The next question I have for the panel, and then for you all, is how do you explain Medicare teaching rules to your students and clinical partners? So that would be my question. So I'll first address the students, and I do think it is really important that they learn about these things, and we do teach them this content in our program. We have a course that is directed by Dr. Jim Walker called Leading and Managing Healthcare Systems, and in that course there is a module titled Healthcare Finance, Fiscal Planning, and Anesthesia Reimbursement, and one of the outcomes of that module is that they are able to identify differences in reimbursement for teaching CRNAs and anesthesiologists, as well as to distinguish between medical supervision direction and non-medical direction in terms of reimbursement implications. So they learn this very early on in our program, and it is very eye-opening for them to recognize some of the disadvantages that we have in terms of reimbursement, and specifically reimbursement related to teaching and training them in the clinical environment. So important, I think, for our students to understand this. So I'm a relatively new program director. I just finished my first year, and I learned this content, I certainly did, but it wasn't until probably about six months ago when I started getting questions from clinical sites about whether or not the SRNAs could be in rooms alone, that I really had to take a deep dive and relearn this content so that I could respond to the concerns of my clinical sites intelligently. And so in terms of explaining it to them, I do a lot of what Brett just did for all of us here. I send them those diagrams, and then I explain things in terms of COA standards and the Medicare teaching rules. So I explicitly, I mean, I just cut and paste, right, those COA standards that talk about supervision, appropriate supervision ratios, and then also explain that CMS does allow for you to bill for teaching SRNAs and up to two to one. And so yes, they can be in rooms by themselves. But it does take a lot of educating, and it's remarkable how many of our colleagues are unaware of these rules and not understanding their impact. Anybody else on the panel? I think she handled it well. We do the same. We teach it, actually, in the very beginning of the program to the students in our very first practicum course. We go over just some basic professional issues and legal aspects and then some billing, just so that they can understand a little bit more about how they're assigned in clinical. And then at the very end, we do it again, so that before they go out into practice, they're re-exposed to the billing and the business aspects of anesthesia as well. And I think the take home here really is that the vast majority of CRNAs and even educators don't understand a lot of these concepts, right? So I think our hope moving forward is that we're providing you with information. You'll take that information back to your shop and really try to educate your colleagues. We wanted, as a group, are looking at other ways that we can help disseminate this information and try to get this information out there, so everybody really has a better grasp of what are these teaching rules, what are the guidelines, because it's just not well understood. So we have to do a better job from a professional standpoint, I think, of really making sure people truly understand that. And it's interesting when you look at the data on faculty turnover, particularly program administrator turnover. It's not surprising that we have faculty who aren't necessarily, you know, these teaching rules came out in 2010, they're not new, right? But if you have such tremendous turnover at the level of the program administrator, it's not terribly surprising that, you know, you're not just inheriting the clinical training culture that you walked into and not maybe understanding how those decisions were made. And so I think it's important that everybody understands what drove that decision locally, because your point is very well taken. Local policy and procedure drives really all of it. But if you understand what we, what drives our policies and our standards, then you can advocate against some of those decisions that were made prior to you being in the position you are. Any other comments from the audience? Brad, if I may add one more thing. You know, unfortunately, as she and I were talking earlier, you know, so many times with this transition, you're kind of just handed the keys to the program and good luck, see you later, right? Well, we all know how much of a heavy lift this is when you're an anesthesiologist and nursing faculty, right? So especially taking on a program director position, right, especially if you haven't had mentorship. So we do have the Faculty Stabilization Task Force, and I'm fortunate to be a part of that. And we're hoping that we're going to take some of these types of things and develop that repository to make things a little bit easier for faculty. So there's a one-stop shop to be able to go to that educator edge and really, okay, how do I do this? Or what are the teaching rules? You know, things that, these are all things that we can have in there in little short videos with content experts for you to be able to go in one area and be like, oh, wow, look at that. That's my question. You know, so that's something that the board has been embraced fully, that that task force has done a phenomenal job to this point. Our work is certainly not over, and it's really exciting, I think, moving forward to see where that's going to go. And I think it's really going to be a phenomenal resource for everyone. Where would the teaching billing rules come in if you have a physician anesthesiologist who's out in the pre-op holding area who's teaching my student to do peripheral nerve blocks? And she's, he or she is out there the whole day, so she's not in a room, just supervising for a procedure. It would be 100%. That would be a situation for 100% because they would be 100% with that one student. That would be my understanding. I know me again. So first of all, I'm Shane Hoglum, I'm University of Miami. I'm not speaking on part of the foundation, just a disclaimer, right? So prior to academia, I had my own independent all-CRNA practice, interventional pain practice. So I kind of look at things a little different. And I really focus, I think that local level is so important that I said earlier, right? And I think it's not just, it's engaging with, and I think this is what we struggle with as a profession, is we're making these fights at a national level, but it's really those grassroots level that we're missing out on. And it's, I think, engaging with the clinical partners, but the CEOs and the CFOs are so important, and they can be our friend, and they can be the people that help drive some of this change. And that's where we need to focus on, is those decision makers, and they look at dollars and cents, and that's what comes down to them. So they can help push that envelope if it makes financial sense to them, or makes institutional sense to them. And I think that's where we can maybe change things and help push that envelope a little bit. Absolutely. Well said. So just to address that just a smidgen, one of the things that the ANA is very actively engaged in is we have a technical expert advisory panel on reimbursement. And this year, one of the activities is that we will be presenting at, let's see, at Becker's, as well as the healthcare executives meeting. And we're going to try, we've developed materials, and we've actually developed different models of practice, and we're trying to also get on the agenda. So to your point, Shane, I think that we have to be much more effective in informing our healthcare executives, whether it's systems, whether it's a hospital, whether it's within a department, on how we get reimbursed as a whole, not just in the student population, which is critical, and I know that that's what this topic is about, but as a whole. Because it's amazing to me, when you talk to a hospital administrator, what they do and don't know about the way we get reimbursed. So from a little bit higher level on the ANA side, we're trying to address it. And then especially at the student level, we're trying to make sure that program directors are at least informed or know where to get the information so that when you're going into negotiate and talk about having students in the facility, what can they reimburse? How do they get reimbursed? And so as this panel continues, please feel free to reach out to Brett, not Lorraine. No. But seriously, please reach out, because I think the more flexibility you have within your program and your clinical rotations, the more opportunities you're going to be able to provide for your students, and the more value they're going to bring. And every program's going to be different on what that looks like, and I know that turnover for our faculty is extremely high. So having this kind of information and sharing it on a more continual basis, I think will only better prepare us and allow us to have those opportunities for students that we may not either be aware of or we just don't think about because we're so busy doing other things. And just to add to that, Lorraine, because you're absolutely right, we have to get back control of the narrative around what makes sense for educating our students. Because I will tell you that this is a... The ASA, and of course they're an advocacy organization, just like the AA and ASA, they are particularly interested in this issue and controlling the narrative around our learners. And they're particularly interested in it because it's a long-term strategy for them. They know that if our learners become the same as every other learner, then eventually we become the same. That's their strategy, right? And so when you talk about... They're willing to lose money right now to win in the end. So these large anesthesia departments, I mean, again, I know this is a political conversation, but these large anesthesia departments, when I'm sitting silently listening to the conversations that I'm not necessarily supposed to be hearing, what I'm hearing is exactly that. We're not going to let them... We know we would make more money. We know we'd be in better financial position if we did it this way. But let's think about our long-term survival, and we're willing to lose money right now to do that. So I think that's why it's critical we get back control of the narrative, and we explain why that's not a good way to do this. So your point...

Medicare rules

CRNAs reimbursement

supervision guidelines

anesthesia education

healthcare advocacy