Anesthesia Leadership Is Changing - and Not Everyone Will Make the Cut

Anesthesia is evolving — and so are its leaders. In this special episode of Anesthesia Deconstructed, we dive into the dynamic shifts happening across the anesthesia landscape, where Certified Registered Nurse Anesthetists (CRNAs) and anesthesiologists are stepping into new leadership roles across clinical, operational, and educational domains.

Our expert panel — including leaders from Norstar Anesthesia, Rutgers University, Sound Physicians, Guide Anesthesia, and BPI Anesthesia — explores what it takes to lead in today's high-pressure, resource-constrained environment. From managing subsidy pressures and navigating insource vs. outsource models, to developing provider culture, expanding service lines, and building sustainable clinical partnerships — this discussion gets candid about the real challenges and the bold leadership required to address them.

Whether you're a CRNA aiming for a leadership role, a physician looking for collaborative models, or a healthcare administrator tasked with rebuilding an anesthesia department, this episode offers practical insights, real-world experiences, and a clear call to action: it's all about the culture, the teamwork, and the long-term vision.

Check your politics at the door — this is about building the future of anesthesia, together.

Keywords: Leadership, Collaboration, Culture, Anesthesia, Innovation

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Transcript

Anesthesia is changing, and so are its leaders. [...5.3s] CRNAs about jumping into a leadership role, I wholeheartedly support that. You just have to be flexible. [...3.4s] We are seeing exponential increases almost across the board. Hey, our subsidy needs to double.Hey, it needs to go up by two and a half times. [...5.6s] But if you were thinking [...0.6s] about it whole purely through a financial lens, [...0.5s] you would not be insourcing your anesthesia program. [...3.7s] Get 10 years experience by having 10 years experience that GBT will not save you. [...2.7s]Together [...0.5s] about the culture. It's all about the culture and everything else. I can't even say that it's secondary. It's, it's way down the line. You check your politics at the door. Uh, we're gonna do this together. [...20.3s]Thank you for the special episode of Anesthesia Deconstructed. Anesthesia [...0.7s] is changing, and so are its leaders as more and more Cnas are stepping into roles as everyone on this call currently is, [...0.5s] uh, that they previously did not occupy.An anesthesiologist, are also looking for strong clinical leaders, strong clinical partners. We really see across the industry that new models of shared leadership are merging.That's why we wanted to have this conversation. So whether you're CRN a who's wanting to step into leadership positions at a local or regional or national level, or you're an anesthesiologist who's looking for reliable partners to run your service line or run your business, or your healthcare administrator who really wants a valuable department, that's the type of conversation that we want to have here today. Uh. So, uh, we're gonna flip over into the introductions.So Andrew Woodmathy is the co host of today's episode. Andrew, do you mind rolling through some of the introductions of our guests today? Yeah, of course. Uh, I think it's better if everyone just kind of introduces themselves. That's a great idea.Randy's been around these things a long time. You can introduce yourself. Executive vice president of clinical strategy at Norstar Anesthesia.I've been in here. I've been in this role for just about three and a/2 years. Prior to that, I was, um, in a very different job, which is the CEO of the American Association of Nurse Semasthetists and, um, did that for four years.And then if we go way back, I will not way, way back, but I was in hospital leadership for a period of time in military leadership as well.Hey, Tom, do you wanna go ahead and introduce yourself? Yeah, hi everybody, uh, I'm Tom Claria. I am, uh, currently [...0.7s] the program director for the Rutgers, uh, Graduate Program in Nursing Anesthesiology, [...0.6s] and I'm also the chief CNA, uh, one of the chief Cnas for the Robert Wood Johnson Barnabas Health Health System, which is the [...0.4s] largest health system in the state of New Jersey. Uh.My background has been a CNA. This is my 25th year. There's gonna be a huge silver Celebration apparently [...0.6s] from my current air anesthesia residents. Uh, but I started, uh, the Rutgers program back in 2004. Um, uh, natural progression I became a chief CNA in 2010 [...0.6s] and I've been with, uh, semanesthesia. Management companies, private practice.I've pretty much done it all clinically and academically, uh, leading up to, uh, [...0.7s] being on this panel with all of you today. So thanks for having me [...2.2s] next time. Uh, Adam, do you wanna introduce yourself?Sure, my pleasure, Adam Boyd. I'm the vice president of clinical performance for Sound Anesthesia Service Line, [...0.4s] um, been here about a year and a half, and, uh, don't let the clinical performance fool you.Uh, very little of what I do is actually [...0.6s] clinical quality, lots of business development, operation, special projects and [...0.8s] anything and everything else they need me to do.Um, [...0.7s] prior to this, I was [...0.5s] director of the Physician Resource Team, which is a team of internal consultants for HCA Healthcare that help all their hospitals and ASCs nationwide negotiate their hospital based service line contracts. Thanks, Adam.John, yes, good evening. John Sykes, cofounder and CEO BPI Anesthesia, [...0.5s] headquartered in Baton Rouge, Louisiana.And it was Crna now for 24 years and the point three of them have been [...0.5s] with DPI. So we are a, [...0.7s] um, small market anesthesia group in the southeast, um, with, um, some exponential growth here in the last, [...0.6s] uh, 5 years and you can continue that any.And Joe, do you wanna go ahead and introduce yourself to those who may not be familiar with you?Yeah, thanks Andrew. Um, my name is Joe Rodriguez and I am the Chief Development Officer at Guide Anesthesia which is, [...0.5s] uh, formerly Arizona Anesthesia Solutions, which is a group were, this were one of the small groups on call.So we're about 204, 200 providers. So I were probably, I don't know, one tenth of the size of most of the organizations on the call, but yeah, we're, we're holding it together here in Phoenix, Arizona and a few other places as well. [...1.3s] Sounds good.So first up we have Tom Polaria sharing insights on into leadership within both large hospital systems as well as on the educational side. So Tom, you wanna [...0.5s] kick us off [...0.4s] with some of your experiences, yeah, and how others could get into leadership as well.Sorry. Um, sure, Andrew. Uh, no, that was a lot. Um, I'll try to keep it as brief as possible. Um, [...0.6s] I, I think I would like to just focus on the insights, my latest insights, which is I'm now an employee of a large health system.Uh, first time for me. Um, I, uh, I think there's a lot of advantages to what I'm currently experiencing right now, [...0.6s] certainly [...0.8s] coming off of [...1.4s] my prior employment models.So I, I guess just for a little bit of background, you know, I've done the institutional model, uh, working for the state at a state facility. Um, and then I, kind of transitioned into smaller private group, um, got that experience as a leader.That's when I first became a cheap CNA, uh, for a group that never employed Cnas.So, uh, that was, that was quite a journey. Uh, I had to learn on the fly [...1.1s] without a lot of guidance. Uh, and, um, I have a lot of people to thank for that, uh, connections that I made through the Ana, through going to regular meetings. Uh.And then I kind of segged into working for a large practice [...0.5s] management company where you and I met Andrew [...0.7s] during that time when all the smaller groups are being kind of, you know bought up by private equity. That was a really great [...0.6s] experience for me.And as far as leadership, [...0.5s] it really gave me the foundation [...0.4s] to continue to expand my role as a leader within the Crnate community. Learns.I can't even tell you how much I Learned at I, I worked for two large anesthesia management companies, and both of those companies, they were, they were tough experiences but they were valuable.Um, and I mean, as far as becoming a leader and being a leader, uh, for people who are listening out there, who are [...0.8s] potentially thinking about jumping into a leadership role, I wholeheartedly, uh, support that. Um.You just have to [...0.9s] be able to be flexible and just know that there's so much to learn. You're never gonna learn at all.I'm still learning new things. And then from there, you know, we went through Covid, a lot of bad times there. And I would say that was one of my [...0.7s] best moments of being a leader getting people through that, starting to deal with serenades from across the country who came to my neck of the woods.As everyone knows that, you know, everything was New York and New Jersey at that point initially in the early months of 2020. Uh, and I gained so much leadership experience there that I'm still using today.And then that brings me to [...0.5s] now working for a health system and with this role that I'm in, I'm a chief over two different campuses [...0.7s] of a large health system.I, I have a lot of responsibilities everywhere, any, anything from day to day management to course scheduling and vacation and PTO and quality and [...0.4s] dealing with the day to day issues of the next generation of anesthesia providers, uh, who have a very, uh, large basket full of expectations that are always challenging, uh, to manage.But I would say in my role now and as an employee, [...0.4s] um, we have, I would, I'd like to think there's like five things I always try to try to find five things in any role that I have and now working with for a large, [...0.4s] uh, [...0.6s] health system.I think that as a brand new service line is anesthesia was not covered by this health system before.It was management company before. I think that we've really taken advantage of a huge opportunity of being kind of the new kids on the block within this large organization, [...0.6s] forging new, uh, partnerships with people who you already clinically knew, uh, they already know your worth and now they feel like they're, you're kind of on their team now and, uh, I mean, as an example now we are, we're all involved all the chief CNA's in choosing, uh, anesthesia machines for the entire system, which is a huge responsibility. It's a huge expense.And, uh, we're meeting on a regular basis to make sure that we all kind of get what we want while also being physically responsible. Um.The next big point is we have this now built in network of leaders, and I had that with them at anesthesia management companies as well, but it's a little bit more intimate now. We all know each other. Um, we sometimes share staff, so, um, we're able to kind of bounce things off each other.And it's really, it's, it's a very collegial environment with both the Cnas and the anesthesiologist. Hey, [...0.4s] Tom, just for, just for clarity, are you the chief CNA of Chief Cnas, cause you've mentioned multiple chiefs [...0.6s] multiple times. Yeah, no, I'm a chief over 2 sites. I'm one of like 7 chief Cnas.Okay, okay, and we only know that, [...0.5s] yeah, we record up to, like a senior vice president of the service line.Yeah, okay, yeah, that makes sense because I only ask because [...0.7s] is this, is this new for the system as well as cause you services brand new, it's still new for me. It's, let's see, it's 25 now, so we hit two years [...1.2s] in August of last year, so it'll be three.This, okay, and this is a new employed system, right, because it's [...0.6s] a emerging trend.It, it is, it, it absolutely is and it's, it started in the summer of 22 with a few of the campuses converting to a service line, kind of arrangement. And then since then, [...0.5s] yeah, the anesthesia service line and then sent it, which is, was the new creation.And, um, since then, uh, whenever a contract, uh, [...0.7s] expires, then that, that next place just gets, uh, uh, added into the service line.So I'm, I'm the chief of last one which was last October. So it's been about, if you could, [...0.7s] cause I wanted to still some of your experience for [...1.2s] hospital administrators that are listening who may not be familiar with this leadership model, [...0.6s] right, if you could, kind of, just fill into one idea, this [...0.6s] chief C Rnas that they're, that they are not used to working with.What's the one thing that they should know about integrating C Rnas into the leadership [...0.5s] that would be useful for them if they are, whether it's internal or external, but in this example, internalizing their service, what's the one thing they should know about CNA leadership that they do not know currently?Um, well, from my perspective, [...0.8s] uh, what the Sea Suite has really embraced since this, uh, transition to, uh, being employed by the system is that we are, [...0.5s] you know, one of two leaders for the anesthesia department.Our expertise is dealing with the CNA provider, [...0.5s] even though it's [...0.6s] anesthesia provider, very different population from the anesthesiologist, uh, provider.CNA can really offer and does offer a lot of specific knowledge and guidance when dealing with what usually works out to be more than 50% of their anesthesia workforce in each individual campus or, or medical center.Yep, [...0.6s] uh, Thomas, a follow up. How has your relationship changed from your prior roles when it comes to running the or schedule and input from the anesthesia team?I know, you know, one of the, the pain points for anesthesia all across the country is being asked to cover inefficient rooms. Is there a bit of an adjustment as in the employed model to [...0.5s] people being more flexible than moving cases to the afternoon? Um, and is there more communication between both parties?From your experience, [...1.0s] I will say that I think the communication has gotten better, [...0.5s] and, and really only because the surgeons nursing her operative leadership, even though they're still dealing in my [...0.5s] situation with the same people.We are now, quote unquote, on their team. We don't work for a separate company. We all work for one 1 [...0.5s] organization with the same goals, which is efficiency [...0.6s] taking care of patients. So I would say the communication has gotten better as far as coverage, Andrew, it's still the same struggles.I like to think that we have even more of a voice now again because we all are [...0.4s] now on the same team, quote unquote, where we're all reporting up to the same higher, you know, beyond Sea Suite structure I can tell you, do you feel it [...1.3s] is there were before, [...0.7s] Tom, do you feel it since you are employee the system now and you're contrasting that from a third party group, do you feel it is more efficient?Do you feel that the system you're, the institution you're part of is [...0.6s] efficient? I think there are some efficiencies that still need some work. Again, coming from a large management company that had been doing it for years, very fine tuned processes, infrastructure, we're still building that.And that's what our expertise, the anesthesia expertise is really being utilized for and leveraged for. But I mean, I can't compare two and a half years, two companies that have been in, in business for, you know, decades for few examples so, but we're, we're getting there.But as far as being streamlined, yes, because I'm seeing that those side meetings that had to take place, they don't have to. Everything is just directly from [...0.5s] the local leadership all the way up. And it seems like things move a little bit faster.Yeah, it makes sense. Just as a, as a contrast and maybe it's good for a point of reference. I think internal, external, that's a certainly hot topic now.Whether it's internal external, I think it's always, maybe the most important thing is competence [...0.8s] rather than internal external, cause there's probably [...0.6s] good examples of both. Randy, you've been a hot, you've been an internal hospital leader, [...0.5s] right? You've been a trade association leader.Now you're on at, I think, you know, a respected third party group with Northstar Anesthesia. Could you just [...0.7s] debrief us on your role with how you're interacting with hospital leadership currently?Or unless you're primarily on the, the CNA side, but imagine you brought in some of the hospital leadership as well. I can see you nodding there. And then can you just speak to how you overcome some of those integration issues?I think [...0.5s] our, our core operating thesis which is the [...0.5s] reason why we do well, is that [...1.2s] the insource versus outsource option, there are pluses and minuses for both. We tend to think that we're able to do about everything else better than an insource model.If you look at [...0.6s] the, our ability to, you know, from an efficiency perspective our abilities recruit, retain clinical talent is probably differentiated because we've got a, you know, in massive infrastructure and and time [...0.9s] tested strategies to make that happen.Obviously, there's also very nitty gritty you get into. Our ability to negotiate rates is probably different than most hospitals or health systems, either from a leverage perspective or an expertise perspective.So [...0.6s] I, I think all of those things are, you know, when I think about as a hospital health system is making that decision, they should weigh the pluses and minuses from a financial perspective.And that's not the only perspective [...0.6s] to be clear that you should think about, you should think about this decision holistically but if you were thinking [...0.6s] about it whole purely through a financial lens, [...0.5s] you, you would not be insourcing your anesthesia program.Um, yeah, but if you are willing to give up some of the finances in order to have complete control [...1.0s] of your anesthesia programs and go for it, you've made a decision and it's a strategic decision that you think you're gonna be able [...0.4s] to leave money on the table, but run things more efficiently. Our experience has been that [...0.5s] it's really difficult to do that.So [...0.4s] as we think about how we partner with our current clients and potential future clients, we take a very consultative approach [...0.6s] which is, you know, we're not, we're gonna be, we're gonna be very transparent.And if we're not the cheapest option, you're gonna find out about that pretty quickly. And we are pretty comfortable in how we differentiate ourselves from the less expensive option, whether that's an insource or [...0.5s] an alternative bid or bids.So we are willing to give up deals in order to make sure we have the right partnership. So I think as we take a complicated approach, the way that we think about this stuff is, look, and this is how I negotiate with, with everybody, including my kids, which is you've got three options.Here are your three options. Pick one [...0.6s] and we can make all three of these work. We recommend option A [...0.7s] option A, I think is the best option for you. But what we've seen sometimes decision makers on the health system side are not always rational in terms of what they want or what they think they want.So we give them options that are, we think tenable to both sides. So it's complex.And, you know, there if you look at the way that anesthesia structured in the United States, it's still highly fractured. You know, it's a highly fractured. There are all kinds of hospitals that have insource that are now outsourcing or hospitals that have outsourced are now trained to insource.And so that's probably going to be what we see evolve over the foreseeable future.Yeah, that, that makes I want to come back to this idea of kind of leadership integration with hospital systems because I think that's an area where many Cnas have not or they don't really have the institutional experience necessarily. But Adam, [...0.5s] you've been on the [...0.5s] financial side for the hospital side, correct?You work for HTA a little bit, now you're on the private side, maybe like hospitals, CNA leaders flip back and forth as well depending on where they're at and their career.But [...0.5s] since you have experience on both, can you just share a little bit on the hospital side of the financial end, what are hospital like, just tell other CNA leaders what hospital leaders are looking for, you know, when they're talking about how much they're spending on anesthetic, is it the same equation cause if a 3rd party groups, that's what's your subsidy, [...0.4s] right?For internal groups, it's probably just payroll, mostly agreeing with everything. Randy said it's almost never cheaper for them to in source. Now some of the larger systems are very successful at negotiating very competitive rates in the marketplace. Smaller systems may not be. There a couple things here.Number one, [...0.9s] being able to accomplish that [...0.4s] and sustain it. I think it is, is the biggest challenge because there's a, there's a dirth of subject matter experts on the facility and, and system side. I actually know how to run an anesthesia practice and we, you know, we all talk about every day about the shortage of anesthesia providers.We need to use providers differently in these settings to try to make up some of that difference. If anything, there's an even greater short, shortage of anesthesia subject matter experts that can facilitate as a system bringing something inside.So it's not just a get the rates, you know, designer staffing, hire the providers, it's [...0.4s] how to maintain it and sustain it successfully is a huge, you know, huge problem.The other thing that I think is a barrier and, and folks are starting to come around and you see different realizations at different levels is, you know, the easy button always used to be let's go get more anesthesia, right?We need to expand our out of our operation. We need it. We're adding a new cardiothoracic surgeon and we're gonna double our volume. Uh, we wanna start a new OB service line that requires 24 hour call.The easy button was always go get more anesthesia and that's not the easy button anymore. So especially for Consolidated Systems, I have at large number of locations in a fairly limited space, you know, alignment of services has to be on their radar.And it isn't always meaning you don't want to start a new cardiac surgery program when your performed volume, half of your performed volume accounts for cannibalizings, those cardiac surgery patients that you're now sending to a sister facility and keeping them at your facility, right?That's a net loss for them when they're talking about adding a 2.3 million dollar call panel, right, they're robbing Peter to pay Paul.That's correct, that's correct. So [...0.6s] that hasn't fully been realized yet. And you know, when you, when systems do employ, [...0.6s] and we talk about operating room efficiency, that's where it's, kind of, all late bear, right. It's like they own everything now. There's full transparency, there is no, um, [...0.5s] creation that has to take place when they wanna change something. All the information is known by all the people.And, and it really, what really opens their eyes is how, how inefficient some places are. We pride ourselves on great data and almost with our interactions with our clients, um, we do. When you say we do, you mean, you mean sound we, yes, on data, yeah, yeah, keep going, please.Oh, great data. And we, you know, we, we do, you know, we were, we're really acting like, you know these are many consulting engagements in some instances especially when it comes to changing the service provision in some way. You know, we and we're frequently getting, hey, we need 14 sites.Well you're, and we come back with data says, you know, you're staffed for 12 today and you're only using over 10, 6% of the time. Okay, we recommend that you don't increase. In fact, there's an opportunity to decrease and decrease cost.So again, there are different levels of understanding that, you know, the light bulbs haven't come on everywhere.Some facilities and leaders are more savvy than others, but that's a, that's a real big deal in this age of [...0.4s] provider shortages and economics that are really flipping everything on its head. And I know we're gonna get to that in just a few minutes.Yeah, indeed. And while we're talking about finance, just Tom, for the chief Cnas that you're working with currently or, or yourself, are you having a deal with some of these? The financial, I mean, there's no surprise we're going to financial pressure right? Given the current environment. But are you having to deal with that?Or you, your colleagues absolutely, I mean, we, we have, we have input in what staffing models are and during the transition, you know, everything was about a staffing model into Adam's point.Yeah, you might want 17 sites, but here's what you're utilizing and here's what we can actually staff now with our current, [...0.6s] with our current, you know, workforce.It's constant it hasn't stopped and that's kind of what I was saying before, Joe, you know, the transition from working for a large group so now working for the health system, I'm still working for a large group.It's just, you know, there's a little bit of a shift in what the experiences is, what the experience level is foundation, um, g of infrastructure.So, uh, it's been, it's actually been very interesting and to watch the changes when when, you know, the players over the years. Um, I'm, I'm enjoying it very much, and more importantly, my team is enjoying it, cause I kept a team intact, and now they can see both sides too. It's actually, you know, because I know our overall thing.Here is also leadership. It's inspiring more people to step up and, and become leaders, because they want to get involved.In fact, very soon, I'm only gonna be the chief of one site, because I'm promoting one of my graduates who came to work with me and is now going to be the chief of one of the sites.So that's the thing that, you know, I'll leave all the finance even though unfortunately I know about it to Adam and to Randy [...1.3s] atom. Do you mind giving us some insights into your role, uh, at rockers and how you, uh, how it, um, [...0.5s] your experiences of running a, [...0.6s] a program of that nature.Uh, just because I think this is an area that's gonna grow throughout the country, especially, uh, with more schools, um, popping up due to the third, uh, year. And just wanted to kind of give people some insights into what that may look like as a new career option.Yeah, sure, I mean that's a big pivot, Andrew. But sure, I can do that. I mean, [...0.6s] uh, it's [...1.1s] be, I've been in education for 20 almost 23 years.I've watched it change [...0.5s] to, you know, you're trying to get into CNA school so now you're trying to get into a three year doctoral program. It's extremely competitive. Um, I don't know, I think, uh, [...0.5s] the guys I'm looking at on the screen are, are kind of similar in how many years we've been in this.Like I don't know I would have gotten in to Columbia if, if the, if the pool was this big back then but I didn't go to an interview, I went and chatted with someone for five minutes. It's we run a business answer.So I guess that's my first thing is anesthesia program is a business. There is pressure to expand constantly. I run a very successful, um, uh, [...0.6s] program that continues to expand. And I have I, we had three clinical sites we started I have 25 now. Um. We just keep growing. Um, the doctoral project has been a bear. Um, I will say it not many of my colleagues will, but it's a bear. Um, but it's something that our association decided that we would convert to.We were one of the first advanced practice nurses to make that as part of entry to practice adoptable degree. Have to tell you the biggest pain point right now is these next generations.That's where I start to sound like an old God of the level of expectation is really at a critical point right now.I think for the, [...1.1s] if we're talking about leadership from an equity holders point of view or owner, [...0.5s] right, I think it's probably he to talk about the transition because the difference where I started and where Thomas and Adam and Randy are is, you know, like it's very different.And, you know, I think from an institutional level, they're working in institutions that are quite, um, much larger, [...0.7s] but when you're starting at leadership and you're working with small facility leaders that sort of thing, the one thing I can tell you is that if you want to get into that sort of thing, you need to, you know, everyone online will tell you now, count the cost measure before you do something. Get to work life balance. And this is very, very, very bad advice, [...0.5s] right?Like if you want to get something off the ground, and it really doesn't matter if it's, it's any service sector thing, right?Whether it's plumbing or anesthesia or a podcast business or whatever, like you've got to be willing to go way, way above and beyond the standard 9 to 5 probably for three or four or five years just to get it off the ground.And I think, as you know, early on, at least you bear individual financial risk which is a different equation. And what I'll share here is that [...1.4s] you guys will appreciate this. We got real financial people involved when we started making big mistakes, right?When things started costing us a lot of money. Then I was like, you know what? We need some expertise that, you know, Randy and Adam were talking about early. You need real expertise. People have done it before and [...0.5s] to break it, to [...0.6s] break it down for everyone who's younger than me chat GBT will not save you right there. That will not get you the answers you need. But you only get 10 years experience by having 10 years experience.So it's a very different leadership phenomenon, I think at that level, [...0.4s] and if you're really lucky, you work with great people who will continue to elevate [...0.5s] your leadership, your organization, and ideally the value that you're bringing to hospitals, surgery centers and like Thomas saying earlier, ultimately [...0.5s] the members of your organization, right?Cause they're the ones taking care of the human beings, take care of those patients, kind of pass it over to Adam. So, uh, you know, as you all know, I am in the consulting space going from facility to facility.One of the big things that I always focus on when starting engagements is really educating my audience on the current state of anesthesia, [...0.5s] um, and the imbalance in terms of the supply and the demand.I just wanted to kind of open to the panel your thoughts on if you think there's any improvements that could be coming down the pipeline and where you think this is heading in the future.I wish I could say I was confident that any big improvement was coming down the pipeline, but I don't believe there is. Where this lands.I don't know that anybody knows, but, but I do know that, you know, a lot of payer, certainly government reimbursement doesn't come anywhere close to, to covering the cost of care.And as we're seeing both with medicate expansions of, of the last decade and an aging population where government portions of the payer mixes at basically every facility are increasing.The entire, the entire bucket of revenue that a service line may receive for professional fees generally doesn't cover the cost of care.I can think of only a handful of programs that I've modeled in the last four years that were fee for service or could remain fee for service. And, and I can count those on one hand and have fingers left, so, um, not, not a great, you know, situation.And, and I know, you know, especially initially, you know, it was, it was shocking, especially to the the facilities uh, that end up, uh, having to cover that cost.Of course, you know, for, for some of your C R N a listeners, there are only [...0.4s] a few sources of revenue, right? No. 1 are the payers. No 2 are the patients, right? There is always gonna be Copay's co insurance or some portion, uh, that's a patient payment due even with the government payers.And then the third is the facility and that's it. So the, the sources of revenue in this equation are, are very, very simple, which also means that there's only a couple places you can go when the economics get worse.You know, I looked up a couple statistics for this talk earlier today. I wanted to see, you know, who, somebody out there I know had calculated what's the inflation adjusted decrease in Medicare reimbursement for [...0.5s] medical services for Part B and it looks it up, 2001 to 2005, [...0.6s] inflation adjusted [...0.5s] decreasing by 33%.So 2,001. 2, sorry, 2,025. So [...0.9s] 33% in the that 24 years and even in the last say since Covid. So last four years or so, we've seen increases in provider compensation [...0.9s] up to 50% in some markets. Um.So those two things are, are just not congruent with each other. And that's why whereas, you know, when an anesthesia group would, would go ask the hospital for assistance, where it might be [...0.5s] a 30% or a 50% increase, we are seeing exponential increases almost across the board.Hey, our subsidy needs to double, hey, it needs to go up by two and a half times. Part of that is, you know, [...0.5s] part of that is utilization efficiency part of that is the expansion of the number of sites of service where anesthesia is required, especially in the out of or space.Your calf Labs, EP lab, IR endoscopy, bronchoscopy, [...0.6s] you know, [...0.4s] there are some facilities that, that we work with where 50% of the volume that we handle every day comes from and out of the world. And that was just unheard of 10 years ago.So the expansion of anesthesia requirements, the increase in anaesthesia compensation and the decrease in anaesthesia reimbursement of all just kind of created this perfect storm of these massively increased requirements for assistance from the facilities.Um, and I, and I, I don't wanna fail to mention this is hitting the HNC space too in a large, large way. And, and I hate to say it, but they're even less prepared to deal with that.Then, then the hospitals are simply because they've absolutely never had to deal with it before, right? An ANC administrator's sole job was to bring volume, any volume and keep the surgeons happy, and that's it that's not the case anymore. That doesn't work anymore.Efficiency is Paramount. Not all volume is good volume for us especially. But the flip side of that is good volume for us is great volume for them. So if I did say, you know, distill that all, especially on the AOC side but on the hospital side too. Don't chase volume, chase margin, right? That's gonna, that's gonna help dig you out of all of these problems.So going to the economics and the effect of the economics and what we're, how we tend to handle this with our current clients perspective clients is a, how can we be as creative and efficient with our staffing as we can be based on their [...0.6s] listed requirements?And sometimes we talk to them about, hey, we really don't think you need a physician here. We can do this with a C R and a and hold back the physician for these three sites or, or whatever that may be.So we really focus on physician and CRN, a collaboration medical direction, right? It's a, it's a billing choice, it's an option and it comes with rules that, when actually properly followed, [...0.9s] wildly affect [...0.6s] the, the operational efficiency of any operating room.So we stay away from that [...0.8s] very often in larger facilities. We're, we're going to model a facility where we might have some sites that are CRN only, some sites that are physician only, some sites that are a team in ratios that would typically be considered care team 1 to 4 or less.And then we may have some sites that are and more of a truly leverage collaborative model where it might be 1 to 5, 1 to 6, 1 to 7, [...0.5s] right? So you still have to think about the through put efficiency in those sites, right?One physician can't be expected to [...0.5s] do every single pre op in a high volume out of or center that's doing, you know, 16 Endos per room per day, something like that so [...0.5s] will typically substitute that with, with float C R A's that are, that are specifically designed to help with through put right.The physician doesn't have to do every pre op, the physician doesn't have to do every block, the physician doesn't have to sign every single person out of the pack, you right, C R A's can do that too.And when we have more people [...0.4s] qualified and allowed to do more things, there are simply more people available to take care of all of these things at any given point.Um, so being, you know, being creative in your modeling [...0.6s] and being as efficient as you can be, uh, [...0.4s] helps take some of the sting out of the, the, the terrible economics that we're all facing today.And I think, you know, certainly for all the facility, uh, administrators, [...0.8s] another executives out there that are hearing this. You know, it doesn't matter who your vendor is or whether you bring it in house.Everybody is subject to the same labor market. We can't magically create people for less, uh, no more so that anybody else can. Randy and I will go to the same market. We often bid on the same facilities and we are all basically doing our market assessments and saying, we think we can recruit to this.And it's all very, very, very close [...0.5s] same thing with, uh, no surprises act which, you know, went into effect in, I think, early 2022.That's the other piece on the commercial side. Uh, that has hurt, you know, some of the traditional large vendors, legacy vendors, um out there had had some very, very preferential rates that were kinda legacy rates back from the late 80s and 90s, right?When no surprises came around, it eliminated a lot of those, those preferential rates.So really everybody's kind of getting cramped, you know, clamped down into the same narrow band of rates within reason. There are still, you know, still some of those preferential rates left out there in certain states. Um.So if everybody's paying the same for labor and everybody's relatively getting reimbursed the same, the value proposition really becomes on service and efficiency.Yeah, you briefly touched on scope of practice. Um, and, you know, kind of being the business person in the middle of this the push back we always get from physicians is that there's like a lack of structure around [...0.5s] independent practice.Just wanted to kind of open to the panel and see, you know, ask the question like, [...0.5s] is there a set of guidelines for independent practice? Like when could someone be a considered independent and working on their own?And why isn't there more, uh, sub specialties within the CNA, like like a cardiac route? You know, Tom, I know you're on the education side. Is that something that's in development?Just wondering where that could be heading in the future. I think when it comes to this idea, there's, there's a lack of structure. [...1.5s]I'm not sure where the, where that concern is exactly coming from. But I think there's probably two points to make here and that this word independent is often misunderstood, right? Most people here independent and they think they're all alone and what we do in our organizations stay.As your level of autonomy increases, whether it's with high acuity cases, working with physicians or working on your own, your responsibility to communicate also increases, [...0.5s] right?Which lends to the second point, which is whether anatomy did a great job describing different models there [...0.5s] take a very similar approach was just spot on, right?Because what I think I would describe there was [...0.9s] really [...0.5s] taking the problem or taking problem you're trying to solve and put that first and then working backwards from that. The problem we're trying to solve is high quality, efficient care. And that can be done in a lot of different ways, right?But the key point is what is the appropriate clinical oversight [...0.5s] for that facility based on the talent and education of the individuals and the culture, the needs of the surgeons and the patients. That's the question to be asking. That's the framework to be deploying.And I think, again, whether it's internal, external, [...1.0s] that has to be the modus operandi if you really want to navigate that well. And I can tell you that look and most people on this call have been involved in CRN a advocacy and one on the regulatory side, which is not today's focus.But I can tell you that debate is very different than what should be happening at a clinical level where you're evaluating the individual skills of individual practitioners. So hopefully that is the structure that, [...0.5s] you know, we're all seeking to employ.And by the way the word employ [...0.4s] was not a common on the internal, external, a debate going on.But it's a great question. I think it's a legitimate question because I, I'll just add this last point. There are some groups to use almost experimental models where they're taking, and this really applies to any type of professional where they're taking people just out of their training and immediately putting them into high responsibility roles just because they have a certain set of letters behind their name. And I think this is generally unwise.I did one also come back to the, the sub specialty. Do you guys see, uh, your specialty creating more routes, um, for people to be more focused, uh, in terms of care in the future? Cardiac PEDs, potentially OB certifications as something that could come down the pipeline?Not [...0.4s] an educator, but I, my job before this job, I had a lot of conversations with the key stakeholders within the community.This is not exactly where you're going, but it was a flavor of the kind of conversations as should we actually move the entire educational construct to be, uh, nurse practitioner slash Crna? Uh, that was a very common question I already got.And then there was the to what level of specialization makes sense [...0.6s] for the community and for the key stakeholders that the community serves. Now we do have acute pain a fellowships in, uh, specialization. We do have chronic pain as well.So in terms of specialization that is about as far as the syranny community is formally moved, I think there is always a conversation, you know, around if the profession doesn't continue to evolve, it will die.So, you know, I think we should look [...0.7s] honestly to what the communities are, what the employers and what the communities that have Siren is, what they're asking for and what they need.And my big push back on the, we should change, we should radically change [...0.5s] the education of C R Nation, include nurse practitioners like like no one's actually asking for that. Like like hospitals aren't calling me up as when I was the CEO of the A and a C so you know what I need.I need to put a very valuable resource out of the or to provide [...0.8s] clinical service that is significantly less important to me relative to the, or stuff. So I think if we look, I use that same kind of construct if we look at like, do we need [...0.9s] cardiac specialization?Well, there's a lot of Cnas who have specialized into cardiac. There are a lot of Cnas who do OB only. There's a lot of Cnas who do PEDs and we can go on and go on. We haven't, I don't think it's a community and again, I'm probably the last person that should be commenting on this, but we haven't said, you know, what, you know, what we really need is we need to stand up another specialization [...0.7s] or, or specialty or subspecially.I should say, so who knows where things go, but we're not at, you know, when we talk to our clients, when we talk to conditions, I'm not hearing a drum beat of request for specialization or sub specialization. And, and Andrew, I would just add to that and yes to everything.Randy just said, [...0.4s] um, from the educator perspective and being in it for so long, uh, there was a time that, there was, that was the focus [...0.5s] of, hey, should we do this and as Randy said, there's acute, there's chronic pain, there's programs out there.Um, I have Cnas who've gone through my program and graduated, who have specialized not a formal additional training [...0.5s] in the vein of a physician residency where they go off and they do an additional year for cardiac fellowship, etc.But they, they want to focus on that because that's just what they're interested in.Just the last couple of years, I've had [...1.1s] three Cnas, 3 graduates who took jobs specifically at institutions where they would be providing probably 80, 90% of their time spent on pediatrics, um, to have gone to places just because they wanted to do cardiac.Um, OB [...0.6s] is kind of a given now in my neck of the woods that you, you actually are expected to do OB.And some people like it and some people don't. And luckily, in my experience as a leader, I've been blessed to have a great mix of people who, you know, no one's forced to do anything. We don't force anyone to do anything. Um, but as Randy said, no one's knocking at the door saying, hey, can you do this?And that, again, was on full display during Covid when we were taking over any space that we could call a unit and we did and we were running it. So we were the intensivists.There was a point where myself and several of my colleagues were running these units and we had or nurses taking care of events and we were just managing them.And even after that, noble was saying, hey, [...0.5s] can you be an NP too? Because no one's gonna pull us again. As Randy said, I'm not getting pulled out of the operating room to do that unless that was all that there was, which was what was happening in 2020.So I just want to kind of kick the conversation over to you, John, and kind of get some feedback [...0.8s] from your end. Uh, I know you are a 25% owner, uh, within your group. Um.Can you give us a little insight into how you're partnering with your physicians to grow your organization? I know [...0.4s] you guys are a little, uh, unique, your group, uh, you guys are focused not only on just providing clinical support but also other lines of service.I just wanted to kind of get some of your insights into some of the things that you're seeing with your physician partners.Sure. So in our group, I think our special sauce is the ability to hire [...0.4s] really top notch providers. At the end of the day, all of the criteria to be a good anesthesia group is the same, whether it's insourced, whether it's outsourced to a large, um, managing group or small managing group.You have to have tons of expertise, you have to have business acumen [...0.7s] or as has been described, a terrible economic venture, [...1.0s] and you have to know what the rules are where, where are the lines in. Each state has a little bit different, [...0.4s] um, set of those, uh, for practice.So when you look at the position side, [...0.9s] we do collaborate a good bit with our physicians and we offer different leadership tracks within the company for those that are interested in it.I think once you start into the leadership realm, the first thing you have to realize it's no longer about you, it's about everybody else.And as the comments were made earlier, what that entails is, is [...0.5s] you're available and your service is there [...0.8s] for [...0.8s] whatever time is necessary for and for whatever thing or whatever situation is at the time. And I don't think everybody really appreciates that until you start into it.You know, when you talk about independent practice, our experience is people a lot of folks wanna be independent.I'm not talking just about Cnas, I'm talking about religions as well. A lot of people say they want to be independent or can be independent until they are independent. So it's not necessarily in our group. It's not [...0.8s] anesthesiologist versus C RNA. When we hire folks, we hire anesthesiologists and we evaluate anesthesiologists with the same criteria as we do Cnas.Certainly, we have Cnas that are really good at certain things and we have anesthesiologists that are really good at certain things, but the spirit within our group is very collaborative.And honestly, the road that we're going down as a profession, I think both, [...0.6s] um, both groups need to look, and I'm talking about as an organization, the CNA, the Ana, and EMD, the Asa organization need to find ways to better collaborate.When you look at, as Adam had talked about early, when you look at the economics of what we're dealing with today, it's not getting any better in five years or 10 years. I say in certain parts of the country, we are full all the way, pretty much down the road to a Medicare for all type mentality.And honestly, it's a little disappointing because there are many physicians and crnades that are just kind of giving away to it, just kind of accepted that's the way it's gonna be. And there's not a whole lot that anybody can do about it.Spending time in DC this January, nobody wanted to really talk about healthcare at all. Um, not, not specifically anesthesia. I'm just talking about our system and where our healthcare system is going right now. Anesthesia is like one microcosm of what's happening throughout the entire system.You look at commercial insurance. We've got what four left and one of them is trying their best [...0.7s] to do everything but commercial insurance. They own practices, they own pharmacies, they own [...0.7s] outpatient ASC chains.So where all that goes, you know, as the Crna organization and a physician organization, if those two could ever come together [...0.9s] and look at [...0.6s] what, what we're real, what's the real issue to me, one of our biggest issues is our Medicare rate versus our commercial rate [...0.8s] is in some states, 20%.Look at every other medical specialty out there, what are their rates? Um, Medicare versus, um, versus commercial, 70, 80, 90. If anesthesia was 50, what kind of difference would that make to everybody's reimbursement? What kind of difference would that make to hospital subsidies or ASC subsidies? And so we're going in the opposite direction of that.And as organizations, I think we're going in different directions as well. So really, when, when physician anesthesiologist [...1.1s] come to our group, it is very well known.We're not a group that beats our chest and sales. We're anti, antisoviology and we, we, we are crnas conquerors of the world. That's not [...0.5s] our mentality. That's not our culture at all. It's how can you come in and [...0.4s] help our group better, be better?And same thing with C R and A's. So we, you know, when you talk about certifications, when you talk about, [...1.2s] uh C R N a independent practice and how does that work? You know, how do you know if they're ready?Certain facilities that we cover [...1.2s] are pretty high comorbidity, pretty big cases. And we're covering it with all Crnas with no anesthesiologist in the house.But when we hire folks, we don't hire anybody with less than five years of experience, we don't hire anybody that can't use a fiber optic telescope.We don't hire anybody that does not understand or know how to use an ultrasound machine. So I think you have to have certain levels of criteria depending on the acuteness of the facility that you're at.And when a facility called or we approach a facility, [...0.5s] we try to be, as Adam and Randy said earlier, we're the same way.We try to be as flexible as we can. I really it doesn't matter to me as the CEO of our organization and one of the partners how we cover, [...0.4s] cause I know we're gonna hire the right people to cover. If they want all in these, [...0.5s] like, out in the west, that's fine. We can do that.If they want all CR names or whatever in between the criteria for good service doesn't change [...0.5s] how we measure if we're doing well or not, doesn't change whether [...0.6s] it's a C r na doing the fibrootic or standardstein knowledge doing fibrootic, [...0.5s] fibrootic success leads to happen.And so [...1.3s] we, you know, when, when we have a new provider come in, they are checked off, there are, you know, we do certain things and they're, they're followed and make sure everything is [...0.6s] up to the standard of the practice, which I think is very important.And that just having that criteria [...0.8s] with the facility, I think makes everybody a lot more comfortable with the idea of having Cnas and physicians practicing at the same time.Not necessarily just physicians doing pre ops, but physicians doing cases, doing breaks, [...0.5s] running flip loans, etcetera, etcetera.So I think, you know, for us to really take the next step as a profession one of the hardest things I think we're gonna, we're gonna find in the coming years, maybe I'm getting ahead of discussion is the anesthesiologist shortage that is now starting to begin. [...2.2s]Yep. And maybe that, that's a good, uh, time to pivot into the future of anesthesia. I know Joe, you had some thoughts on this, I just wanna go ahead and kick it over to you as well. We've certainly [...1.2s] alluded to it during the conversation already.Appreciate everybody's comments. I think, you know, I approach, I think about this in two ways and maybe it's the, [...0.7s] the concept is easy, the application is hard, right?And I think the concept is, [...1.2s] rather than [...0.6s] living in a world, I'm gonna use the cliche, living in a world of either or I think anesthesia as a specialty increasingly needs to think of both and right, or best of both [...0.6s] and using the game giving Adam credit for [...0.5s] really articulately describing models that really advocate for the full utilization of those professionals, whatever that looks like at a local level.I think increasingly that has to be the, the question we are answering. How do we get the most possible value [...0.4s] out of those professionals for those patients? And when we come in with that mindset, the answers should get different. I, overtime.I don't think it's wise for us as an industry to keep saying we're gonna do things the way we did them in 1965 and we're gonna hope for a different result. That's, I mean, maybe, but it seems unwise to me.And I think the other half of it, [...0.5s] uh, to not make my answer go too long, [...0.5s] is that all the, there's this [...0.6s] very negative cultural thing that's been going on in anesthesia, as [...0.4s] I think for those of us who have experienced outside of anesthesia as well, it's all a bit weird, [...0.5s] right?That there's so much inner professional tension in this business. But figuring out how to undo that and disengage that tension and begin to [...0.6s] not be focused on who can grab the pie, [...0.5s] right?But be focused on how do we create value for that hospital, for that surgery center, for that surgeon and ultimately for that patient, having those cultural conversations, that's the really, really hard part.And I think firms, whether they're private service firms or internal lines, people who do that well are going to be well positioned for the future to navigate the very difficult economic landscape that everyone is described.That's how I both in concept and an application, I think it's a diplomacy, the cultural aspect that's really hard for the future.I'll add a little bit onto that. Joe, you know, I've kind of always said that the politics of our business the negative politics of our business are filtered down and have been become so ubiquitous that they truly affect [...0.5s] negatively, affect operational efficiency [...0.9s] wherever they are pervasive.Um, I've been in, I've worked in some great team environments where hey, the Cnas break, the physicians the physicians break the Cnas.Everybody teaches, everybody blocks everybody discusses difficult cases together and and tries to learn together from them, you know, [...1.2s] not forgetting that everybody has something, that you can learn something from everybody, being able to drop the politics, keep that out of your practice.Create a truly collaborative environment where everybody learns from and helps everyone else. That is the ideal goal.I think, you know, John talked about it, Joe, I think you talked about it Randy. I [...0.4s] think we all kind of hinted to this, you know, [...0.6s] we wanna create places that people want to work and that ideal state is, [...0.6s] you know, what people want, uh, want to work.And, and frankly, [...0.7s] if if you have a bad apple, that bad apple needs to go, [...0.4s] um, because they are going to disrupt the achievement of that ideal state. Of course, it's not perfect everywhere, it's probably not perfect anywhere, but trying to get there is, is, you know, is the key.Uh, and [...1.0s] again, going into a new facility check your politics at the door. Uh, we're gonna do this together.And, and we've actually frequently especially starting up a new, new practice location, we frequently go through a weed out process where we, um, you know, ask the disruptors politely to, to exit even in this recruiting market because there's just way more damage done by keeping them.To avoid that one additional temporary Lochemist provider rather than cutting ties and trying to put your ideal team in place as soon as you can.Anyway, Andrew, I wanna add on because yes, what Joe and what Adam just added to, I, I just wanna kind of give you a little bubble here. I now work for a huge health system. We all, every site pays exactly the same amount of money, we get the same benefits, everything is the same.It is all about the culture. It's all about the culture and everything else I can't even say that it's secondary it's it's way down the line. You have to build a culture where, where people want to come to work, as I said earlier, that want to give their best and go home with a sense of satisfaction.We all know that we're going home with a paycheck, that part is a give it, but we need to have an environment where everyone gets along, and I'm not talking about strumming your guitar, but we all have to have mutual respect. We all want to have a feeling that we made [...0.4s] a difference.I think that's one of the main reasons people get into any healthcare profession.And, um, I will say that, you know, [...0.5s] the sites that have a great culture, they're the first ones to, to fill up with providers. And I'm very lucky to work in a place where I have no openings, I have no [...0.5s] CNA or physician openings.It's a huge, huge [...1.4s] edge that we're trying to, to replicate in other places. Um, so I think, um, I agree with all that. Um, [...0.5s] the one thing that I, I see [...0.9s] pretty clearly that isn't always [...0.6s] articulated clearly is if you look at people or organizations or teams that are doing well, [...0.9s] the thing that is almost always there without exception is long term orientation.And that's really hard to be long term oriented, especially in our environment [...0.6s] where, you know, you know, [...0.5s] but my, my job is probably 60% putting out fires and 40% being strategic. That's, that's actually that's election.Like I'm fortunate they have that a lot of my senior level leaders are, you know, probably in this, you know, 80% to 90% putting out fires and so [...0.6s] I think as we look at, and I think the reason I bring that up in the context of the previous [...0.9s] comments is that what you're talking about culture and culture is built [...0.6s] over time by great leadership.And great leadership is built over time and often requires a lot of short term discomfort.So to at this point, you know, you go into a site, you wanna turn a site around you, you know, the, the first condition that has to exist in order for you to be successful is you have to have solid frontline lasers at that site.If you don't, you're dead, [...0.6s] you're, and, you're, and you'll be having locum tenants there until the cows come home.And so as we think about what it means to be successful, what competitive advantage really is, it is long term orientation [...0.5s] with a strong orientation towards leadership performance at the side level.Once you get that sorted out, [...1.7s] excuse me, most things fall into place. Now, it may take a year, [...0.6s] it may take a year and a half and which is why a lot of sites don't do it because they don't wanna experience a short term discomfort of doing the hard thing.My overarching goal when I asked Joe to kind of help with this was to kind of put in front of physicians cause I see it a lot of the time where they're leading the practice that there are equals from an operational perspective on the C RNA side that have the best interest of the community [...0.4s] involved.And I think you guys have done a great job of articulating that. So I just wanna thank you guys, uh, for joining and giving your insights. Um, and I appreciate your time