Listen carefully, because this is how we're going to continue our profession and make it wonderful. First of all, what I'd like to do is have each of our panel members introduce themselves. Today. We're going to talk about the efficiency driven anesthesia models. It's it's friendly name is EDAM and the purpose of the efficiency driven anesthesia models is really. To kind of be much, much more cost effective in the way we provide anesthesia services and today these gentlemen who've all implemented are going to explain not only what EDAM is, but we're going to talk about what are the issues that they've had to move and remove barriers so that we can implement this this type of model. So, I'm going to go ahead and start, and I'm going to let you guys just introduce yourself and move down and talk a little bit about who you are and why did you get invited? So, Chris, you're 1st. Hello, my name's Chris. I'm currently the president of middle Tennessee school of anesthesia and the chair of the reimbursement technical advisory panel real fancy sounding. But that is the group of people up here that are putting together this information and we're going to talk along the way is how we're rolling it out across the country as well. Glad to be here. Thanks, Chris. My name is Adam Boyd. I'm the vice president of clinical performance for sound anesthesia. That's a big fancy title, which means I get to be the utility knife for anything business operations and business development related and we use a lot of these principles in our day to day. Our day to day efforts in expanding the business and actually making our current business even more efficient. I'm Scott Reagan. I also serve on the technical task force and I provide primarily non surgical pain management services, but we also provide anesthesia services to our companies. And multiple states 14 states in the United States and dealing with this sort of implementation program is something that I'm glad the ANA has put it together. I'm glad we get to work together on this and it's super efficient and, you know, cutting to the point, not having long drawn out conversations and helping Move your practice along. Thanks, Scott Tracy young day in a region seven director from the great state of Louisiana. There's any Cajuns here. So a couple earlier, but they're probably at the bar. We, we ran out of lavalier. So I'm have to hold the microphone today. The in my role in my non advocacy life with the ANA. I'm the chief operating officer of essential anesthesia management. We implement these practices across our hundred and thirty seven hospitals across six states really trying to find the most efficient and safe way to deliver care across all of our facilities. Thank you. Let's go ahead and get into this and a couple disclaimers and warning. I am an educator. So we're going to go to school for a minute. And also kind of framing from my own perspective. I was a hospital administrator for eight years. So some of this language and talk comes from that experience as well. And as an educator. I really believe in frameworks driving conversation. So, so we're going to talk. This is our disclosure. We have nothing to disclose. We're having a conversation. About our profession and we don't are. We all benefit. Nobody benefits independently for this some outcomes in this first one. I want to take this take a little moment here. Identify options for health policy research for students. We have educators in here. We have students in here and we are going to talk about the current literature that's available today. You know what guys we need more literature. Okay. So anybody out there in an education role at a loss of a doctoral project. Call me. I can throw out all kinds of ideas. And also with that educators you're not on your own. The people you see before you will will be content experts on your committees. You can reach out across campuses because this is we're all in this together. We need to work together for success also want you to be able to lead a discussion in this. We also nationally recognized policy framework. What we're presenting to you today is actually from a book that is on the refer the recommended reading list. If you're going to sit for your certified health care executive credentials. So possible administrators are reading this. They understand this language educate key stakeholders. We are here to talk to key stakeholders. And what we're trying to do at the A&A level and with our task force is we're trying to get a conversation that's unified across the country because when people hear things in a unified approach they believe it. They those micro impressions become major impressions when they're along the same line of talk. So we're going to teach all of us how to have a unified conversation. And then there's obviously in here maximize anesthesia staffing because we are talking about money. We use the word efficiency. Three components here and it's really pretty easy. Efficiency effectiveness and equity cost quality and access. Right. But people like frameworks. We like fancy words. So this is what we're using at the three cost quality and access just doesn't sound as good at the top of this where you can see also I want you to know and if anybody here does public policy. This lines up very much with what's called the triple aim by the health institutes. OK. So improve health lower cost better care follows the same pattern. Those three pieces you'll see over and over in policy research. What we're looking for is the pound of the point of sound decision making. Where do those areas come together if we're doing a health policy analysis and where's that sweet spot. So that's really what we're looking for. How do we find the balance between equity effectiveness and efficiency. Now I dig health policy research because I got a little bit of ADD and look at this. It comes in when you think about this. I want you to kind of think hey have I considered the political science economics and management science psychology sociology epidemiology and public health because that is health policy. What we're doing today is we're going to wrap all that stuff up in an easy to communicate framework again. So the effectiveness what is this effectiveness piece. It is the intended or desired outcome in the components that you're going to read about and hear about our overall well-being physical mental functions disease treatment quality of life all those things that we're used to when we read about how did this component work. Was it effective. However I want you to when we're having this conversation and we're talking to these stakeholders this is not efficacy. They're all CRNAs and you think I push propofol patients eyes fall they go to sleep. Yeah it works. But when you push propofol on everybody in this room how does it work. Some people have some major allergy. Some people just you know have the cardiac collapse because it was just too much. That's when we get into effectiveness. Population population a state a country a hospital a surgical unit. Think up in that level intended for the population. Efficiency efficiency is all about the money. Okay. When you were talking efficiency it's all about the money. There's an outcome side and there's an input side. The outcome side is productive efficiency and when we talk about that what are the pieces that make up. So if we're talking maybe regional anesthesia. Okay. IQ pump versus a single shot that type of thing. That's your outcome. When we talk though on the hill we're talking more of the input. And this is the allocation efficiency when economics and this is the combination of services. Doctors CRNAs AAs combination of services put them all together. What do we come up with in cost overall cost. And then equity access the few different areas to consider disparities rural health equality. Now keep in mind equity means the same access to opportunities right. Equality means same treatment. But what we're looking for is equal access that people if you're in a rural America are their providers they're doing regional anesthesia or do you have to go to the big city. You have access to care. That's what we're really paying attention here in the equity. A little bit about effectiveness. Okay. So really the biggest thing that I want to put forth to you guys is that the safety question is really has been answered. All right. Cut the Cochran group probably the preeminent independence analyzer of research studies meta analysis meta analysis in the world looked at all of the data from the physicians from our research and looked at all of the data that we have. And basically said there is nothing out there that demonstrates superiority of one model or the other. So we know the question is answered. But in leading those discussions you are going to have to be able to speak to the flaws in the research to misinformed or uninformed stakeholders throughout your entire career. We have these conversations every day. And I want you guys to to be clear on some of the points especially with silver. And I really I have to laugh every time silver comes up because we've looked at this study. It's now 25 years old. The data is 30 years old at this point. And I have to go you know gosh what were those researchers thinking at the time and that they were planning this study and their strategy session like OK OK. The data out the outcomes data doesn't support us being superior to the CRNA. But we've got to find something to scare everybody with. Right. OK. So what are we going to do. I know. Let's let's get a group of non physician or excuse me non anesthesiologist anesthesia cases from all sorts of different types of providers. Let's lump a few CRNA cases in there with these non anesthesiologist physicians some residents. We're going to make sure that that group has higher rates of pre-existing comorbidities. We're going to evaluate the groups on outcomes that really have very little to do with anesthesia 30 days out. And then we're going to roll all that up and say this is what happens when CRNAs provide care. And then the best part is you guys ready for this. We're not going to tell them how many CRNAs were included. It sounds like a great strategy plan. Right. Great strategy plan. Well it didn't take very long for the anesthesiologist colleagues. I think I'm jumping ahead here. The anesthesiologist colleagues to to say hey you know this is this is really a flawed study. It was published in the Journal of the A.S.A. right. Anesthesiology. And it was published in. I'm just going to come out here because I can't see this. And it was published in. What's that. Oh yeah. No Silber was published in 2000. And also I'm trying to figure out the other group. I can't remember off the top of my head. That's OK. Oh excuse me. A little known group called the HHS. Right. Of the U.S. government said hey this is flawed. It doesn't demonstrate you know effectiveness of physician care over CRNA care. You guys need to start you know stop using this. So Silber is getting kind of dated. They're still using it. Around 2012 we say well gosh we've got to come up with some other study. Right. So we get the the physicians and the anesthesiologists together. We get physicians from HHS in New York. Let's just do the Silber study again and call it something different. Right. Different group of patients different facility different time. They basically repeated the methodology more or less. They lumped us you know CRNA cases in with other non physician cases or non directed cases rolled it all up into a big package and said this is what happens when anesthesiologists are involved in this care. In contrast Duleese and Cromwell did a fabulous job looking at an even larger sample size of patients and looking at anesthesia specific outcomes during the length or the episode of care of the actual surgery and found no harm when CRNAs function without anesthesiologists. So those are your those are your three big studies that you guys have to be able to talk to basically that quickly with that you know efficient bullet points when you're having these stakeholder conversations. So effectiveness you know the the AA question is is is always you know the other question that comes up when you're looking at care team. The one big point right. Everybody's equally safe. AA is operating in a strict care team model with anesthesiologists, anesthesiologists operating independently, CRNAs operating independently or in some sort of supervisory model with anesthesiologists. There is no demonstration that safety differs. Right. So you have to then start talking about the restrictions of AA care operating inside a strict care team model, the restriction in ratios, the restriction in billing modifiers that can be used. You have to use the medical direction modifier and the seven tougher steps that go along with that. That is an impediment to the efficient effective care in the operating room on a day to day basis. Cases have to stagger. Supervision requirements have to be met. You've got to be able to speak to those points. I think that goes on to the next one. We already talked about that. And we skipped through this already. This is HHS and the anesthesiologists themselves talking about how flawed the Silber study is. But yet you continue to see it brought up in state testimony and federal testimony. It's kind of a flawed study that will never die. All right. I'll be talking about efficiency. And just to kind of give a little bit of background, what we're trying to do up here is give you the three E's and just give you some basis for those three E's. You can utilize those as you need and you can add to them or take away because in your specific state, for example, there may be things that you need to tell someone and you can add it to these three E's and utilize this however you need. But it gives you a framework to kind of throw everything into. So when we look at efficiency, what we're really looking at here is let's look at the money side of this, right? Because we argue back and forth about this all the time. If you've never been at the table in one of these discussions, if you've never had to negotiate your contract, you may not have these discussions, but consistently you're told, for example, you might be a cost center. How many people have heard that before? If you haven't heard it, that discussion is taking place behind closed doors. I've heard it numerous times and we are definitely not a cost center unless your subsidy is so high that you're maybe doing a few cases a week and not actually paying for yourself. But from an efficiency standpoint, when we look at this, when we look at potential cost saving strategies would be to increase the number of procedures performed by CRNAs alone. So that means working to this top of your scope of your practice, right? Not having these one-to-one, one-to-two, one-to-four, these types of ratios. All this does is add cost. It adds cost to the system. And as long as you are a fully trained independent provider and you are safe, potentially have someone run on the board so you have a set of hands if you need it, that's what we're discussing here when we talk about efficiency. That's the best way to utilize our service. It makes literally no sense. If anyone in here thinks one-to-one is a great ratio, I'd love to have that discussion later. Does anybody have that? No? Okay. So we'll move on. And then the second piece of this is to increase the proportion of procedures under the supervisory model, right? So the difference between direction, supervision, those pieces, okay? Physician-led care saves lives, reduces cost when seconds count, right? I'm sure everybody here has gotten push notifications. If you're on Facebook and you mention the word or you talk about it or they know you're in anesthesia, you're going to get these push notifications if you're in the right geo-tracking area, which everybody's been talking about today. When we look at the studies that say this, you know, is physician anesthesia cost effective? And you look at how they develop the study because you will be asked these pieces. You need to be able to respond in an informed, data-driven way. So if we look at the primary basis, there's no cost difference for insurers, Medicare, or provider class, right? How many people, and I want to really see hands this time, know what a subsidy is? Okay, good. There's 50% did not raise their hand, so I will tell you. A subsidy is what the reality of anesthesia looks like. Everybody knows that right now, everybody's like, I want that $300,000 salary, right? I want that 280. I want whatever number it is that's out there. There's a good chance that that's not actually being generated by the performance of your work. And hospitals rely on some kind of a piece of, if they're employing you, they rely on some sort of overage, right? If you just do a basic math and you say it's 30% cost to the hospital for employing you at 300, right? So 30%, they're into it. They're almost 400 to employ you. That's, you know, napkin math. It's probably different for each facility, depending on your benefits, right? But that's the reality. Do you really think if you're, you know, in some places where you have 13 to 26 weeks off a year, you're generating that much revenue? You're not. They're having to take from somewhere else to pay that salary, right? So when you look at what a subsidy is, most physician-led practices, if you're looking at it from this verbiage, have some form of a subsidy that may or may not be reported, most likely not, in that calculation. So when they say, this is all we have to run this, we have a, you know, for example, they'll just recently looking at a contract. They need basically $6.5 million to cover the department, and they have a $4.6 million capture. Somebody's got to make up that revenue. Right? That is a subsidy, and it has to happen, or you will not have an anesthesia department, and you won't be doing those high reimbursing cases for ortho, or your spine, or hearts, or whatever it is that you're doing there. Right? Okay. So that's basically what this is looking at. And when they claim that opt-out does not improve patient access, well, right. We didn't change where the primary care providers are. We don't change their referral patterns. We don't change where people live, but you do improve the ability for a facility to perform procedures if they have the right subspecialists in those areas. And if you look at geographic distribution, like, for example, where I work most mostly in Montana, we're able to bring those folks in. We have lots of small critical access hospitals that are doing spines. They got robots. They're doing everything that is done in big cities, and they're recruiting those individuals because people are after a lifestyle now. They don't necessarily want to live in a city and grind it out hard. So having said that, this fails to demonstrate any tangible cost savings from the evaluative literature, just so you're aware. And it takes too long, and this is the same, what is going on right now. It takes too long to hire a CRNA, and there's not enough anesthesia providers, so we need AAs. Has anybody, how many people, I'm sorry, my questions aren't always formed right. How many people have fought an AA bill? All right. We got a reasonable amount of people in here. Having done that myself, all these questions come up, right? I want to go back to my home. There's not enough people. But when we really look at the reality of what's going on, if everybody sat in a chair that was trained to do anesthesia and did their job, and they weren't looking for somewhere else to do their job while they trade stocks, then we would all, we would actually have an overage, right? But we, the reality is a lot of the things that are being done outside the operating rooms are now being, you know, kind of clamped down, pushed, they're removing anesthesia. I, this is like a little bit off topic, but the set assist, I guarantee is on its way back. I've been telling you, if you don't know what that is, that is a propofol box, and you will know what that is because it's already gone all the way up to medical device utilization. Jackie Rawls did an awesome job of advocating for our profession and kicking that down in around 2010-ish, but it is AI now. It talks to them back and forth. You know exactly what's going on with the patient, and it is notifying everyone. It's almost a person in the room. It's used outside the United States everywhere. So if you're not managing those cases in your GI suite and your eyes and anything else that requires minimal sedation, be aware that that is something else that's going to be an issue for us. So we have to be providing service, high-quality work, good relationships, all those pieces. All right, so as Chris mentioned earlier, when we talk about equity, we're talking about access. We're talking about making sure that communities can get the services that they need. I don't think it's going to come to a surprise to anyone in this room. CRNAs do 50 million anesthetics a year. We make up over 80% of all anesthetics in rural America. We have studies by Dr. Lorraine Jarden that show that CRNAs are correlated, where we provide care to lower-income populations than anesthesiologists. Furthermore, CRNAs are correlated with more vulnerable populations, such as Medicaid and Medicare-eligible populations, including indigent care. So we are the ones out there increasing access. We're providing care to communities that need our services, where anesthesiologists typically are not. Across the board, when you look at the studies, they're not there. So that's where we are. We increase access to care. That is the equity component. So this, I don't think there's much debate on that area anywhere in healthcare today. You go to any rural hospital, it's going to be predominantly CRNA-led care. This study from 2015 from Nursing Economics is in the process of being updated. Hopefully within the next 6 to 12 months, we'll get to see some fresh data. Our anesthesiologist colleagues are still bringing pamphlets with silver from 2000, and that data was probably from 1997 to 1998 that they used in silver already debunked They're still handing that out on the hill. We have data much more recent much more relevant and that is not flawed We've never had HHS come out and say hey your studies are so flawed. You need to stop talking about them, right? That's what they're doing with silver. So this is a big deal So Equity CRNAs are the answer Anesthesiologists, are they the answer? There's no literature to prove that they did one study in the VA and They said wait times aren't terribly long We don't have a whole bunch of patients waiting for surgery and we don't have a bunch of CRNA openings currently This was in 2014 So they hypothesized We don't need to give CRNAs full scope of practice because we don't have a shortage we don't have an equity We don't have an access issue. So this was all they could really state related to Related to access and CRNAs. They tried to extrapolate that, you know opt-out has not improved access and Scott mentioned earlier, I believe on his section opt-out doesn't change where people live, right? People still get care in their communities CRNAs typically were there before anyway practicing in non opt-out states under CRNA only models where the physician or the operating practitioner is our supervising physician when I go speak to legislators and when I speak to policymakers and They're like, how does that work? You know a surgeon supervising a CRNA says I answer it works on paper They don't know the drugs we give they don't know they don't know the difference between succinylcholine and sigamodex, right? They don't so why are they are supervising physician? It's due to some arbitrary Law that's in place and that's what we're trying to remove So we're working around it. The market is five ten years ahead of legislation and policymakers We're just trying to get the policymakers and legislation to catch up to what's happening to the market Also when we look at a A's and equity This was coming from North Carolina they said that Licensing anesthesiologist assistants will not harm access to care. Yeah, they're right. It won't Anesthesiology assistants they can provide anesthesia care. They just have to do it with an anesthesiologist with them If they're gonna go into a rural community They're gonna have to have a tag-along buddy with them that's an anesthesiologist that cost a lot of money to go do it with them So it hurts efficiency, but they can increase access potentially just by sheer numbers So maybe they work at tertiary care centers if they all of a sudden graduate 10,000 A's tomorrow. Is that going to increase access to care? It will right it's gonna displace CRNAs most likely From more urban centers and they'll get displaced out somewhere else, but they can potentially increase access to care This is the take-home slide if you remember nothing else from us today remember this That all three providers are effective There's no data that says there's any difference in outcome between CRNAs MDs or A's working with MDs Efficiency we are the only efficient anesthesia provider in the market No doubt about that Anesthesiologists are not efficient. They cost more to train. They cost more to employ A's are not efficient because they have to have a tag-along buddy with them everywhere. They go. That's the anesthesiologist And when we look at equity We're already there. We're already meeting the needs of communities across the United States and A's the answer and equities Maybe right if there's a bunch more A's that's a bunch more anesthesia providers So potentially they could increase access to care. But as we know we don't have an anesthesia provider shortage It was just mentioned by my colleagues here. We have a shortage of anesthesia professionals doing anesthesia So we don't really need more We need a new framework a new way of thinking about delivering anesthesia care in America And that's what this is about today It's to change the way people think about how to staff anesthesia departments Historically, we staffed anesthesia departments, especially in physician-led centers from the top down If there's 16 operating rooms, the first question is okay How many anesthesiologists we need to supervise all these rooms? The next question is how many advanced practice professionals to start staffing these rooms? We want to change the narrative from an efficiency driven standpoint to look from the bedside up What does this patient need? What does this subset of the population need? What does this community need? What is this community's resources or anesthesiologists moving to this community? Maybe maybe not and can this hospital afford a higher cost level of service right now in America? Sorry, you stood up too soon. I started rambling right now in America. No you stay stay stay I'm done. I'm done Yeah, now I'm really done you can go back Right now in America We we have the highest number of hospitals that are on the brink of financial failure than any other time in history the hospitals that are struggling the most are community hospitals and rural hospitals, so This is a crucial conversation that hospital administrators need to hear if they don't have an efficient model They need to hear about it. You can go to anesthesia facts or anesthesia facts calm get some of this info Help bring it to your hospital administrators We'll probably touch on that on the panel part of the discussion but this is a critical time to be having these conversations and Explaining to people how we're the only provider that checks all three of the e-boxes. Sorry, Lorraine These guys are the experts they truly are and the gist of all this is You can give anesthesia by yourself. Wow, really? That's shocking So what we want to do is really take the health care system And we want to really maximize the utilization of every provider and for us CRNAs So you've all been involved in trying to move departments move systems talk to people, right? so tell me a little bit about What's the biggest barrier when you walk into a facility and You see that the anesthesia department is much less than efficient. I'm sorry for giving people my back So, what are the barriers what are you stuck with how do you walk in and say something Who wants to take it? I'll start and I know others are gonna have to add You don't want to add some stuff on I think something I mentioned previously you're going you're battling this information It's not just Uninformed people it's misinformed people. That's the biggest barrier that I see day in and day out We can't do X because of Y well Y is not true so let's forget that for a second and figure out what we actually can do within the framework of your facility and you see a Lot of eye-opening and you see maybe some jaws drop and you see some You know a little bit of arguments every now and then so you have to be able to have a productive conversation to navigate around that I will say that Speaking as a past hospital administrator, you don't know which they don't know what they don't know I was building a 250 million dollar hospital and Arguing with architects that every or had to be divisible by four Because I thought that was Medicare law at the same time in my OB I had two CR and A's covering seven days on seven days off But over here because I thought was part of Medicare. Sorry. I was ignorant. Nobody told me different I was really ticked when I was a CR and A school and heard that no colleagues told me anything different But I thought that was law I thought with Medicare's only way I could do it was one before and you know what bylaws drive your practice We talk a lot about stuff that happens on the national level We talk a lot about stuff happens on the state level, but where it really happens is your bylaws Yeah, there is no state in this country that you can't operate independently if the bylaws are lined up correctly So you've got to get to that c-suite and we've titled this efficiency driven anesthesia modeling because you know What efficiency is something that hospital administrators care about is code word for cost. So Get out there meet your decision makers and we're talking about the same conversation the legislators but to answer this question is responsibility of all of you here to have those conversations with the c-suite because The only other people talking to them or the other side and again I ran hospitals for eight years and how many times to the CR and A come tell me I could do something different It's on you Yeah, okay, I would say the most probably one of the highest Misunderstood things by the average CR and A if you're gonna try and go into a facility and for example somebody invites you I'm sure people in this room have been invited in before to discuss what it would look like to transition to another Model or for you to come and take over a contract. Well Physicians are very good at putting themselves on the medical staff bylaws committee Which you just mentioned and they will create all kinds of landmines and those landmines are a problem because they only meet so often In a year and you could for example This is a real story come in and pick up a contract and you do not have the ability to do ultrasound guided regional anesthesia central lines or a lines and You don't know that coming in because you don't know what the landmines are in the medical staff bylaws and nobody can snap their finger And fix it. So there's a lot of these pieces that going in you kind of have to understand You may have the idea that you're in a state that all does independent practice It does these pieces and there is a series of landmines and misinformation as you discussed It's already in place and you're already starting behind all of that before you get started So so when I look at the barriers to this, I always start big and then move small from a big standpoint It's federal is a state an opt-out state or is it not there are Thousands and thousands of CRNA only practices in opt-out states. However, it is a Non-opt-out states. However, it's a lot easier to convince administrators and surgeons to move to a more CRNA centric or CRNA only model in an opt-out state because it removes that Supervision word and that supervision word scares a lot of surgeons when they When they hear supervision they think of one thing they think of liability and It takes a lot of time a lot of education I've done this throughout my career of sending all these documents to surgeons that they don't read Explaining that here's case law. You're not liable the facts of the case Determine liability if you didn't direct the anesthesia, you're not liable for it, right? That's one thing our judicial system has gotten, right? But beyond that once you get past a federal level and you start looking at your state laws your state scope of practice and then Below that your hospital bylaws. This was mentioned by some of my other colleagues here and then hospital culture What have they had before? How long have they had it? How much misinformation is circulating around that department? I've converted a bunch of hospitals from physician only so Maybe loose collaborative models introducing CRNAs and you'll be surprised where we see resistance Sometimes it's PACU nurses. Sometimes it's pre-op nurses. CRNA will go to do a block and be like, well, you can't do that You're just a nurse like no, right? Or we'll order post-operative medication and PACU while we're going through this transition even though we've educated them the answer They're like, oh you're a CRNA. You can't do that. So it takes a lot of education there's a lot of barriers all the way from the federal government down to individual nurses and Individual surgeons who the surgeons ask the same two questions. Is it going to be safe? And will I be liable you answer those two questions? You usually can get past a lot of that and one quick topic on bylaws Every time we take over a hospital we review the bylaws we read every bit of it because it determines how you could practice in the hospital and Everywhere usually where it says an anesthesiologist must do this. We change it to anesthesia provider, right? Make it agnostic So as long as you're it's within your scope within your skill set an anesthesia provider can do it to change bylaws You have to have a quorum of their medical staff and it has to usually pass by about a 70% majority to change bylaws It's not terribly easy to do. You'd never know where your opposition is. We had a hospital in Oklahoma last year We was uh, we had a physician and seven CRNA's we decided to go CRNA only hospital administration was behind us The surgeons were behind us. I edited the bylaws. I was not at the medical staff meeting. It got voted down. It didn't pass We had all the support we thought we needed the primary care physicians were concerned that it might open up independent practice for nurse Practitioners they weren't understanding what we were doing So I had to jump on there in an airplane Go to Oklahoma talk to these primary care physicians bring it back up at the next minute staff meeting for it to be able to Pass so just it's a it's a process. It is a slow ship to turn But it's it's a worthwhile ship to turn it just takes time. I Can tell you that? to Tracy's point If you're trying to shift your anesthesia models, I can't tell you how much time it takes. I Think that people think they can do it on a dime and everything will shift Unless unless the place is in crisis and I mean real crisis. It's almost impossible To turn it over very quickly So I would say my biggest my biggest words is tenacity With this kind of with this kind of a move, especially because we've been ingrained Many many facilities have been ingrained with misconceptions misperceptions of what we as CRNA's can do Without physicians without anesthesiologists now I just want to make one statement about this our intent up here is not to say we don't need anesthesiologist That is not our intent Our intent is let every anesthesia provider provide anesthesia So when we hear the rhetoric You're trying to get rid of us That's not true at all We just want you giving anesthesia. That's what you're supposed to be doing that. That's what we understand. Anyway, so I Tracy did a little bit but I'm gonna ask the other three if you don't and Tracy if you'd like to add I'm gonna get a little up close and personal but you're gonna not tell us what you're talking about No, not really what I really need from you is give me an example Give me an actual Case in which you had to go in and talk about this model and How that evolved over time and maybe even provide for the audience Your best guess of how long that process took and who you talked to and how did you align? Yourselves to be successful at introducing the EDM model So Chris, you're looking at me. So you win you go first. Are you ready? I don't run Groups, but I do consult I I go and consult hospitals I talk to hospital administrators and tell them what they don't know. They didn't know and certainly, I I don't implement I educate but When I sit around that boardroom, I'm telling you they don't know what they don't know It's amazing how many times when I'm in talking to them and go over and I bring all the data I bring all this that we just went over and It's like wow, where is this information been? However to your point they want it. They see millions of dollars. They want it really bad the hospital administrators are very very Concerned let's say scared. We're scared To tick off surgeons because all of our revenue comes from surgery. That's why they pay the subsidies This group I was talking to had 27 million dollars that they had to come up with a 27 million dollar hole to cover anesthesia Before they made the first nickel in their OR 27 million dollars and they wouldn't change their model. They're scared of the surgeons. So Even though you can educate and they're talking about it. Now. That was four years ago that I consulted I got a call Recently because this place that stands out because a few weeks ago and they're like hey We're got we're up against the wall. They're looking at bidding a new company. I said, well, I was out there a while ago Let me throw you my my report and it came back like that is exactly what we're telling them today So they heard it four years ago Four years later, they're shopping it again And I guess some things have changed are willing maybe to take the risk But it is very slow and it's very very scary a lot of hand-holding need for administration in these things Yeah, I think it all depends from our standpoint at least on the business development side It all depends on where we start, right? You we get some people that contact us that say we have an all physician model. We're tired of it You know tired of it. They're holding us hostage We want we don't want any more of this and they're ready to switch to it either either a care team model or even looser collaborative model right away Bylaws is one of the very first questions that we ask. It's part of our initial data request We want to address that as soon as we possibly can as a barrier so that it just depends on you know How comfortable is everybody do you have an administrator that is misinformed that needs to be you know? That we need to spend some time with quality time hand-holding time. Is it the surgeons? You look at some states like Texas and Arizona that have Explicit language in their statutes that surgeons are not liable for the supervision of CRNAs like if that doesn't get them I don't know what will I mean you get some people that are just Willfully ignorant they're they're going to hold to their position even though every bit of evidence states Otherwise, they're going to and you just have to keep hand-holding and massaging and getting those people You know turned around the corner to get done what you need to get done So it really all depends on where you start how big the facility is and where you identify barriers They're gonna they're gonna be in all sorts of places like Tracy mentioned that you may not expect I Mentioned earlier a you know seven-figure gap in production versus salary basically what you need to go against each department and a specific example was when we came in and picked up contract to be The agreed-upon deal in the contract was that we were going to increase the number of peripheral nerve blocks We were going to increase Calls the night before so that there weren't so many cancellations and keeping people in the keeping the throughput you know optimized and What occurred in that process was a bunch of pushback and it turns out they were employed surgeons But a bunch of pushback from surgeons. We don't need blocks. We don't need this. It slows me down It does all these things and so it takes six to eight months to work through this because you gotta gather the data Say this is what we said we were gonna do. This is how many blocks we didn't perform Which would have potentially improved patient experience got you better age cap scores generated more revenue But at the end of the day if we continue to be blocked by these things We cannot do these things our providers are more than trained to do all of these blocks So by the end of that time then they have to bring the surgeons in rain them in a little bit explain how it works To make money in the facility and it's the best thing for the patient It's not like we're saying we need to do this extra thing so we can add a bill It's actually overall gonna be better long term So that's a very specific example and it's not gonna make up that seven-figure gap But it's gonna make a dent in that gap We potentially picks up half of somebody's salary a lot more revenue coming into the facility So it does make a difference because we believe that we are generating lots of excess revenue But at the end of the day oftentimes, that's not the case I'll take a look i'm gonna tag a little bit onto that, you know, you can walk in there and change some things operationally So they may be used to the blocks delaying them, but you have to go in there and speak to you Hey, we're gonna do this differently and here's what we're gonna do So it doesn't delay you at all ever and that's you know, even specific conversation from ops that you have to have with those Yeah, um scott you mentioned something that I wasn't planning on talking about but since you did it it brought up a good point He talked about employed surgeons versus potentially surgeons that own centers ascs Ascs 97 of them all have some some form of physician ownership in the united states That is their pocketbook now That is their dividends they're getting from their ascs when they pay anesthesia subsidy. It's coming out of their pocket so these are the Much more open-minded individuals now about changing models because it's coming out of their pocket They've never had to worry about that in the past because asc anesthesia typically was always profitable enough And efficient enough to be able to generate enough billing from pro-fee revenues so that a subsidy was not needed What's happened in the last three years? Salaries have gone up 20 25 potentially 30 some places what's reimbursement done medicare's cut reimbursement 12 over the last three years largest payer in the united states. So reimbursement's going down compensation's going up It doesn't take a math whiz or an mba to see something's got to give right? And what's given is ases are being asked for subsidies all the time Ases now are more willing to switch to a more crna centric or crna only model because of who's footing the bill Some community hospitals the administrators are the ones that are keeping tabs of the beans, right? They're counting the beans. The surgeons are often employed and they don't care. It's easy for them to say No, I still want anesthesiologist-centric care because they're not paying for it. So I'm glad you mentioned that. One thing for me that shows the, we call this a slow cell cycle in anesthesia. We had a hospital, it was a surgical hospital, means it was owned by surgeons, so it's like an ASC but with overnight capacity. And this facility reached out to us in 2016 and said, hey, we'd like you to come in, make a presentation, give us a bid because we're having to pay a subsidy for the model we have. Went, did it. Administration loved it. Surgeons weren't so sure about it. Said no thanks. They kept their model. 2017, they call back. Come talk to us again. This was the problem last time. The surgeons were worried about liability. Explain it to them again. We did it. Surgeons like, I think we got it. Not everybody was on board. Didn't pull the trigger. One year later, took three years, they called us back. If you're still interested, please come one more time. And we did. Made the pitch again. It took three times of them hearing the message before they were willing to accept it. We've got that contract. We've had it now for eight years. It is CRNA only. Huge block program. Big orthopedic volume. We're doing great. The surgeons are happier than they've ever been. It's a great success story, but the, it takes a long time. Sometimes they have to hear the message multiple times before it sinks in. So just a few things I want to inform the audience and then I'm going to open up the mic so you can ask questions about this because I think it may be very helpful. AANA has been very proactive in the last two years. We've really ramped up having and informing and making other individuals become more knowledgeable about this particular model. So one of the things that we've really reached out to is the ambulatory surgery centers. And we just had Dr. Collins yesterday, Friday, speak to them. And actually we made some very good communication amongst the ambulatory surgery centers because frankly, when I look at workforce numbers and I look at trending, you guys are working in ambulatory surgery centers. You're all moving out of the hospital. That's where we're all moving. So if we can capture that market and have that market understand, which I think they're understanding pretty quickly, frankly, I think we will begin to see this even begin to explode even more and more. We're seeing the QZ, that's a, that's a billing model that we use to indicate that CRNAs are providing anesthesia on their own. We see that trend going up. So this trend is happening, but it's our job to try to educate people to even move even more faster and more importantly, to be very well educated and understand the environment to be able to save money and be more efficient. So if you don't mind, if you guys are okay with this, I think what I'd like to do is go ahead and open up the mics and just have people come to the mic, introduce yourself and ask all the panelists or a particular panelist, if you wish, the question. So I'll go to this mic first. Sure. Thank you so much. I'm Megan Cackle. I practice in Minnesota and hearing you talk about the surgeon models, whether or not they're employed versus owning the hospital, it made me think about that very thing for us, whether or not we're hospital employees or whether we're contract. And in the hospital employee scenario, you really, you're saying, you know, in all the scenarios we need a voice at the table, but when you're an employee, that really a lot of times functions as the chief CRNA. And I feel like when thinking about efficiency, what we're seeing is a whittling down of that appointment. What used to be a 1.0 is now a 0.9, a 0.8. You can get it done in a 0.2, right? And that just cuts you out of the conversation. And so I'm curious if you have any thoughts, input about how you value that position, how you fight for that position so that you can keep your voice heard in a system where you're an employee. So I would not be considered the expert on that because I'm an outsource vendor and every month they send a subsidy check for us. That's when that conversation happens very frequently about the most efficient model. Adam, you've worked at the HCA model. Do you have anything to add? Yeah. You know, I think it really, the responsibility is, they don't necessarily get any admin time. Typically there's some, you know, kind of off the books consideration. That's, certainly there's a stipend for that role in the compensation. They don't necessarily get any, again, on the books time. It's usually just off the books when they can slide out to have some of those conversations. And they're usually done in kind of a dyad or triad way. Meaning it's, if it's a team type practice, it's going to be the facility medical director, right? The chief anesthesiologist, the chief CRNA, maybe an operator sitting down together with the admin. Having those conversations. And usually that's a little bit more structured. Yes, they'll get out for that, you know, type of conversation. So if you're, if you know, they're being excluded from that, I'd say that's, that's a big problem. And that's probably something to definitely address with the administration, you know, sooner rather than later. I wanted to clarify what you said just a little bit, though. Did you say that there was a 1.0 chief job, but that's all you did was the administrative stuff? There was a clinical appointment, like, sort of, you know, a clinical appointment. There was a clinical appointment, like, sort of fixed into that. And it was sort of a managing of multiple different, but just over time in the sort of efficiency, sort of, we need you in the OR, kind of, you know, contributing. And so you can't be in an OR and in a meeting at the same time, right? And so it's just sort of a keeping our voice heard at the table. It's hard to happen if they decide to have the meeting when you're administering an anesthetic. Yeah, I say that, like, as a department, that's something you have to value as a team. If you are a team, if you're a bunch of contractors that are coming in, like we see now in facilities where it's seven or eight low-income providers, they're not necessarily bound to that hospital community or service line, that makes it a little bit of a challenge. But I would say somewhere in the 0.2 range, and that's usually what about a subsidy would be, would be about average. And the rest of it is like value-added service and pizza party time, right? So that's about average, would be about 0.2. Okay, thank you. Okay, let's go over to this mic. Hi, Melissa from Massachusetts. So in Massachusetts, we talk about time. So in 2017, the Massachusetts Association of Nurse Anesthetists, we developed a long-term strategy where we were going to try to reach out to stakeholders and join as affiliate members. We joined the American College of Healthcare Executives, Massachusetts chapter. We joined the Massachusetts Hospital Association, and also the Massachusetts Association of Health Plans. And up until recently, it's really yielded us like nothing. So we send them money. If they had a conference, we would go and exhibit, you know, whatever. And then COVID happened, and then there was nothing in person, and yada, yada, yada. So now we're still at it. So you want to say seven years, right, of trying to do all of this. And I love that the AANA came out with EDAM, because now it gives it a name, right? We've all been sort of advocating for this type of practice model, but now it's a name. And I love that we've got the anesthesia facts. So we finally, finally, finally got a little bit of a hook. The ACHE of Massachusetts, I guess it was the, I wasn't there at this particular thing, but the president of that organization stopped by our exhibit and said, I'm really interested in hearing about this. So we've got on the books now a webinar. They do these webinars, I don't know, quarterly, monthly, whatever it is. So we, so, and I'm thinking, okay, there's no way I can do this. So we've got Tracy Young is going to be speaking to the ACHE of Massachusetts slash Rhode Island about EDAM. This is more of a question and comment. So Massachusetts specifically, it's weird because we have no, we have absolutely no supervision rules, laws, or anything. Yet we live in the Northeast, which is notoriously really restrictive, right? So we've got this really restrictive culture without the laws that back that up. And I would say, I would say I'm close to a hundred percent facilities where the CRNAs cannot walk in and have a conversation with administrators. It's just not a thing, right? Whereas other parts of the country, it seems like CRNAs are kind of welcome to do that. Like we're not. And so the question, I guess, really is, in a state like Massachusetts, we're doing this. Is there anything else we could do, number one? And number two, all we would need is an organization like Sound, for example. We would desperately love to have Sound come in and take over one of our hospitals. This would be awesome because I feel like in Massachusetts, all we would need is one. One to see how, see how it would work. And then I think it would catch on, right? So that's sort of my question. Is there something we could be doing more? Yeah, it feels like you're doing it. Yeah, yeah. It's plugging away, right? It really is. It's plugging away. It's slow. It's painful. But you're right. Sometimes it just takes one. San Antonio, Texas was a physician-only model across, I believe, maybe 16 of the hospitals in the community. We started at one, introduced a new model, word got out, access increased. They were canceling cases because they didn't have enough rooms covered prior. We're covering all the rooms. I think we've converted 13 hospitals just in that metropolitan area in the last year. But it takes one. But it takes one. I would say I'm going to challenge you on something. I don't, I've never met a hospital administrator that doesn't want to save millions of dollars. So to say that you can't talk to them, they just don't know what you have to say yet. So somehow and maybe what you're doing with Tracy's lecture getting out there may open up that door. That's the only thing I see is still work on those relationships. There's millions and millions of dollars on the table. I think what I'm saying is that in just about every, I can't even think of one facility where a CRNA would be welcome to go into the, we call it mahogany row, to just walk it stride in there and say hey, you know. Because you don't do it that way. It's relationship first. Yeah. Then you show up at their door. But we could talk about that offline. I think there's some strategies you could use. I'll give you a quick strategy. I live in the country. I grew up in the country. So I know how to meet people. So if you truly want to get an inroad into a hospital, you don't pick your biggest hospital in the area that has, you know, 30 ORs that need to be covered. You pick one of your hospitals that's maybe a four to six holer. You figure, you go on their website. You look and see when they have their foundation dinner. You look and see when they have a fundraiser for the hospital. And you show up there. You bring your little, you bring your name badge. You do something and you show up in that area and you meet the people that are there. And it needs to be a place where you can make some inroads. And it might take one or two trips, but that's how you make those initial contacts. Because you're taking your time to support their facility and show up in a place where they're casual. They're laid back. Their defenses aren't up. They don't think somebody's going to be coming and proposing a business deal to them, right? That is probably like the number one thing that I would say. If you truly identify a place that you want to go after, that's what I would, you know, work on that. We want sound to go after it. I don't want to do it myself. I'll speak very briefly. Yeah, we're happy to look at anything in Massachusetts. But, you know, going back to the relationships, you know, we don't shove any of these models down anybody's throat. I mean, it's a, it's a negotiation. It's a constant negotiation. If they want a strict care team at first, that's what we might start with. And we'll, we may show them two or three different models to begin with. They want to pick the care team. That's fine. We still won't operate. We'll operate it in a care team fashion, but the CRNAs will still be functioning top of license. The relationships between the physicians and the CRNAs will be very collaborative. And then we'll slowly get them there. Sometimes it takes years, as Tracy mentioned. Okay, before we take the next question, because I want to get one more question, but before we take the next question, a couple things. Number one, we really want to get the word out. So we have panelists here that are available to speak at any of your state meetings at any point in time. And we've got a few other individuals that are not here today that can do that. That's number one. Number two, we have brochures, folders with all of this information. If not in the back of the room, we have a booth out there. So please feel free. There, she's back there. Wave, wave, Trin. There's Trin. She's waving. So please feel free to come, stop, and get those. And most of all, I want you to know, AAN is really taking an active role. We're trying to get into ACHE, AHA, ambulatory surgery centers. We're trying to make those connections. And I'm going to say to you, on the national level, that's great. But what we need is you at the state level trying to make those same connections to help move the model. So if you don't mind, we'll take one more question, and then we'll close it down. And I'm going to ask the gentleman, after we get through this question, the question I'm going to ask you is, take home, give them one take-home point after we have this question answered. So please. Hi, I'm Emily from Washington State. I work at an academic center in an ACT model. And so I am lucky that I've been able to start talking to leadership about different models. And so I asked them, like, why can't we move to supervision? Why can't we build QZ? And the answer that I got last week was, well, in supervision, we get less reimbursement. So we have 50% for the CRNA, but then less for the physician. So that's not really, you know, that's not as cost effective. And then the second part, I said, well, what about QZ? And their response was, well, Cigna is now reimbursing at a lower rate. We expect other insurance companies might do the same. So this, we're not sure that's the great model for right now. So what should I say to them? So you're right. Supervision does have less units attached to it the way the mechanism is. Supervision makes up 2% of all Medicare billing for that reason, right? So you're talking about supervision from a billing term. I would not use that. I'll talk about supervision or a loose collaborative model and then building QZ. To answer the QZ question, I would challenge them. What percentage of your payer mix is Cigna? It's probably 2% or less. A 15% reduction of 2% or less of their billing is going to be a drop in the bucket compared to potentially reducing three FTEs from an anesthesia standpoint or an anesthesiologist standpoint and increasing the access across multiple sites of service where CRNAs can deliver. Plus, not having to wait for anesthesiologists for medical direction to show up for induction, literally saving thousands of dollars in OR time every day for not having to meet those seven steps of Tefra. Plus, you all of a sudden no longer have any fraud from not meeting those seven steps of Tefra, which can get even more expensive. So that would be my response to that. Cigna is probably a very, very small percentage of their payer mix. Do you think his statement is correct that other insurance companies will follow suit? They already are. Cigna is the only one with national payer policy to that effect. So a lot of the payers attempt when they're negotiating with private entities, Tracy's entity, our entity, they're trying to force you into something that's better for them and worse for you. And a lot of groups, regional groups, local groups, and even some large groups have agreed to reductions in reimbursement for QZ. For the most part, from what I've seen in four or five different organizations now, they're generally around 15%, right? Some of them can get a little bit higher. Texas can be a little bit higher, blue in Texas, but yet they also cap the physician component. So you start to catch up as you're doing a side-by-side comparison. I will say this, eliminating physician costs or redundant costs to implement a more collaborative model, it's typically, it's still cheaper to do that and take your 15% hit. You almost have to get to 30% plus before it starts becoming equivalent. So it's still cheaper to take the hit and move collaboratively. Thank you. All right, so give me your one takeaway. Chris? All right. Let's quit trying to make this debate about quality, okay? Why? Because all the data shows that anesthesia is safe. And we're not going to win on a quality conversation. And really it's the only thing that those who stand against us have to throw out there. So quickly put that to bed. Guys, I'm sorry to say it, AAs are safe in a directed model. Quit bashing them about it. You're not going to win. The data does not support it. It's disingenuous and it just looks like peeing downhill because they don't have far scope. They're safe. They're not killing people. What I say is there's a self-leveling in anesthesia. A surgeon is watching every case and if any provider group was killing their patients, don't you think they'd raise their hand? Move it to the side because it's all our opponents have against us. Nobody can beat us on the efficiency. Hands down, across the board, we win. That's why we titled this Efficiency Driven Anesthesia Modeling. Look at what's efficient and appropriate for your institution. We're not throwing doctors out, but for every physician we can move out of the model, we save half a million dollars. So if you've got 12 ORs, one to six might work and be really safe. Pull a doctor out of that collaborative model. You just save that hospital $500,000. Efficiency talks. Effectiveness, all same. Let's move it to the side. I'd put the challenge on all of you sitting out there. The market is driving these conversations, right? Administrators are looking for ways to reduce cost because their costs are increasing exponentially, or the cost of these services. Reimbursements going down, salaries are going up. These conversations are going to happen. A lot of your facilities will eventually move in this direction. With less physician involvement, let's say with loose collaborative model, more of you are going to be doing more of the things that they had traditionally done at your facilities. You got to be ready for that. That means you're going to be doing pre-ops. You're going to be doing lines. You're going to be doing blocks. Or you're going to be asked to do those things. That's where the comprehensive, prepared, well-rounded provider is even more valuable in those types of models. You guys got to be ready for it. Probably the biggest thing that everybody needs to be able to do, we have a lot of residents here, right? And residents are listening to this talk and you're going to go out and get her done, right? You got to be able to talk, walk the walk for you, talk the talk, meaning your responsibility as an anesthesia provider should be the best you can be. If your program doesn't offer ultrasound, there's lots of programs that are CRNA driven that do that. If you don't have those components that you need to be a full service, comprehensive provider who gets along with all the staff and is a solution, not a problem, as we were talking about earlier, then that is an issue before you can even get to the step where you're trying to move this model in a facility because they need to see you as a leader. They need to see you as someone who's a go-to person. They need to see you as someone who has already done that part and you're ready to do the next part, right? So just think of it in those terms. Everybody wants to go kill it on day one. Get the skillset established first, be an excellent provider and then move on. Great points, everyone. I'll look at this pretty simply. We can either be a solution or a hindrance. There's already a problem. The problem is access to care, the cost of care, hospitals are struggling. Insurance companies are the only ones making money right now in healthcare. That's a problem. So are we a solution or are we a hindrance? When you talk about these three E's, it is clear, it's easy to articulate that we're the answer, we're the solution. Someone that's trying to prevent us from practicing from full scope is being a hindrance and is being a problem. So you don't have to advocate because you love CRNAs, right? You don't have to go in there and say we need to be CRNA only or we need to be CRNA centric because blah blah blah blah and I love being a CRNA. No, it's because we're the solution. We're here to help you. We're here to solve your problem. How can we help you? Let's have a dialogue. If you take that message to them, it works much better. So that's my take home here. I got one story. He's got a story. This is quick. We have to just give them time. This is quick. It's a good story. My board member recently, as we were preparing in Tennessee to fight the AA bill, I never got a chance to say it in testimony so I'll say it here, but when we talk about AAs and something that you may want to consider using, I have a couple different ways of this, but it's like that toy at Christmas and you get a lot of pressure and the pressure came in this time from docs to go get that toy. You want to make your kids happy so you run out to the store and you buy that toy and you come home and you wrap it up and it's under there and it's Christmas morning and you're sitting around and your kid unwraps the toy and what you discover is you bought an accessory piece that does nothing on its own. You got to go back to the store and buy the primary unit to get this thing to do anything. Well there's your story for the day. I thought that was cool. I never got to do it in testimony so I ran it here.

Efficiency Driven Anesthesia Models

cost-effective anesthesia

CRNA autonomy

anesthesia management

medical bylaws

hospital administrators

relationship-building

healthcare cost savings

anesthesia care models

CRNA advocacy