Anesthesia Deconstructed: Moving Anesthesia Forward
Anesthesia Deconstructed: Unraveling the Complexities of Modern Anesthesia Practice
Founded in 2018 by Mike MacKinnon, DNP, FNP, CRNA, FAAN, and later joined by co-host Joe Rodriguez, DNAP, CRNA, Anesthesia Deconstructed is an award-winning podcast that consistently ranks as the nation's top-downloaded anesthesia podcast, with two of the most well-known CRNAs in the country as hosts. We feature industry experts from across the spectrum, exploring scientific issues, policy matters, and the day-to-day realities of anesthesia practice.
Our mission is to deconstruct complex topics, recognizing that the truth often lies in the nuanced middle ground rather than at extremes. We bring unique value to our listeners by examining the nexus of clinical practice, education, and policy, offering insights that go beyond any single perspective.
Join us for thought-provoking discussions that bridge the gap between theory and practice in the world of anesthesia.
Anesthesia Deconstructed: Moving Anesthesia Forward
Mike MacKinnon is Back! Massachusetts Opt Out and What it Means vs
- Removing barriers to competition and promoting a level playing field in healthcare is important.
- The supervision clarification advisor opinion from the Arizona Board of Nursing allows CRNAs to supervise other health professionals.
- The opt-out of Medicare Part A physician supervision requirements in Massachusetts eliminates the perception of supervision and reduces liability concerns for CRNAs.
- The opt-out also simplifies contract negotiations and promotes collaboration between CRNAs and surgeons.
- CRNAs should have the opportunity to choose the model of care that best suits their practice and the needs of their patients.
- More states should consider opting out of Medicare Part A physician supervision requirements to improve access to care and increase provider options.
Introduction and Background of Michael McKinnon
Supervision Clarification Advisor Opinion in Arizona
Opposition to Anti-Competitive Legislation
Opting Out of Medicare Part A Supervision Requirements in Massachusetts
Impact of Opting Out on CRNAs and Service Line Management
Future Plans and Conclusion
Joe Rodriguez (00:01.113)
Welcome back to the show, the one and only Dark Lord himself, Michael McKinnon. How are you?
Mike MacKinnon (00:08.558)
I'm doing great Joe, how you doing?
Joe Rodriguez (00:10.297)
Does I'm doing great. Does anyone not know who you are? I don't know. Should I actually do like a real introduction for you? This is Dr. Mike McKinnon, Michael McKinnon. What's your middle name, Mike? Michael Alexander McKinnon, current assistant program director at National University, current director on the American Association of Nurse Antisusology and all around badass CRNA. How was that?
Mike MacKinnon (00:20.558)
Alexander.
Mike MacKinnon (00:33.934)
Yeah, that was overblown, but thanks.
Joe Rodriguez (00:36.281)
All right. So today we have you on. So you're one of the hosts of this podcast, but you're never on because you're too damn busy. So here to get your comments on two things. First, last week, the Arizona Board of Nursing, as you know, sent out an email to all the nurses in the state of Arizona. One of the links in that document was the supervision clarification advisor opinion from the Board of Nursing that stated that CRNAs can supervise other health professionals.
Obviously this relates directly or indirectly to this AA issue. I think it's fair to say that was part of the drivers in the state. You are one of the originators of this idea by way of background. So the audience knows this idea of CRNA is supervising or using an assistant, just like physician anesthesiologists do stemmed from a live panel, I think back in 2018 with when one of the members of that panel was a surgeon who is a
fellow for the Goldwater Institute, which is a free market think tank in Phoenix, Arizona. So thanks for being on the show. Thanks for making time for us. What are your thoughts and comments on this advisory opinion coming out?
Mike MacKinnon (01:47.246)
Well, you know, I think that it's always been understood in Arizona that CRNAs, APRNs as a group, if you will, can supervise other providers. It's never been explicitly written. Obviously, we provide orders to many providers. We can supervise rad techs for pain management, doing injections. We can supervise RNs, techs, et cetera, and write orders for them. Except for that when the time came to have this conversation about, you know,
As a free market guy, you know, and let me preface all this, but I'm speaking on behalf of Mike McKinnon, not on the ANA board behalf. But as a free market guy, you know, I'm all about removing barriers to competition and I'm all about eliminating regulation that gets in the way. So when AA's want to come into Arizona, the question came up, well, if one group gets to be able to supervise an assistant, then.
That's a competitive advantage and the other group should too. Well, the other side of that legislation was suggesting that a CRNA could never supervise an AA because we're the same. And so what the Arizona Association of Nurse Anesthesiology did was seek clarification about who and how a CRNA or an APRN could supervise another person or another provider, regardless of their initials. And that's where this all came from.
Joe Rodriguez (03:14.137)
Yeah. Yeah. Okay. And just for clarification, when you say we're all the same, you mean essentially the quad A, the American Association, American Academy of anesthesiologists assistance position is that CRNAs and AA's are identical. I don't even think they use words like overlapping. They just say identical. They have the exact same scope of practice. That's, that's what you're saying there. Correct.
Mike MacKinnon (03:37.166)
Yeah, that's correct. So that's their position that we're equivalent and they like to use the term mid -level providers and should be working in the same capacity.
Joe Rodriguez (03:47.449)
Right. And then the Arizona position is put this in general terms, because I don't speak for the Arizona association that in regard to anesthesia, there's an overlap. Obviously there's different and broad scope of practices with physicians and CRNAs, but in regard to anesthesia, that's where the overlap occurs. And that is, it sounds like informing your position in terms of, or the position in terms of if one group gets an assistant, the other gets an assistant too, which seems pretty simple.
Mike MacKinnon (04:17.23)
Yeah, I mean, it's basic free market economics, right? Like if you're going to have competition, you want to expand access to care in an economically or fiscal responsible way, then more people is good. Yeah, I don't disagree with that premise, except that when you have competition, it should be on a level playing field. And we are not on a level playing field with, with AAs, you know, AAs are hold them out to be assistants to physician anesthesiologists. They are not independent providers. They are not.
experts in anesthesia in the same way that independent providers are and the only independent providers in the country right now are dentist anesthesiologists, physician anesthesiologists, and nurse anesthesiologists. And so because of that position that we're different than if one group who we don't we don't compete with AA's for contracts, they can't get them, right? We compete with physician anesthesiologists, groups for contracts and hospitals and other CRNA groups for contracts. If we're going to be competing for contracts against these people, they shouldn't have a competitive advantage.
That is the antithesis of a free market economy and deregulation. So it's just wrong, right?
Joe Rodriguez (05:21.913)
So you're a national leader on this and obviously you don't control all state capitals, but all things being equal, if you were in the driver's seat for that specific negotiation at a specific state, the Quad A comes to you and says, we'll give you everything you're looking for in regards to full practice for CRNAs. And in exchange, we'll also authorize you to supervise the AA. Your response is...
Mike MacKinnon (05:48.494)
Absolutely. Let's do it.
Joe Rodriguez (05:50.745)
Okay, then let's let's flesh this out for the cause. I know there's a lot of CRNAs listening. I think in this audience, there's probably a lot of people who have heard about this previously. I think there's many who have not, but for those who have not, what's the, what's the real world impact of this? Right? I mean, you know, cause a lot of people hear this and they're like, I don't want to supervise an AA. I don't want to supervise anybody. Right? I just want to take care of my room and that's it. So what do you say to those people?
Mike MacKinnon (06:11.054)
Sure, sure, sure. I would say that there's physician anesthesiologists that say the exact same thing. And they choose jobs where they don't have to supervise a CRNA or an AA in any kind of manner. It is a choice then where you work. So the real world implication is this, and I'll use Arizona as a microcosm just as an example. The argument for bringing AAs into the state is pretty clear, right? We're concerned about a shortage of anesthesia providers, although...
Having said that, if every anesthesia provider in Arizona sat on a stool and did anesthesia, we wouldn't have a shortage. But if we went under the assumption that there is a provider shortage nationally, then more bodies means more cases done, right? I'm all for that. I think that's a win, right? If AA's want to come into Arizona and provide anesthesia under the direction of a CRNA or a physician anesthesiologist, I think that's also okay. The problem comes in when they only want
And I don't mean them as in they're being mean or they're being, you know, the evil empire. I don't think that at all. They're just people trying to work. Right. So ultimately the ASA wants to bring them in as only they're assisted. And the problem with that is it doesn't serve anyone, right? Doesn't serve AAs because if AAs can be supervised by CRNAs, then they could work in the places in the state where the most need is. It exists, you know, rural underserved. And that doesn't mean just rural areas. That also means underinsured.
Joe Rodriguez (07:16.665)
Hmm.
Mike MacKinnon (07:37.998)
areas, right, with high, high populations that don't have insurance or they're underinsured with high, high deductibles, where you're not going to generate the kind of revenue you can if you're in a place like, let's say Scottsdale. So, you know, when you look at that, that option, AAs get to choose whoever they work for. They don't have to come work for a CRNA and be supervisor. They don't have to just like in CRNA.
Joe Rodriguez (07:50.617)
Sure, of course.
Mike MacKinnon (08:02.574)
doesn't have to go work in an anesthesia care team in Arizona and be under medical direction of an MDA, just like an MDA doesn't have to choose a practice where they have to supervise someone else because they like to do anesthesia themselves. These are choices, right? And choice is freedom. So ultimately, in the marketplace, AAs get served by having more opportunities for more jobs in more places in the state that they can be supervised by CRNAs. The market gets served by having more providers to sit the stool, provide anesthesia in the state.
So people get served by having more providers to provide anesthesia to do surgeries. Everybody wins. There is not a valid argument against that because you can choose not to work in the places where that happens. So the only real reason you would come out against having CRNA supervise AA's, obviously it's not in the AA's best interest to come out against that because that means more jobs for them. They can choose where they want to work. The only real reason is ultimately political control, right?
And I think that's really what we're talking about.
Joe Rodriguez (09:02.481)
Yeah, yeah, it makes a lot of sense. So two follow up questions. If it is it your general position and just for full disclosure, I've worked on these issues too, but right now I'm wearing I'm working on these issues, but right now I'm wearing the host hat, so to speak. Is it your general as an individual, your general opinion that a legislation should always be opposed until some sort of version of this concept is in the bill?
Is that your?
Mike MacKinnon (09:32.334)
It's my position that any anti -competitive legislation should be opposed. It doesn't matter what it's about. It doesn't matter if it's about AAs, it doesn't matter if it's about dental assistance, it doesn't matter what it is. Anything that's involving anti -competitive practices that puts someone at a disadvantage in the marketplace is just wrong. It doesn't serve anyone.
Joe Rodriguez (09:52.537)
And the policy as written, as proposed 40, 50 times over the past 10 years, you're characterizing that as anti -competitive.
Mike MacKinnon (10:03.726)
Yeah, 100%.
Joe Rodriguez (10:05.433)
if I'm going to put you on the spot a little bit, if this passed, right. And you, you know, had to manage the contract for services at, you know, I don't know a two or four room endo center. Would you hire an AA?
Mike MacKinnon (10:20.622)
So that's a great question. And the answer is complicated. Not that I wouldn't hire an AA, I would. But it would have to be the right person in the right place providing the right services. So ultimately, yes. The call read to that is I would also hire a physician anesthesiologist in our practice. If one was willing to work in rural Arizona and provide all the services we provide for the hours we provide for what we make, we'd hire one.
Joe Rodriguez (10:28.665)
Yeah. Just like any professional, right? Or any professional situation.
Mike MacKinnon (10:47.822)
wouldn't think twice about it. I have nothing negative to say about physician anesthesiologists, either as a profession or individually. And so I feel the same way about AAs. I know that they often think that I'm like, you know, they're antichrist, but the truth is, I'm a free market, you know, perspective. All solutions are good as long as they don't overtly favor one competitor over another. So if I had a contract and I'm developing a contract where there's an, there's going to be a care team situation.
where they want someone available for four other people, right? That's ultimately what this has to look like to work because that's what it looks like for them with physician anesthesiologists. If I had a contract like that and I was bidding on that contract, I could bid on that contract. I would hire AA's if that was something that they were interested in as well. Obviously, you know, this is not a one -way street here. You're the contract holder and there's the person you're in contract with.
Joe Rodriguez (11:27.321)
Of course, yeah.
Mike MacKinnon (11:45.742)
And if they don't want a specific model or they want a specific model, when you are a business individual who's providing a service, you're going to give them all the options and they can pick based on cost. And that's what it's going to come down to.
Joe Rodriguez (11:55.897)
Sure. Yeah, now that makes a lot of sense. Going to switch gears. So this past week, the state of Massachusetts, the Bay State became the 25th state, I believe the 26th state or territory, because Guam is included in there as well, to opt out of Medicare Part A physician supervision requirements for CRNAs. General comments?
Mike MacKinnon (12:20.302)
Yeah, like, I mean, this is this is the big mark, right? We hit the 50 % mark of states across the country that are now opted out of the medical supervision requirement for billing for part A Medicare from CMS. So, you know, before we move on about what this means, I think we have to talk about what it is. I think it's very confusing to people. They think that opt out means independent practice. No, that's not the case. Opt out means removing the perception of supervision requirement. You can already be working independently in places that are not opted out. It has to do with facility billing.
Right. But that barrier, that perceptual barrier of the word supervision, even though it doesn't mean control or liability, always puts a bad taste and you have to get into the weeds to explain it to hospital administrators who are choosing contracts and surgeons who you're going to be working with. Eliminating that word supervision. It's like the evil word of the century, right? Your supervisor is always responsible for you, aren't they? That's not true. That comes right down to local control and policy. That's not what CMS requires, but.
That's what people think because everyone's worked at McDonald's and they got their supervisor in trouble for doing something stupid. So they automatically assume that's the way it works and it isn't.
Joe Rodriguez (13:26.489)
Yeah, my sense on that issue is that that word supervision can also be problematic, at least in my experience, for the physicians involved because it tends to infer liability and it doesn't promote professional relationships, collaboration, what are your thoughts, what are my thoughts, let's reach consensus, yada yada, but it is what it is. So what do you say then to, what does this mean for individual CRNAs and or?
CRNAs who are involved in or directly responsible for running a service line, whether that's employed or in a private practice, what does it mean for those two groups of people?
Mike MacKinnon (14:05.422)
you know, ultimately, it kicks away one of the obstacles that in the flaming hoops that you have to jump through to explain when you're negotiating contracts and moving the ball forward. You know, this this whole requirement when you're not an opt out state, then you're going to have to have some sort of policy in place at the bylaw facility level that says that a surgeon will meet the conditions medication for Medicare Part A, this does not imply liability.
As you can see, I've already said too many words for most people who are going to be listening to, to, so, so just to get to the answer that fixes the problem of perceptual concern, and eliminates it on a bylaw level takes a lot of jumping through hoops. And look, if you're a facility and you're, you're, and you're a C -suite, your administration, and you're not probably clinical, all you hear is, well, you know, maybe there's risk here. Better move on.
Joe Rodriguez (14:35.449)
Right. Right.
Mike MacKinnon (14:59.086)
And so it becomes a problem. So what does this mean for the individual CRNA on an individual level? It probably means less concern of liability, even if it didn't exist. And so the surgeon can be assured that there's no word supervision, assuming there's none in state language and there's none in hospital bylaw language, because obviously those are the three levers of control, right? You know, federal law, state law, and then hospital facility bylaw, local control.
Joe Rodriguez (14:59.257)
Mm -hmm.
Joe Rodriguez (15:26.649)
Mm -hmm.
Mike MacKinnon (15:27.406)
If none of those levers, none of the other two levers, state and hospital, have supervision in there, and you remove the medical, the supervision from the Medicare conditions of participation for facilities to bill, then it eliminates the discussion. Right? You no longer have to explain away that, yeah, it says it's supervision. No, that's not really what it means. Here's what Medicare says. Again, too many words, right? We've already lost.
Joe Rodriguez (15:41.913)
Yeah. Yeah.
Mike MacKinnon (15:50.926)
The average surgeon just wants to surgery eyes, right? That's what they want to do. They want to do cases. They want to get it done. They don't want to have to worry about what you're doing. They don't want to know what you're doing. You know, they want, yeah, they want to collaborate with the team.
Joe Rodriguez (15:59.161)
Yeah, no, I appreciate. Yeah, no, man. It makes a lot of sense. Makes a lot of sense. Appreciate the input. What is going to switch gears one more time? what's next for you? You are wrapping, you know, I'm not sure how long your term is on our professional association board. Are you running for office this next year? I don't mean like, are you, are you going to be in the Senate in, in the state of Arizona? What's, what's keeping you busy these days? Cause you haven't, you haven't been on the show for a while, right? So what's going on?
Mike MacKinnon (16:29.166)
Yeah, I think that the the my tenure on the board, I've got another year left of that. What's going to happen after that? I really don't know. I don't I don't plan these things ahead. I'm not I'm not in search of the next level. So if I decide it's worth my time, I'll do it. If I can make real change. So the the thing has kept me very busy this last two years. In addition to that, you know, teaching in a program and being adjunct faculty, multiple other programs has also kept me really busy this last year, plus running.
as one of three owners of our anesthesia company, running the business keeps me busy. So I haven't had the time to sit down and work at the podcast stuff to do more, although I do plan to do more. Ultimately, I think, you know, where am I headed? Who knows? I mean, I'm interested in new challenges. So I'm probably going to do more education, more management related stuff in the future related to anesthesia. But I will certainly never run for public office. I'm not built for that.
I can't pretend that I like people if I don't. So it's unlikely that that is ever in my future.
Joe Rodriguez (17:32.665)
Got it. Mike, thanks for being on, man.
Mike MacKinnon (17:35.566)
Thanks, Joe. Have a good one.
Joe Rodriguez (17:37.241)
All right, cool. Great, done.
