still exist, Joe, by the way. 

Joe: Oh, [00:31:00] oh yeah. Oh yeah. That's a- 

Gary: Now it's a whole 'nother subject. 

Joe: Randy, in your role you probably don't, um, 'cause you're not on the, the business development side as much, right?

But- At my end of things, I have those conversations and they-- I've been literally asked for a kickback numerous times. Like, the phrasing was the... One time it was, "Well, what about the profit share?" And I said, "We do, we do profit sharing. We do bonuses for, for our group members." And they're like, "No, no, no, for us."

And I was like What, what do you mean? And another one was like, well, I, I had to-- I was convert- canceling a contract. I was like, "Hey, you know, we're, we're subsidizing..." Or the, the ortho guys were giving us, you know, a quarter million a room or whatever. I was consulting for this group. And you're giving us nothing, and you're taking all this profit that we should have, so we don't have to take so much from the ortho guys.

And they were like, "Yeah, we'll give you the billing, but what's in it for me?" And that conversation went back and forth a number of times and well, we don't have that relationship anymore. So that's, that's, uh... But still legal, and there's plenty of cases out there. I [00:32:00] digress. It's one of my, my pet peeves 'cause we're in that segment of the market.

Um, but yeah, back to this anesthesia conversion effect. I think it just, it just leads to more and more consolidation, right? And more-- And it-- This, you know, North Star, our group will be fine, uh, you know, 'cause we're at that m-much, you know, North Star is much, much larger and much more mature in that sense.

Um, it just gets hard to get things off the ground. 

Randy: Then the other just, uh, you know, the double down on the point, like, th-this is-- this will ultimately be passed through to the, to the facility. 

Gary: That's exactly what I was gonna say. 

Joe: Yeah. 

Gary: Is this hurts the facility at the end of the day. Yeah. That's really what hurts.

Joe: Yeah. And ultimately, you know, when healthcare is funded, and this is what I enjoy about our conversations 'cause you can connect it to some broader ideas. When healthcare is funded by the taxpayer, and it, you, you know, you look at state governments, you look at federal governments, you know, something like, you know, I think in Arizona it was like thirty percent goes to healthcare funding or something like that in talking to my local senator, uh, a couple months back.

Ultimately, it's the, it's the taxpayer that funds these things, and that's why I think it's [00:33:00] incumbent upon leaders to make the full use. The whole, the whole framework around this MD-CRNA thing is, you know, kind of my team versus your team, right? But I think a better framework is, are we making full use of every professional that we have?

And that varies quite a bit, right? Some, some folks are not as skilled as others. Some are quite bad, right? So they need a lot and lot of oversight. But other folks are quite talented, and we should use those talents 'cause ultimately it's everybody on this phone call who's, you know, paying for our services.

Now, I, I sound... You know, I'm gonna start a new organization- Yeah ...Anesthesia Providers, Friends of the Taxpayer. You know, Anesthesia for Friends of the Taxpayer. Keep going, Randy. 

Randy: The-- We, we talked about incentives before, so show me the incentive, and I'll show you the outcome. 

Joe: Yeah. 

Randy: So the government has created this incentive program.

We, we build a m- you know, a mousetrap in order to maximize our revenue like anyone else would. And so we're, we're there, we're incen- The current incentive is making sure that you have the internal infr-infrastructure to maximize your [00:34:00] revenue on a program that doesn't really impact patient care or patient access.

That's the current state of play in anesthesia. It's a joke, right? 

Joe: Mm-hmm. 

Randy: If 

Joe: we were re- And when you say that, are you referring to the MIPS thing? 

Randy: The MIPS, uh, the MI- the value-based program relative to anesthesia- 

Joe: Oh, sure. Got 

Randy: it. Yeah ...is, is, is a joke. Mm-hmm. Now, if we were really serious about solving problems in healthcare, which is about access, cost of care, and efficiency- And the government wanted to create a program where groups that optimize access to care, cost of care, and perioperative efficiency, now that's moving the needle.

It's because it's creating an incentive plan where- Mm-hmm ... you're going to force groups who are immune to their, to their poor utilization, um, because they have a big subsidy. If you s- if you say, "Hey, actually, you know, based on the clinical resources you have, CRNAs, anesthesiologists, whatever, you, you're not a particularly productive group," and you had at-risk [00:35:00] reimbursement from the federal government, then you would see practice models change pretty quickly.

And you would see- Yeah, 

Joe: rapidly. Rapidly ... 

Randy: you would see perioperative efficiency improve. And I understand that anesthesia's not the only input here. The, the- Mm-hmm ... biggest stakeholder is the surgeon, which is why I would put them- That's right ... and the hospital at risk as well, then you're actually M- moving the needle in, in a real way, where anesthesia is particularly well-positioned to move the needle.

Joe: Indeed. And yeah, if the-- That's a, a great point. We're not incentivized to make full use of our resources currently. 

Randy: Yeah. 

Joe: Right? And then like we're-- Especially with the, the like almost philosophical and it, it's the deep turf war thing. I see it play out at the local level. I get phone calls, not in our group, thank God, we're effectively apolitical, but, um, at other practices it gets political, and then the incentive is, "I want my team to win" versus, "I wanna create the best experience."

G- Gary, any o- any other thoughts? 

Gary: Yeah. Uh, I, I agree with everything Randy said, is this is, is [00:36:00] really more just of a nuisance, a, a checkbox thing. And I work for, uh, the biggest, um, billing company in the country, and we still run into, uh, local groups that are with a local billing company and, and they'll say, "Hey, you know, what I hate about billing the most is filling out these silly MIPS forms."

And they, it ha- There's a lot of providers in the market that still are-- The ones that are doing it don't realize they don't have to do it anymore. Mm-hmm. So it's, it's really a, a wasted program when it comes to anesthesia. I mean, whatever the government's spending to administer the anesthesia portion of it, it- it's, it's kind of- Yeah

a waste of, of taxpayer money. 

Joe: Yeah. It's, it's unfortunate. Um, yeah, there's a whole conversation here on, on government incentives, but, uh, and, and social contract, which is maybe a good segue. Uh, so in the news- Um, before we 

Randy: go there, just- 

Joe: Oh, go ahead ... 

Randy: this, we can cut this out. Joe, have you ever attempted to talk to a patient about smoking absince- 

Joe: uh, absinths?

No. We should definitely keep this in. See, we're, we're actually having [00:37:00] the-- You know what's funny? We're, we're it's a meta conversation. We're debating what we, what should stay in. It's great. Which shows we're having fun. Um, and by the way, I get good feedback on that aspect of things. Like that's part of the working theory of the show is people enjoy our sense of humor.

Uh, I actually talked to an anesthesiologist who was like, he's very earnest and, uh, like very-- He's almost a voice guy. He's like, "You know, it's a, it's an important question to ask, and now I ask it in my preoperative interviews." And I was like, "I'm a bad person. I never ever do that." I mean, 

Randy: in, in, in the history of humankind, has anyone ever been talked out of smoking right before they have a- Right

a, a procedure? Like, "Oh, shit, I hadn't really thought about that until- Yeah ... the CRNA or anesthesiologist mentioned it. Maybe I should stop smoking." Yeah. Right. Right. So I mean, this is an example of like just the ridiculous nature of these, like smoking... Oh, yes. Do I check the box? I check the shit out of the box.

But- Yep ... do, do I actually have a conversation with a patient who's been smoking for thirty-five years before they're gonna have their below-the-knee amputation [00:38:00] about stopping smoking? Is that my role as a proceduralist, as an anesthesia provider? And even if I did, would that change that patient's- Probably not

decision-making? Of course not. I mean, that- No ... that patient has had, I'm sure, dozens of conversations with people who are better positioned than me, and this is an example of why does this shit make it into the program? Why is this a something that you measure and ha- being held accountable? Because I can guarantee you, I check the box 100% of the time.

Am I having those conversations? 0% of the time. 

Joe: It's a passing comment at best. 

Randy: Yes. Not- 

Joe: Right ... not even that. 

Randy: Yeah, so- 

Gary: And it's not even funny, but w- how about when you walk into the hospital, you see people out there in their gowns with a cigarette hanging out of their mouth waiting outside, and you're like, "You just had an operation and you lit it up right after that."

So, uh, it's... It, it-- the whole thing is silly. It really is. 

Joe: You know, the o- the thing I would, um, add here is that the world is small, and someone hopefully is listening to these things. I [00:39:00] mean, you know, I know Lee Fleischer is involved in the anesthesia side at CMS. Maybe they see something th- that we don't, you know, but I'm not sure.

It doesn't-- sure doesn't seem like it. Um, so I, I think, uh, the conversation on incentives and anesthesia, you know, getting to a more pragmatic way of doing things is wise, and hopefully somebody out there is listening, uh, to, or future leaders of CMS are listening. Uh, also, moving on to our next segment, UnitedHealthcare, everyone's, uh, favorite American company, posts a $5.5 billion profit for those- Good 

Randy: for 

Joe: them

who can- 

Randy: I, I was worried about them. 

Joe: Oh my gosh. Yes. Yes, y- they were suffering. Yes. They were suffering. Uh, from-- this is from Becker's, the news a-aggregator, uh, and I did verify this with Forbes as well. Five point five billion in profit for the second quarter of 2026, up sharply from the same period of last year.

Uh, they appear to be a public... Um, I wasn't certain [00:40:00] of this, but they appear to be a publicly traded company, so their adjusted earnings per share has gone up. Revenue was $112 billion for the three months prior, or that ended June 30th, which was essentially flat, so they lowered costs. Margin went up to about 7%.

Just for the, uh, and well, Randy, we'll come to you first here, but just to give an even view, a l- a little bit of a balanced view, uh, try to steel man the argument a little bit. And, uh, for those who are not trained in really esoteric verbal arts, steel man versus straw man, right? Trying to understand both sides of an argument.

Uh, 7% is not a large margin Right? I mean, that's not a large margin for like a, a plumbing company or something like that. That's not a lot of breathing room. A lot of bad things can happen. However, 5.5 billion is an awful lot. And look, you know, when we look in the societal context of this, it's a tough sell, right?

It's, it's constant denials. You see all the videos of surgeons calling insurance companies dealing with this, which is crazy that surgeons are dealing with [00:41:00] that. That's not what they should be doing. Uh, so Randy, we're gonna come to you first. UnitedHealthcare, 5.5 billion. 

Randy: I'm-- I-- Like I said, I'm really excited for them.

This is, this is really good. I hope they have-- I hope their bonuses are, are as fat as possible. I mean, just the- Oh my gosh ... I mean, I mean, five, I mean, 5.5 billion in one quarter. Jeepers. Wow. That's just awesome. So- ... I mean, I think there's... If I were slightly less sarcastic, I think there's a conversation around...

And again, I, I tend to be, uh, pro-competition, you know, let the market figure things out. And UnitedHealthcare has positioned it itself in a way, they've, to benefit from their positioning in the market. So I don't, like I mean, the, the challenge here is like I can't be completely objective because I'm on the other end of this in that, you know, some portion of that $5.5 billion in the second quarter of 2026 came from me.

So, you know- 

Joe: That's 

Randy: right ... uh, and so, and I, I- You 

Joe: guys use United? [00:42:00] 

Randy: Uh, yeah, yeah. Uh, uh- Yeah ... well, I mean, in terms of like my, my role within the company- Got it ... I'm in. Got it. So, um, so I think there is like, you know, this is all kind of academic conversation until you have to butt up against them as a patient or as a provider or as a company owner, then you realize like they have structured themselves as a, uh, to optimize and extract as much value as they can out of the healthcare system.

And we can argue about whether that's appropriate or not. Um, again, show me the incentive and I'll show you the outcome. Um, you know, I think it's probably, you know, in a weird way it's less of a criticism of UnitedHealthcare and more of a cri-criticism in terms of how healthcare is structured in the United States, that a company can position itself and extract that much value from the healthcare system when we've been talking over and over again about the financial, uh, problems and headwinds that we have in healthcare.

Joe: Gerry? Gerry, what do you, what, what's the chatter over at, uh, at the Water [00:43:00] cooler and Coronas with UnitedHealthcare making five, 5.5 billion 

Gary: I should probably recuse myself from this discussion. The good news is, uh, they are a very well-run company, right? They make the hard decisions on a daily basis, right?

If, if money's down, they lay off 5,000 people, right? It's a ruthless organization. Um, so if you wanna be an investor, it's a good company to invest in because the stock's always gonna go up. But I worked for a company that was, was taken over by UnitedHealthcare. And we had 6,000 employees. I bet you there's 10 of them left there now, right?

Mm-hmm. So, um, you know, they, they run a very good business, but I, I agree with Randy. It's, it's It's just really a profit center, and they've worked their way into the marketplace, and they know where to put their money, and they know where to generate profits. And, you know, at this point, I don't know how you fix it, right?

They have become such a Goliath that it-- I, I don't know. [00:44:00] It's-- It always boggles my mind is you meet with hospital administrators, and they're either barely breaking even or they're losing money every year. Mm-hmm. And then you have one of the biggest vendors to the healthcare system that's making record profits every year.

And it's not just UnitedHealthcare, it's all the health insurance companies. So it's, uh, it, it, it's a sad state of affairs, in my opinion. 

Joe: Honestly, when I see these headlines, I think of two things, which is first, when I see Zoran Mamdani and other Democratic socialists winning, and, uh, again, I'm, I'm approaching this carefully because people are very sensitive about politics and these issues, and our country is in such a hot place, right?

But I like to pay attention, and I, I think, again, it's incumbent upon leaders to be at least aware of these things and to try to lead effectively through these dark times. Um, when UnitedHealthcare is making five point five billion dollars in profit and Democratic [00:45:00] socialists, who are not Democrats in the traditional sense, right?

They're not the, um, your old school Democrats. They're, they're socialists more so, which effectively means public ownership of goods and services. And I think socialism is very misunderstood. This is, you know, Scandinavian countries often get quoted, Switzerland, Germany, et cetera. They're-- These are not really socialist, um, countries as it were.

They're more like social capitalists, capitalistic countries that have for-profit healthcare systems, but they have very strong safety nets. But when I see this headline and I think of those elections going on and I think of people suffering relative to their peers, relative to their consumers, they don't feel like they're doing well, this tells me that the, the social contract needs improved, right?

And the other half of that is when we have very strong opinions about politics in this country, we often mistake the lack of [00:46:00] execution on a given idea or a given principle. And this doesn't matter if you're running, you know, a large anesthesia company or you're a politician or whatever. If you have an idea that, you know, a company should run well or a government should run well and in a certain way and you fail to execute, I think what's happening right now is in the citizenry is people are saying, "Well, it's your idea that's bad Right?

It's the idea that, you know, you see some of this chatter, right? Uh, you know, no, none of these big companies should exist or anything like that. It's like, you know, capitalism is evil and all these sorts of things. And it's like, no, we're, you're, we're seeing a corrupted form of capitalism where people are not healthy, right?

People are not getting care in a timely, accessible way, right? We see those stories. It's a general feeling out there. But companies, you know, like this, these ultra large, these things are 100 times our size, are making all this money. That tells me the system is broken. It doesn't tell me that a free enterprise system, which is probably a more accurate characterization, is [00:47:00] flawed as an idea.

It tells me that the application of the idea is flawed. And you could-- That, you know, socialism is not inherently evil per se, right? I mean, that can work, especially in smaller countries. That can go well or it can go very, very poorly, right? So I think that, that's what I think about when I see UnitedHealthcare posting $5.5 billion in profits.

And when we're partnering, uh, just, you know, we're partnering with other groups and trying to build economies of scale, or in North Star's case, doing, uh, more organic growth, or y- in USAP's case, trying to buy up everything in a given market, this is why they're doing it, right? I mean, this, this is, the, it, all those behaviors are a very natural reaction of in an ideal world, healthcare is lightly regulated, but effectively regulated, right?

We want the right guidelines to produce the, produce the right incentives to get good outcomes for the cit- citizenry. And so it's, I, I just, you know, I feel discouraged when I see this 'cause like, oh man, this just, this just pours fuel on the fire of these kind of extreme parts of our society. It's, [00:48:00] uh, it's not a good thing.

Randy: I think it's also, I mean, there's, there's, there's a natural tension that exists, I think, like in this conversation around, you know, what is the role of regul- you know, government regulation in all of this? And I, I don't pretend to know what the right answer is. But- Mm ... if there, you know, i-i-if there is a, a compelling indication that the amount of value a company is extracting is disproportionate to the value that it brings the marketplace and, and the, the customers or the key stakeholders, then I would say, you know, there, maybe there is a, a, a larger role for the federal government here on, on regulation.

And this is the kind of the threshold we've seen in the tension around, you know, you know, anti-competitive, anti-monopoly legislation back towards, you know, Theodore Roosevelt. Uh- Mm-hmm ... you know, you know, you know, breaking up, you know, mega companies, and I'm, I'm not proposing At least not right now. You know, UnitedHealthcare needs to be broken up, but you know- Sure

there is a, there is a thing of- There's 

Joe: an idea [00:49:00] out there though. 

Randy: There's an idea and, and there's a, there's a hard conversation here. Like, what is the value this company brings beyond its investors and its employees and its executives? And what are its policies and practices, and how is that impacting healthcare, healthcare's most important segment, which is the patients?

And, and I think there is a lot of questions here that need to be answered, and I c- I, you know, and I know it's a, it's a slippery slope when you talk about government intervention And, and to be perfectly candid, like, UnitedHealthcare owns Congress a- and, and the White House. Yeah. 

Joe: So- 

Randy: Highly, 

Joe: highly influential.

Yeah. Highly influential. Yes. 

Randy: Yeah. So, so any government intervention is, is a bit of a, is a bit of a stretch right now, whether it's, you know, whether it's appropriate or not. But I think it's an important conversation we have considering the economic ha- headwinds we have in, in this country relative to healthcare spending.

Joe: Indeed. G- Gerry, any thoughts, any, any further thoughts here? 

Gary: No. I, it's just, um- That's enough, right? ... one of those things I don't even, I don't even know where I would [00:50:00] start, you know what I mean? It's, uh, it's... we're, we're down to really four major companies now. Uh- Yeah ... United, Blue Cross, Aetna, and Cigna, and, and arguably Cigna's the smallest of all of those.

It, the competition is, is getting more limited every day. 

Joe: We all understand the value, everybody here. We've, you know, all competed against or with each other on some level. Yeah. It, it, the system's gotta improve. And the, again, this is about the rest, right? I think a lot of this goes back to, like, Citizens United, right?

This is a little bit far out, but we, we gotta get money out of Congress and elections. Let's get back down to, uh, some s- anesthesia-specific items here. Going over to the ASA, the American Society of Anesthesiologists, July 15th submitted, uh, their rural healthcare bill, right? This is, uh, from Dr. Greg Murphy in North Carolina, some other congressmen as well.

But effectively what this does, it's a bill. Right now, current state, we'll get your reaction here, guys, in a moment. Current state, if a very small hospital has less than 800 cases, they can [00:51:00] change their reimbursement mechanism and effectively get higher reimbursement, specifically for CRNA services. This would allow anesthesiologists to be eligible for that function as well.

And, uh, r- Gary, we'll start with you. Any, any reactions on this bill? I, I don't know how likely it is to pass or not, but I know they, they've tried this more than once. 

Gary: Yeah. I mean, uh, again, it's a, it's a good effort, right? Is, you know, it's all based off of, of Medicare rates, so I, I believe the real numbers are, you know, let's just say $20 a unit, uh, for, for Medicare.

Across the country it varies, but 20, let's use 20 as a round number. I believe they pay, like, 26 in these rural facilities. And again, it's, it's a 20% higher than, or 30% higher than the normal Medicare rate. But when you're talking in small numbers, big percentages of small numbers are still small numbers, right?

Does that make sense, right? Like, so- 

Joe: Indeed ... 

Gary: if you're gonna get an extra $6 a unit, they're 10 unit cases, you're gonna get [00:52:00] an extra 60 bucks a case I- it's a good effort, but I just don't know if it's gonna relieve the pain for these community care hospitals. It's just, I, I, I just don't know. It's, it doesn't seem like it's gonna do a whole lot 

Joe: The, the phrase, uh, h- 100% of nothing is still nothing, right?

Just small, small amounts. Uh, Ra- Randy, any thoughts here? 

Randy: Uh, I'll be generous here and say I think the, the strategic thesis here is that if you open up pass-through to anesthesiologists, you'll have more anesthesiologists going to these rural and underserved areas. 'Cause right now it's, it's, you know, the vast majority are CRNA only I think that's a, I think that's a long putt.

I think that's-- I mean, even if this was passed through, uh, pardon the pun, even if this was, you know, uh, moved to the president's desk and he signed it, uh, I, I don't-- My hunch is that you're not gonna see a material increase in anesthesiologist coverage in these rural and underserved areas. I think there are geographic, uh, [00:53:00] issues, there are, uh, opportunity cost con-considerations here that when you do the math, that it actually still doesn't make sense.

It doesn't make sense for the anesthesiologist, and it doesn't make sense for the hospital, uh, to bring in anesthesiologists. So this is another one where if you look at this, if you looked this, looked at this purely from a political or partisan perspective, the anesthesiologists are gonna like it, and the CRNAs are gonna hate it.

Joe: Mm-hmm. 

Randy: Uh, I would s- I would invite us to think about it in a slightly different way, which is what are the practical implications here? Does this increase access to anesthesia care in rural and underserved areas? And the answer's gonna be no. Uh, will ho- will rural and underserved hospitals aggressively move towards trying to recruit anesthesiologists because now there's this new funding mechanism?

The answer's gonna be no, because they're gonna do the math- Yeah, absolutely no ... and see that the all-in cost still is not worth it. Will anesthesiologists all of sudden decide that, "Hey, I can make [00:54:00] $600,000, uh, working in Dallas-Fort Worth, uh, or I can go to the middle of nowhere, Texas, and make the same amount of money, or maybe a little bit less actually, unless the hospital covers the, you know- Really kicks 

Joe: in

Randy: will they start to migrate into those areas? The answer's gonna be no. So, so I think there is, you know, this is a, one of those things, you know, from a partisan perspective that gets people's blood boiling. But at the end of the day, whether this thing passes or not, it's going to have no material impact on anesthesiologist employment in rural or underserved communities.

Full stop. 

Gary: I get requests for people to, to provide revenue projections for new facilities all the time, probably 100 a year. I've had one group ask me about a rural hospital that would fall under this. 

Joe: Mm-hmm. 

Gary: And they, they chose not to do it anyways, right? 'Cause the, the numbers just don't make any sense, right?

When, when you have a shortage and you're having trouble getting people anyways, do you really wanna send them an hour and a half out into to the sticks? It's just, it doesn't, it doesn't happen. It's [00:55:00] just at this point it w- it's not gonna make a difference. 

Joe: Yeah, indeed. Uh, I think you, you guys have, have said it all in this.

It's-- I, I doubt it'll pass, right? For a, for a whole host of reasons, and I doubt it'll pass because the framework and, uh, just keeping my eye on the time, this is gonna be my thought of, uh, of the week on this rumination section moving on here. I doubt it'll pass because the framework of the last 100 years, so to speak, has been generally how do I limit the value of that other group, right?

Like that, that's what Uh, and I s- I, I think it's fair to say that the ASA, which is a, you know, powerful and well-funded and, you know, they've done a lot of good in the world. This is not a criticism, it's an observation. You know, the gener- Well, a big part of their agenda has been putting these supervision laws into place, all that sort of thing.

I, I already said I don't think laws really pr- protect them. Their value is inherent, right? There's value to that profession for American society, there's no doubt about that. But the faster we can get, and this is [00:56:00] part of the reason we have this show is try to have this conversation. The faster we can get away from how do we limit value to instead focusing on how we grow the pie and increase the value proposition of our members, of our community, help them do more for patients, help them do more for the system, to grow their leadership capability, to move into new areas.

If we start having that conversation collectively, I think it's a much more powerful conversation to have. The eas- the low stakes, you know, the kind of the table stakes thing is let's work on reimbursement together. And we should, right? I think we should generally stop using the government to try to influence markets, which is what is really happening, right?

Regulatory capture. Get away from that and empower local groups. And aga- and then rather than talking, rather than trying to use the federal government to legislate scope of practice, which is crazy, let's talk about competence at the local level. There's plenty of local me- mechanisms, medical exec, peer review, quality [00:57:00] committees.

They are gonna be much more keen on the competence of their teams than anything that we can come up with, uh, that's written into paper at a state capital or federal, federal law. And again, that's not, it's just not what our government does well. Government should do things like long-term funding, big audacious goals, going to the moon, national academies of science, all those things are super important.

Uh, so- social safety nets, of course. I 

Randy: mean, a lot of our conversations have been focused on the cost of healthcare. Uh, a- and I think that will probably be a trend. Uh, and obviously anesthesia is a, is a, is a very small portion of that, but an important portion to this audience. So I happen to think that healthcare has less of a cost issue than most people realize.

Hmm. I think healthcare has a productivity issue And if we look that through the lens of how are we maximizing the productivity of the system versus how do we engineer reimbursement in a certain way, I think you're going to [00:58:00] have, um, probably some more productive conversation. So if productivity improved dramatically, I think a lot of our financial problems would go away.

And whether that's in anesthesia, uh, whether that's in, you know, in throughput through a, you know, a, a, a physician office or any element within healthcare, if we focused more on how do we improve productivity, not all of our cost conversations are g- will, will go away, but I think a lot of what we are positioning as cost is actually a productivity problem.

And I, you know, I s- you know, we see this every day in anesthesia, which is they're like, "Oh, your, your, you know, anesthesia services are too costly." And I say, "Well, if, if we compared the cost relative to your productivity," which is often a proxy of OR utilization, "we actually don't have a cost problem. You have an OR utilization problem."

And I think that is, you know, an issue writ large across healthcare, and I think is often missed in this debate around cost. 

Joe: Well said. I think, uh, one of the big themes is, is just [00:59:00] that we've been talking about is high performance, right? It's, it's well-run organizations. It's productivity, and that's, that's the real conversation to have.

Gerry? 

Gary: Yeah, I, I don't know. You know, I guess my, my thoughts are I don't know where this is gonna end, right? Like we talked earlier about, uh, more micro hospitals being built, right? So to get more efficient, you're gonna need to, um, run more patients through those f- through those facilities, and if you keep adding more facilities, you're increasing the inefficiency, right?

So, uh, you know, we have an aging population, but we have a birth rate that is, is either level or negative, right? 

Joe: I don't think it will change a great deal I hope I'm wrong. But assuming it does not, I think, and this is one of the-- I just keep thinking about this. Well, what do we do in the meantime? And then it's like, well, let's make our group, let's-- And this applies to the individual and the s- and the system.

Let's make our group, let's make our community, let's make our organization as [01:00:00] effective and high performance as we can be given this current situation. And I, I think that's a, that's a individual responsibility of every functional citizen, right? Like, we should be doing those things. Uh, that's how the country runs well.

All right, everybody. I hope you enjoyed the episode. We are really, we are really enjoying these conversations. This is the stuff that no one's ever taught about, that no one talks about. It's connecting these big societal issues to our tiny little world, our tiny little community of anesthesia. So there's a lot of ways to reach out to us.

You can email social@abouttherest.com. If you don't like what we said or you do like what we said, we still wanna hear from you. Please send us an email. We will often take that commentary and bring it right into our show. We have a website, abouttherest.com. I'm on all the socials, LinkedIn, Instagram, TikTok, et cetera.

So is the podcast. There's some crossover there. Human Content has a podcast family on Instagram and TikTok. You can find their stuff @humancontentpods. So for all those who have been leaving feedback, [01:01:00] thank you very much. We are very appreciative. This is on video. For those listening on Spotify or watching on Spotify, listening on Apple Podcasts, we are on YouTube as well.

And finally, I am your host, Joe Rodriguez. On the show today, Randy Moore and Gerry Keeling. Our executive producers are myself, Aron Korney, Rob Goldman, and Shahnti Brooke. Editing and engineering is by Andrew Sims, and our music is by Omer Ben-Zvi. To learn more about our disclaimer program and ethics policy, our submission verification and licensing terms, HIPAA release terms, you can go to our website or you can reach at, out to us at production@abouttherest.com with any feedback, thoughts, questions, comments, concerns, any fun medical puns you wanna send our way.

About the Rest is a Human Content [01:02:00] production.