Well, Sharon, we're going to be talking today about the industry outlook for CRNAs. You know, I think this is an important component. Anytime you're talking about 1099, I think one of the things that CRNAs are always worried about, and I hear it today, just like I did in 2008, was, is the industry going to dry up? Am I going to have to be scrambling to get back to W-2? You remember 2008. I do remember 2008, but I was a W-2 worker. Yeah, yeah. Well, and, you know, everybody was scrambling, but, you know, I'm going to say that this is a different industry today than it was in 2008 for a lot of different reasons. One is the passage of the Affordable Care Act added a whole lot more capacity into the system. And we'll get into some of these other things as we go along here. But, you know, what we're going to cover today is, you know, what does the next few years for CRNAs look like, especially on the 1099 side? And I know, Sharon, since you're doing 1099 as well, this will be very interesting to you. Well, as we all know, there are about 61,000 CRNAs, SRNAs, and we provide about 50 million anesthetics in the U.S. every year. CRNAs give about 80% of all the rural anesthesia. Actually, we think it's probably closer to 100%. Opt-out states, we've had 24 states that have opted out. And as of this taping, Delaware was the last state. And trust me, it's no mistake that the lieutenant governor there is a nurse and running for governor. Guam has also opted out of the federal supervision requirement. And nothing really has changed in the CRNA environment, the APRN environment. We're the highest paid advanced practice nurse. Yeah, Sharon, you know, as we continue to see more and more opt-outs around the country, that gives CRNAs opportunities to actually work up to their full scope. And I think that makes a big difference. I alluded to a minute ago, 2008. I don't remember how many states had opted out in 08, but I know it was less than 24. And that's another thing that has changed dramatically since then, is we're seeing more and more opportunities for CRNAs to go 1099, because they're able to work up a little more to their scope of practice as well. Yeah, this is something you always like to cover. I mean, you know, we all know that CRNAs make a good income. And I thought this chart was really interesting to kind of compare to other folks in the medical industry what CRNAs actually make. And, you know, this is actually probably low. You know, you can look at 100 different places and find 100 different ideas for what CRNAs make. And I think this is a low iteration here. But, you know, take a look at this. I mean, CRNAs, more than some dentists, podiatrists, pharmacists, optometrists, you know, the list goes on and on. And Sharon, you know, the reason for that is what? Why do CRNAs make more than a lot of these other professions? Well, number one, our level of pay is commensurate with our level of responsibility. Yes. And we are pretty much, pretty close to 50-50 males to females within our profession. And mainstream nursing is about 9% male. They just go to nursing school to come to anesthesia school. And, you know, anytime you have a feminized profession, the salary is low. So I thank my lucky stars every day that we have this many men in our profession. And that's another reason why we are paid more than other APRNs. You don't see a whole lot of nurse practitioners who are male. So that's another reason why. I don't know the exact breakdown of nurse practitioners, male and female. I know there will be more than mainstream nursing, but that's, in my mind, a reason why our salaries are higher. I think that's interesting. Here we are in 2023, and we're still having to have these types of conversations, but it really is true. You know, I read something the other day that I think it said that in most industries, females make about 83 cents on the dollar for what a male makes. And hopefully that is changing for the better here, but you're right. CRNAs get paid what they do because you guys have a lot of responsibility. When you anesthetize somebody, they don't care if you anesthetize them. What do they care about? They want to make sure you're going to wake them up, and they're going to get up off of that table and can continue to enjoy their life and so forth. And I think there's another reason in here. If you look at what CRNAs do, you guys are in the room for surgical procedures, right? Exactly. There are surgeons present, correct? Yes. And where does most profit come from in the hospital? In most systems, it comes from surgery. Yes. Well, it's the economic engine of any hospital. Right. There again, they cannot perform that without you guys. That is the economic engine, as you just said. So again, CRNA salaries are higher because of all these factors that go into that. This is kind of another interesting slide sharing. I'd like to kind of paint that picture of where we are. I mean, CRNA, number eight best healthcare jobs in America, number nine best paying jobs. I mean, 6.9 out of 10, I think is still low because I've been doing this for a long time. You've been a CRNA for a long time. I would say overwhelmingly, the majority of CRNAs love their job. Well, 88%, if given the opportunity, would choose the same profession all over again. And I can't think of many professions that have that type of statistic. No, I mean, again, I've been doing this for a long time and I think over the years, I might've had one or two CRNAs that didn't, they got into it and realized this wasn't for them. They didn't want to do it. And they tried their hardest to get out of that industry. You know, if you look at- Or something or, you know, they still love the theory of giving anesthesia. They just might not want to give anesthesia every single day. So a lot of people will teach. Right, very true. And if you look at the projected growth in the CRNA industry, 12.69%. And that was from 2020 to 2030. I think that's probably about where we're still seeing it over a 10 year period. Here we are in 2023. So again, amazing profession. I think that what we're also seeing is more and more students, more and more opportunities out there for students, more and more schools coming online. And we'll talk about a lot of that in what we cover, but absolutely one of the best professions out there, in my opinion. And Sharon, I know because you wear the CRNA pin proudly, you definitely think the same thing. But there are some things that people need to be aware of. There is this massive supply, demand, and balance in anesthesia. And Sharon, you've seen it like this before. I mean, you've been a CRNA for how long now? 31 years. 31 years. And you've seen the ebbs and the flows of this industry, just like I have. You've obviously seen it more than I have, but there are some reasons for that. We're aging. I used to be on the front of the bell curve. Now I've gone over the hump and I'm going down on the other side of the bell curve. So CRNAs, we're an aging population. Yeah, we've got an aging population of CRNAs and we have an aging population in the United States. Period. Yes. That's the other part of this is, Sharon, as you get a little age on, you're kind of like a car, right? As the car ages, does it need more maintenance or less maintenance? More maintenance. And it's the same thing here, which means, maybe they throw a hip out, break a hip. They have a cardiac event and need to go in there and clean some things out. They get something wrong with them. They need some sort of procedure, which just means more work for CRNAs. And obviously that is helping the CRNA industry as well. We've seen a lot of practice consolidations throughout the last few years, merging and hospital systems and anesthesia group mergings, and you've got private equity money in anesthesia. So again, these have caused some supply-demand imbalances as well. We've seen this shift to the value-based healthcare, which again, breeds opportunities there for CRNAs and outcomes. And this is a big one, trends toward more anesthesia services in outpatient settings. This has been going on for quite some time now. I remember when we first started having anesthesia services in outpatient settings in ASCs, and now we're transitioning more to office-based practices, and those are popping up everywhere, especially GI. And nurse anesthetists have found a niche, especially doing GI. Yeah, yeah. No pun intended there, right? Right. But you're right. I mean, these ASCs popped up everywhere and we kind of saw this push out of the hospital environment to these ASCs, which basically led kind of to a split in the CRNA industry as well, because in ASCs, more times than not, you've got CRNAs giving the anesthetic. And then hospitals, they still kept on the same amount of CRNAs there to kind of push more caseload to the hospital and then push it out of the hospital to the ASCs. So we've seen some splintering of CRNA workforces because of this as well, which has kind of led to this demand problem. So right now where we are is we've got about a 10.7% excess demand for anesthesia providers. That means if you look at this on a chart, you know, you need 100 CRNAs, you've got about 89.3. And that is the case all across the country. And again, there's a lot of things, as you said, CRNAs are aging. I think the average age of a CRNA is close to 50 right now, and a lot are retiring. We're not replenishing at a really fast clip comparison to retirements and new grads coming out. But I alluded to earlier, and Sharon, you told me the other day, I think, how many new schools are being chartered right now? Do you remember? Well, there's about 130 right now. We have gotten down to in the 80s, in the 1980s, and we've been trending upward. So 130 schools at last count, and there are some in the hopper. I can't tell you how many right now. Yeah, I thought somebody said the other day there were 13 or 16 that were out there to be chartered. And what we're also seeing is as we switch to the DMP, I mean, that costs a little bit because you really had about a year in there of non-SRNA to CRNA production, which kind of put us in this situation as well. And then every school out there, for the most part, is taking more students each year than they used to. So we're trying to increase some of that supply side. And although it won't be done quickly, that supply does go down. By the time you get out to 2027, that demand will then be down to about 3.6%. So as you look out over kind of a 10-year period, it doesn't look like that supply-demand is going to be balanced anytime soon, which lends itself to the opportunity for CRNAs to have a lot of good work ahead of them, Sharon. Absolutely. Another great chart, and Sharon, I know you love all my charts with all the numbers. Oh, Lord, yes. Gets me glassy-eyed. But again, you want to paint the picture here. And there is a disequilibrium in the marketplace. If you look at the supply-demand, here we are in 2023. And again, these were projections that were put out there. That supply-demand, 95,000, the demand of full-time employees. Supply was about 90, so the difference was about 4,800 or 5.3%. It's actually greater than that. This was something that was done in 2021. But again, that's how they got to 3.6% projection in 2027. Now it looks like it's going to be pushed out basically somewhere in 2030 to 2033 before we get closer to there, which again builds a lot of opportunity out there for not only W2 CRNAs, but also 1099 CRNAs in the marketplace, because that is a big concern, as we alluded to earlier. what if the market, you know, goes back to a 2008 like event? What if they stop hiring 1099s? Everybody thinks that way, but it looks like for the foreseeable future that there's going to be plenty of demand and a lack of supply so that those opportunities should still be there. We'll talk about pay later, you know, and what that means, because we have seen this dramatic uptick in pay, especially as of late, but this is just a pure supply demand problem here. Hey, see, this is you, Sharon. What did you make when you first came out of anesthesia school? $70,000 a year, and that included all call. I was on call every fifth night, every fifth weekend, started out every fourth night, every fourth weekend, but $70,000. Yeah, I mean, and now look at where we are, and it's well over $200,000 a year, and this is a W-2 salary. We've seen dramatic growth, especially over the last few years. And again, that goes back to that supply demand part of what we were talking about, you know, and we hear all the time, can this continue? What is this going to look like as we move forward? CRNAs today on a W-2 side are somewhere in that 220 range typically, but we're also seeing this massive growth in income on the 1099 side, which is probably why we're doing this whole video series, Sharon, is because there's been this massive opportunity and massive growth on the 1099 side, and people really need to understand it and understand what they're getting into and make the best decisions for them. But you know, over a 10-year period, this is a pretty dramatic growth to go from 154,000 to 200,000. And basically, if you're going to look at the next 10 years moving forward, the growth rate is going to be even higher because you see early on in 2013, 14, and 15, you didn't have a lot, but then 16, 17, 18, 19, 20, and 21, you had these massive jumps, and we saw that again in 22, and we've seen it again in 2023. Well, Jeremy, it looks as if, like Juan Quintana used to say, the future is bright for CRNAs. The future is bright for CRNAs. You know, I think that's kind of a picture we're painting here. In fact, you know, my wife has a CRNA, Sharon, and my daughter's going back to anesthesia school after she pays her dues in the medical ICU. So I believe as well that the future is bright for this industry. This is something else, you know, that we always talk about and really want to get across. I mean, Sharon, we know that anesthesiologists are probably not going to sit at the head of the bed, right? That is correct. And this is one of the reasons that makes it really a disincentive for anesthesiologists to do this as well. And this is a fairly low salary for a physician anesthesiologist, $450,000. If you were staffing, you know, a facility and it was all MDs, you know, it costs you $7.2 million a year just in salary alone. And then you kind of switch that to the ACT model and a three-to-one supervision with six MDs and 14 CRNAs making 225. We can obviously see that that goes down pretty dramatically in that scenario, Sharon, to 5.85 million. But overwhelmingly the model that saves the most money is CRNA only. And Sharon, why are we still talking about this? Well, that is the $10,000 question, right? I mean, I believe that models are changing and we had a system in North Carolina that actually changed their staffing models where they went to all QZ billing. So they were over-utilizing and under-utilizing, over-utilizing CRNAs, under-utilizing anesthesiologists by changing the staffing role ratios. And guess what? They saw millions of dollars in savings. So I think as this word gets out and hospital systems are understanding it, we will trend more to that in the future, which will make the market heavier for CRNAs. Yeah, well, you know, and I think too, if we just look at this logically where we are in our country and you look at GDP, I mean, 20% plus of GDP right now is healthcare costs. You know, eventually the folks in Washington have got to take notice of this and start to kind of put their finger on some of the holes in the system. And, you know, again, we're not here today to bash anesthesiologists in any way at all. I mean, you and I both know anesthesiologists do have a role in anesthetics and they're always gonna be there. But I think moving forward, the roles have to change and the money is the big reason. And as the government starts to look at this and they really see that there is no difference in most cases between a CRNA given an anesthetic and a physician anesthesiologist given an anesthetic, this will come to more and more fruition because it has to. You know, I've been thinking of Jan Settner in her speech the other day, and, you know, CRNAs give pretty much all the anesthetics out on the battlefield, right? Yes. And what do you say, what happens when they leave the battlefield, Sharon? All of a sudden they cross an imaginary line, which is a border to a state, or they lose their IQ as they fly over the ocean back home. And we know that that is not the case. What they did yesterday in a battlefield, they can't do today whenever they come home, which is absolutely ludicrous. So that tells you right there that anesthesia is politicized. Yeah, yeah. Well, you know, I don't think I've ever seen a more politicized industry than this industry. I mean, really, if you're not in it every day and dealing with it and understand it like an outsider like me does, you wouldn't get that. But I think CRNAs recognize that, I think anesthesiologists recognize that. I think people outside of that industry really don't know it unless you eat, sleep, live and breathe it like I do. But it is, I mean, it's so politically charged. And the bottom line, Sharon, is it's over. What you always say. What, yeah. Money, money, money. The answer is money, what was the question? That's exactly right. Yeah, so again, we know that moving forward, there's gonna be more opportunities for CRNAs out there. And there just has to be. As long as CRNAs continue to deliver safe anesthetics across this country. Well, reality is we are a solution to the healthcare problem. Because we are low hanging fruit to help the problems with GDP, the problems with healthcare. We are low hanging fruit for that. And we're the only nursing specialty that is exactly interchangeable with our medical specialty. And therein lies the problem. Therein lies the problem. Yeah, and as we said earlier, if there is a, a lot of hospitals out there are really working on extremely thin margins. And if we know that one of the profit centers of the hospital, the main driver is surgery, and we can lower the cost or the input of that surgery, then it increases the revenue to the hospital, which in turn pushes up their bottom line. So eventually this will all catch up and CRNAs will be the winner to some extent of this political battle, for sure. Again, Sharon, you know, I mean, this is another way of looking at it. You know, if you're looking at staffing 10 surgical operating rooms, if we had CRNAs working up to the full scope of their practice, the cost of that would be 2 million versus physician anesthesiologists of four. And even if you add our friends, the AAs into that model, that still jumps it up, you know, to 3.22 million. Sharon, I want you to talk about this a little bit, you know, on the anesthesia assistance. You know, what is the reasoning behind AAs out there and how does this benefit the anesthesiologists? Well, Terry Wicks so aptly in his presidency said that you might as well classify AAs as the Anesthesiologist Job Protection Act, because you have to have an anesthesiologist when you have an AA. You can't QZ build the way that you can with CRNAs because they have to be supervised. So you will always have to have an anesthesiologist so that will increase the cost of care. Right, right. Yeah, and I mean, you know, we see that like writing on the wall that this is, you know, Job Protection Act is really what it is. You know, there's what, a little over 3,000 AAs out there. And you said something the other day when we were talking about this and I found it interesting is that now you're seeing anesthesiologists actually go out and recruit RNs to go to AA school. Yes, because one of the biggest things that we have utilized whenever we have talked about AAs is that they did not even have to have a healthcare degree. So what we were saying was a valid argument. So now they're trying to take care of that by recruiting RNs to go to anesthesia school, but there'd be an AA. So that's kind of a tough argument for us. If they were already a registered nurse, which is exactly the way we are, they're just going a different route to become an anesthesia provider. Yeah. Well, you know, knowing nurses and nursing like I do, you know, I think that most nurses would probably prefer to be a nurse, anesthetist, anesthesiologist, whichever side of the equation you're on. But, you know, looking at it from a true cost standpoint, you know, to be an AA, you go back to school for two years and you're done. To be a CRNA, you go back for now three years and get your doctorate level. Now the difference is that that nurse who went back and got her AA, she is now beholden to that anesthesiologist and is never going to really be able to practice on her own. Whereas the CRNA is going to be able to practice on their own without that anesthesiologist there, which potentially could lead to more money. I mean, you know, most AA's come out making almost the same as what CRNA's make. They do make the same. And even though CRNA's get some anxiety about that, the reality is that's in our favor because if they do make less, then they would be hired just from a pure monetary aspect of it. But whenever there's a choice between a CRNA who can take call alone, or there's an AA making the same amount of money, the two are going up for one job, the CRNA is the most likely to be hired because everybody does realize they can work independently. They can take call, they can do so much more. So even though CRNA's have not been happy with the fact that they make the same amount of money, I think it's been in our best interest. And if they ever make less, then we should be worried. Great point. Great point. All right. Now this is, you know, we're going to end here in just a second for this module, but I felt like this was something that was very interesting. You know, if you go back and you look at anesthesiologists delivering anesthesia care, and Sharon, you know, I know you've been with CRNA for a long time. It happens less and less. And that's what this slide is telling us over 2010 to 2019, when they did the modifier AA, which basically means that the anesthesiologist did the anesthetic, it declined from 40% to 31%. And I would demise that that probably is continuing to go down. I would agree. Yeah. So we know that one of the solutions for some of the shortage would be for anesthesiologists to actually be getting anesthetics. But what we're seeing is we're seeing that trend the opposite way, which again, the whole idea behind this particular module, Sharon, was to paint the picture of what the future looks like for CRNAs. And after we painted, you know, this picture, what do you think? Again, the future is bright. Future is bright. I think that ends this one right there.

Certified Registered Nurse Anesthetists

CRNAs

healthcare industry

roles and salaries

responsibility

growing demand