Dr. Chris Thu: Building a High-Performance Anesthesia Group

What does it take to recruit, retain, and grow a successful anesthesia practice in today’s market? Host Jeff McLaren talks with Chris Thu, M.D. about leadership, culture, provider shortages, hospital relationships, and the evolving economics of anesthesia care. The conversation explores why transparency, alignment, and operational flexibility matter more than ever for anesthesia organizations nationwide. 

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Transcript

Introductions

SPEAKER_01 0:06

Welcome to another edition of Anesthesia Economics, and I'm very pleased today to have a longtime friend, Chris Thu from Austin. Chris is with a large national practice in their Austin subsidiary. Thank you, Chris, for joining today.

SPEAKER_00 0:26

It's my pleasure, Jeff. Thanks for inviting me.

SPEAKER_01 0:29

So, how long have we known each other?

SPEAKER_00 0:33

Back to 2014, so 12 years coming up on the summer of summer of 14 is uh yep, summer of 14. That's right.

SPEAKER_01 0:40

I think you're right. Yeah. Um you guys have a great group in Austin. Um we're seeing, you know, across the industry, I'm sure you guys see it in spades in a dynamic city like Austin, a lot of change in the hospital environment, what's being asked of you. If you could encapsulate what you see as the biggest set of changes over the last four to five years, how would you distill that down?

NORA Growth

SPEAKER_00 1:11

I think the two the two biggest things are the demand uh that the hospital is asking of us. And it's obviously there's operating rooms, and and you know, if you're fortunate enough to have a hospital that's growing, you're gonna have an increasing number of operating rooms, but the biggest thing is the non-operating room sites. Uh obviously they've always existed. I think that over the last five years uh have really grown to a much greater extent. And at the same time, I think the the staffing challenges post-COVID, so you know, kind of five years, four and a half, five years-ish, just the uh explosion in different offers and things out there for anesthesiologists, uh, you know, CRAs, um, care team members, I think that has really put the uh put the pinch on on practices in hospitals for that matter, uh, of trying to staff in a very, very competitive um uh you know, anesthesia marketplace and trying to staff more sites at the same time. And so at least that's what we've seen in Austin here. And then I I know a little bit about you know my my overall company and and how it works nationally, and that's that's what we've seen reflective um become reflected elsewhere as well.

SPEAKER_01 2:17

Yeah, I would say the repeat refrain of Nora being a demand driver uh is extreme. And um what we're hearing is that the scheduling dynamics and the variability relative to NORA versus OR cases just compounds the problem. So, yeah, there's more demand on the NORA side, but it's also more variable in most environments.

Scheduling Challenges

SPEAKER_00 2:42

And then and I will say also that you know, historically, there's been an anesthesia provider uh or or two in in each operating room. So that is sort of the the natural growth of the operating room environment, has always meant that there's one central scheduling for however many ORs you have. Um the the non-operating room environments, so the outer departments, we we also call it um endoscopy, cath labs, radiology, places like that, they have not historically been in most hospitals, definitely in the ones that I work at, they have not been under the sort of the same umbrella. And so then now you have for us, we've got 29 operating rooms uh that are all sort of staffed for the same central location and the same OR staff and anesthesia and you know, all at the same front board and all that, it's a little bit easier. There are definitely challenges when it when it comes to what hospital wants or what we have, there's no question there. But then in addition, you've got endoscopy that does their own thing. You've got the CAF that does their own thing. And they don't typically are they're not really usually talking to each other. And so I don't think their intent is to try to stress us and add things on to last minute. But when they when that when they don't have any rules, or at least they just yeah, right. And so they they definitely are, and so you know what we struggle with when we when we talk to hospital, especially when it comes to the other big you know, mover in my career of almost 20 years, has been the a greater reliance on hospital support. So as you're talking to them and say, hey, we're we're happy to cover these things, but you got sort of you gotta corral all the departments and kind of put them under one roof, so to speak. Um, yeah, we've had better success um at certain hospitals than others. And it's really the ones where we've we've had a relationship or have been talking to administration for a longer period of time, um, that we've had better success. And it's just uh an education, re-education as administrators change over of trying to, you know, uh explain our limitations, um, what what stresses us, what strains our our coverage model, um, and and what the hospital wants and trying to get those to meld together, which can be a challenge.

SPEAKER_01 4:50

Do you think that they do they see the problem? Um do they do they understand the impact of having you know they probably think that well the OR schedule is set. What's the problem when really they're not mapping in? But it's more than one schedule because there's the OR schedule, there's the endoscopy schedule, the cap lab schedule, interventional radiology schedule, whatever it might be, that's stacking on top without coordination between the silos.

Administrator Incentives

SPEAKER_00 5:21

Yeah, I think, I mean, I like to give people the benefit of the doubt. So I I I hope that they are not doing this intentionally, and I don't think they are. I think that everybody um has has different um kind of metrics that they're held to. So if they want to, if if their hospital, the the high up administrators saying we're gonna judge your quarterly performance based on how many cases you do, well then I obviously they've got an open room and drive a case in that room. Um if they if that changes to efficiency, which is kind of how we like to push it at least, uh, especially when we have a limited resource, is trying to use people efficiently, that's where we're trying to get people. Um and then it comes at a certain point, you can be maximally efficient, but that may come at a little bit of cost of surgeon or or a proceduralist convenience. Or if if you want to grow, I mean you if the hospital wants to grow and grow cases and bring new uh surgeons and proceduralists in, then they want to be a little more flexible. And that's fine. And and and and we realize the long-term play there is is good for us as well. But in the short term, we still gotta, we still gotta pay our providers. People still need to make the right compensation. And so um there's a give and take there. So I do think they get it. So we we may go and say, hey, the number of sites that your uh facility needs on a given day, let's call it 10. And 10 is what you would need. But if we're in a they're in a growth mode, they're gonna be like, okay, well, we know 10 would work, but we really need 12 or 13 to try to attract people in, which we can get. We can, but then they gotta understand that that comes at a cost to us. And so if if if we we get people on the right page there, um, I think to answer your question, I think people do sort of understand that. And then the other problem is, and I'm sure it's uh it's true on the anesthesia side, is that you have turnover in in the administrators. And so uh the administrator, one ministry will leave, and then the next person comes in and you feel like you're starting over again. So I've been fortunate enough to be at the same location for my entire career, so almost 19 years, and it's uh education, and you get on the same page, and then you think this is great, and then that person, you know, hopefully is going off to do something bigger and better, and then you have a new person there, and so you sort of feel like you're starting over again, uh, which is okay. And we're used to that. And um, so we're just kind of telling our story and then telling the story again and trying to get people on the same page, or especially if we can get to the state where we're aligning incentives. So, you know, we want to grow, hospital wants to grow. We know that there's a cost of growth, um, and and we can do that together. And so, you know, a lot of people would talk about hospital support, which you know, a long time ago was was really uh a negative thing, a negative term to say that you're you're receiving a stipend or support from a hospital. Now I think it's it's really the reality, uh, and we've seen that across the country. But it's not so much too, right? Oh, yeah, now surgery centers as well. And it's not so much that they're supporting you. I mean, we actually we have one one of my colleagues uh calls it this is their their advertising budget. So if if if they want to have another room open, they can bring a surgeon in and at the right time. That's actually they're investing, and and we can somewhat in invest. We don't have the the the coffers per se that a hospital might, but they can invest a little bit there to then fill that room. And so it's another way to look at it, but but just trying to educate people along the way. Um, and so you what I never I never want to be, I never want to be considered a vendor at a hospital. I mean, I understand that I'm not necessarily a hospital employee at any places that I work, but I don't want to be viewed as a vendor, I'd like to be viewed as a partner. Um, and so you know, if if if you enter into a partnership, there are there are gives and takes, and uh, some of them will be financial, others will be lifestyle or you name it. And we try to come to an agreement where uh we can both be be happy and both you know prosper going forward.

SPEAKER_01 9:05

And I would imagine the administrator turnover, which presents a challenge, is true not just in the OR, but whoever's coordinating the various Nora specialty silos. I imagine that that's also a challenge as well.

SPEAKER_00 9:20

Yeah, and and and to be fair, it it it we have turnover as well. So so there's turnover on both sides, and so you know, the the job that I do was done by you know a colleague of mine prior to me doing it, and then I'll pass it on at some point as well. So, you know, to to to to our extent on our side, just trying to educate people, we try to speak with one voice. Um, and we would hope that the hospitals would do the same. It's not always the case. Um and again, I like to give people the benefit of the doubt. It's usually just because they're new and they're trying to figure things out. Um, and we've been fortunate to have a great, great hospital partners, plural, but uh, I mean different systems. But uh, you know, I mean, I think again, if you can figure out align incentives and say, hey, we're all in this together, we want to grow business, do more cases, serve more patients, all of those things which which are good, um, uh good good goals to have, that works well. And then there's gonna be certain pressure points that the hospital has that we need to address, and then that we have that you know, we'd like to get some some help from the hospital.

SPEAKER_01 10:16

So, do you think that conversations with surgeons and larger surgical groups that are especially the ones that are driving volume at hospitals, has that become more challenging? Do they understand the economic pressure that's on the hospital when increased amounts of coverage is provided that's not being filled with cases? I mean, is there more of an understanding there, or is or maybe that continues to be a challenge?

Surgeon Education

SPEAKER_00 10:43

Yeah, I mean I mean, for for sure on the surgeon side, I mean, you know, historically it was just like they just they brought a case and just expected the anesthesiologist or you know, care team or whoever to be able to do that case. And there were certain times, you know, long time ago when compensation needs weren't what they were now. Uh payer mix may have been better, uh, commercial uh you know reimbursements were were better. And and like like in you know, the ASCs that you mentioned, I mean, there's there's a day where no ambitious surgery center needed needed support. That's definitely changed now. Uh I think the there's a lot of I mean, there's a lot of reasons for that of payer mix changing in the ASCs and then compensation driving up. And so there's everyone's getting squeezed. And so I think the um, you know, so I'm I'm uh probably past mid-career now. I'm 50 years old, and I think all the surgeons kind of kind of my age and older, they weren't used to that. So they they were still in the old uh mindset of just bring cases get covered and everyone's happy. Um, I think that the younger surgeons sort of understand it a little bit more. Uh, we've tried to educate not just our administrators over and over again, but uh our surgical colleagues as well. And like if if, especially if a if a uh a NORA proceduralist, um, you know, usually uh or a cardiologist, if they want a case done, we've explained to them like, well, we can't always be available right when you want to be available because that you know provide it requires a whole other person and what are they gonna do the rest of the day and all those things. I think they sort of understand it. Um but it's it's education again and again on that front as well. Um if if you can talk to somebody who actually say owns their own practice, uh a surgeon or a cardiologist or something, and you talk to them and say, talk about like what overhead is, and you sort of speak to them in terms that they can sort of understand versus running an anesthetic department, which they don't really know, um, they can sort of get that. Like, would you build another clinic if it was gonna sit empty all the time just to see that one extra patient one day a week? They would, of course, say no. And well, that's kind of the same thing. I mean, it's it's two two a little bit different of a of a scale, but it's the same concept. Are we gonna open up a whole nother room and get a provider here that sits there for eight hours to do a one case? That just doesn't make sense. They understand that there. That doesn't mean that they don't want to ask and they don't want to push for the flip room or whatever. And and and and I get it, you know. I mean, I if I were in their shoes, I'd I'd stick up for what makes their lives better than I would too. We come to an agreement and say we can get to you, but not now in 30 minutes or something like that.

SPEAKER_01 13:09

What um what data do you think is the most persuasive with surgeons? Um is it the relationship generally, or are you showing um how a typical week manifests and certain pressure points that are natural during either days of the week or time of day? And how they would have a lot more flexibility in the cases they might want to put in if they chose these windows. And here's the reasons why. I mean, is it do you do you show the whole case board um on a week on how or do you drive into their specific takedown of time?

SPEAKER_00 13:48

I mean, I I think it I think it depends somewhat on on the size of the of the hospital. Uh, I mean, specifically, I've been working with a hospital, a smaller hospital right now that has you know five sites of service a day, so very small. Um, a little bit easier to to kind of move some people around. I mean, and then it gets into clinic space and all these things that I don't uh necessarily have have you know uh visibility into. So I understand that that just because it makes sense for us to swing uh you know six cases of various two different days, it'll ripple effects. Um, but I think if you if you try to speak to um a an administrator or a surgeon or an operating you know director or whatever, you try to speak to them in in the terms that they understand, and which is all gonna come down to supply and demand when it comes to manpower and then and then finances. Um so you know, my example just previously on staffing a whole or you know, building and staffing a whole new clinic for one patient, sort of the same idea. If you can get to that, they at least understand that. Doesn't mean they're not gonna ask for the same thing, but they at least understand that. Um, you know, but if it if it was an OR director, then you talk about staffing, you know, you talk about are you gonna hire a whole you know circulator and and surgical tech team for one case? And then they would say, of course they wouldn't do that, right? And and so if you can do all those things, because if you just say, I can't hire a cRNA, I can't do this, they don't understand what that even means. They may not even know what a CRNA is, or they don't they understand those things. If you just speak to it in in your terms, you're not gonna get so far. If you try to just make the analogy, um, I think that goes a little bit further. And so to take it to your answer, you you've got different ways to speak to different people. You're all dealing with the same thing. And I mean, uh, having never been in the business world, I can't speak from experience, but it's the same thing. If I was if I was talking about uh, you know, manufacturing widgets and things, you you'd speak in the same terms. I mean, obviously, people are a little different than than than you know, raw materials type thing, but that's it's effectively the same thing. It's a supply-demand thing. And you know, I just gave a talk uh on on kind of supply and demand for for a uh uh anesthesia conference here recently. And you you the the basics of supply and demand, if you think back to like basic economic class, if something is in short supply, then the price goes up. And then typically, if the price goes up on something, then somebody will say, hey, I maybe I should start producing more of those because then I can get more. And then you know, then the the the supply goes up a little bit, the demand bounces out. Well, it's a little bit hard when you're talking about providers because the price goes up and we can only make you know so many anesthesia clinicians. I mean, we're trying to expand. I mean, I mean, our our uh um whole uh uh specialty is trying to expand training sites of all different types of anesthesia clinicians. They don't they don't go quickly, and so it's um it's a little bit of of um economics that you bring in here. And then, you know, the anesthesia um actual reimbursement part, you know, we've got the you know, they used to call it a 33% problem. It's more of a 25% problem based on what Medicare pays compared to a commercial payer, a little bit different than in the surgical world and things. So trying to just educate uh people on anesthesia-specific problems, but in a way that they can understand that, that's been what we found to be most successful.

Workforce Supply

SPEAKER_01 17:12

Yeah, because you know you mentioned the the supply of providers, but it's just not keeping up with the rise in demand. I mean, yeah, there is capacity, but it takes years to train a provider and then to expand programs, it just doesn't happen overnight. Um now, you guys, um do you employ AAs as well as CRAs? Is are AAs even an option in Texas? I'm I'm not aware of that.

SPEAKER_00 17:41

They are not they are an option legally in Texas, yeah, yeah. There's there's no limitations there. Uh, you know, we we don't, uh a variety of reasons. Um, I mean, I think in in in in our bigger company, we definitely use AAs across across our um platforms, but not in not in my practice, specifically in in Austin. Um, I don't know that that was necessarily a conscious thing. You know, we've had a much larger pool of of CRNAs. Um, you know, we're typically probably at a two to one, two CRNAs for every one MD that we have, roughly, is kind of how we have been for almost my entire career. Uh, and so you know, that's that's how we choose to have done here in Austin.

SPEAKER_01 18:20

Do you find the the is the pressure more acute in securing new CRNA talent or is it physician talent? Where do you where do you see the pressure?

SPEAKER_00 18:30

Uh I mean, I I know I know that I know the numbers and the data. So that you know, cRNA demands a little bit higher than than uh anesthesiologist demand currently. Uh and if you look at AAs, they're the smallest group, but the highest demand right now. So they're the ones that are growing the fastest, but from a much, much smaller number. I mean, measured in the you know, single thousands uh nationwide and obviously growing growing quickly. Um CRNAs are are far and away the the most abundant nationally, uh, and then and then you know MDs and uh physicians um after that. Um so I mean I but uh honestly it's it's equally challenging um at all times.

SPEAKER_01 19:10

And in Austin in your group too, it's equally challenging between yeah, between MDs and CRNAs.

SPEAKER_00 19:16

I I I think it's probably I mean the the number of CRNAs we look to hire in a year is always greater than the number of MDs. So just because of that, it it seems like a hiring cycle is a hiring cycle. You still have to go through the mechanics. That's correct. Um but you know, we we look to hire you know four to eight MDs in a given year, um, and we're probably hiring 20 to 30 CRNAs in a year, and so just based on on scale there, it's a it's a little bit harder just to to to bring in you know three times the number of people.

SPEAKER_01 19:48

So now are you um are you pulling in new uh physicians and CRNAs from other cities? Are you hiring um within the market there?

SPEAKER_00 20:00

Uh no, the majority of our of our hires come from elsewhere. So we we don't have an actual training program until recently. We we now have a CRNA program. They don't have any graduates yet, they're a year and a half in, I believe. Um and so you know, we we we pull a lot of people from the state of Texas, obviously, just it's a very popular state. And so um a lot of Dallas, a lot of Houston, some San Antonio, or at least people who are from that area that may go train elsewhere and then and then come back to Texas. So um, like I said, we got a lot of Texans to choose from, so to speak. So that gives us a little bit of advantage. But um, compared to when when I first started, the majority of people had some sort of tie to Austin, were from Austin, went to school in Austin, had a spouse from Austin. That's kind of who who came here. I mean, we were talking about much smaller numbers. Um, now we we pull from everywhere. So we have people who've never been to Texas, I don't never been, but at least are not from Texas, they've trained elsewhere from the northeast, from the West Coast, from from the south. Uh still, I would say, you know, the majority, I would say in the southern region. So, you know, lots of lots of Texas, Louisiana, Oklahoma, a lot of folks there. Uh, but we got them from all over now. You have to.

SPEAKER_01 21:12

Yeah. I would imagine that Austin, you know, being a great place to live, a high quality of life, makes the job easier. That doesn't make it easy.

SPEAKER_00 21:22

Yes, correct. I mean, I I think um for the longest time Austin was a was a big, big draw. Um, it is a great place to live. There's no question about that. The cost of living has has not uh you know risen as gradually as as uh as some other places. So cost of living is a little bit harder, um, at least, at least for people to come and stay. And not obviously not impossible, but if if people are are looking to put roots down and they don't have family or something like that, it's a little harder uh in Austin. But um, no, I mean, I think overall, I also tried to help recruit at some other smaller um, you know, kind of rural Texas sites, and it is it's much more difficult there than. And it isn't awesome for sure.

National Platform

SPEAKER_01 22:01

Yeah, that I would think that telegraphs across the country too. Um because you know, you guys are one platform in a in a large, you know, large national, you know, great company, great industry company. How does being a part of that larger organization um does it help or hurt on recruiting um uh specifically? Yeah, um I think overall it's it's uh I mean it's an attraction for someone to land because they would land within that organization, right?

SPEAKER_00 22:37

Yeah, I I I I would say on the whole, yes, it's it's a positive, um, mainly because it allows us to understand the overall you know national marketplace for clinicians to a much greater extent at a time when we when we've had to actually reach out much farther. So before we knew our you know kind of bread and butter, which like I said was Texas in the South. Um, but now that we've had to reach out, it it you know, having more data more understanding is has been great. Um, I mean, I think that some people have historically wanted to work for a small group, um, and obviously we're part of a larger company. And that being said, we still run it as a as a small group. So, you know, all of the decision making and everything for us is all made locally. And so we kind of have uh have what I would say kind of the best of both worlds of the access uh to the data and and resources of a large company. But sort of when you come to work here, you you feel like you're you're being um involved and and you're kind of making decisions here locally, which is which has been a nice plus.

SPEAKER_01 23:41

Yeah, knowing knowing your group, I mean you guys of uh I was always impressed with the cohesion that exists between those in leadership, and you've been a part of leadership you know for a number of years there, and what I would you know call the you know, the rank and file, you know, uh members of the team. You guys just have done such a good job of ensuring there's transparency and communication up and down the chain. I could easily see what what you say is that yeah, we're part of a big company, but we do operate um like like your owners. You know, we're uh we're all in this together and um we listen and we care, you know, about that's exactly right.

SPEAKER_00 24:25

And and creating that kind of culture is something that you know requires a lot of effort ongoing. And by no means am I am I taking credit for uh for for the majority of that. Well, it was all pre-existing me, and I'm just a steward of it now, and then I hopefully hand it off to to my you know talented younger partners to to keep going for a long time. Um, but I do think that that is important in trying to trying to attract people to any job. Um, it's obviously you know relying on multiple factors, you know, compensation is one for sure, work-life balance, but I think also just being involved and and feeling like uh you have a say, you can help make decisions and things. And we try to do that for for all of all of our team members. And some of those are, you know, you know, partners who are actually sort of the owners of the business, and and some of them are our employees, um, but we still want to make sure that they feel like they're part of the team. And so, you know, with there may be decisions to make that they may not necessarily be the ones together make those decisions, but we certainly want to give them the impact and the input to understand, you know, kind of what are the pressure points for whatever facet of our company. Uh, because the last thing we want to do is make it make a uh a move, a decision, a change that is um it ends up being worse off. Uh and so you know, involving people and bringing those people and and and bringing them into the decision-making table as best we can has been something that's been successful for us for a long time.

SPEAKER_01 25:48

Yeah, I it uh I would my my sense of your group is that it's a high culture group, you know, really in a high culture city. You know, you you've got the you've got some real advantages, you know, in terms of recruiting. You know, so how does um being a part of the larger platform uh help or challenge you in discussions with hospitals? You know, as you have the difficult discussions about subsidy, you know, there's there's concern that PE back companies um you know make um you know outsized demands. There have been you know concerns out of the industry that make outsized demands for subsidy, but you know, in reality, it's the economics of the local platform, right? I mean those those perceptions might be there, but there's also efficiencies that are driven by large companies

Hospital Support

SPEAKER_01 26:39

to yeah, so uh yes, that's a great question, Jeff.

SPEAKER_00 26:42

And I think that um the way, and I can only speak to the the to to to you know to our company, and and as with anything, you know, there's there's uh bad players in any market, that that is not us. So, you know, the way we do that, like I said, we try to be be partners with with the hospital or or the ASC if we're talking about uh you know subsidy negotiations. And it's really just you know there's a cost um to staff in in whatever way they they're what they're asking for. And then there's an amount of money that that is brought in there. And the difference is is the level support, and that's what it comes down to. And we we can quibble on how much the cost is and what the revenue is and all those things, but it comes down to that that gap is what we just need to be made made whole. And we're not trying to profit off those things, it's just that we've got to bring the people in and we've got to keep them there. And if we're not gonna pay them right, they're not gonna stay, and then you're not gonna be able to cover your hospital. So if you look at the amount of revenue brought in, um, that is where we've been able to optimize all all facets of our of our billing you know process. And so it has nothing to do with how much money you you you may put on a charge sheet, it's just how quickly you can get that in and how efficiently you can get that money in. You know, that greatly obviously you know helps our company, but it also helps our hospital system. Because if we can shrink that gap, then that that stipend is less. And so it, I think also just um, you know, when I first started in Austin, we had some some smaller stipend than we do now. And there were lots and lots of places that had no stipends at all. And there are places that um independent groups are still covering now that their stipend are significantly more. So if you just look over the course of the, like I said, I've been out for 19 years, the amount of stipends that are needed rise for a big company, a small company is just the realities of the Anneced landscape now. So I think it was really coincidental, uh oftentimes where you've got bigger groups coming together at a at a time when stipends have gone up. And so, yes, sure. Uh coincidentally, you might say that that's that's a a causal relationship. I don't actually say no, it's not. Because if you look at people that are that are independent, they're they're in the they're in the same boat. Um, and and the reason why we've we've had as an anesthesia specialty, have had to, you know, get into bigger groups is that you know, we're we're talking to very big insurance companies that are obviously dwarf us, any of us, any of our companies in size. The quality reporting, uh, the IT requirements and things are just very, very difficult to do as a small group. And so unfortunately, you've seen either either groups having to sort of coalesce into into bigger groups, be employed by a hospital. Um, uh the true independent group, it's harder and harder. And I think that's you know, it's it's been it's been the case in lots of other industries outside of medicine. Um and it's it's now just come into medicine. Um, and you know, like it or not, that's just kind of kind of where it is. And so the way we did it, we try to do it in a way that we can still be the best partners to our facilities and still provide a good place to work for our providers.

SPEAKER_01 29:43

Yeah, I think scale, you you hit on it. I think scale really does matter. Um I I think there's a lot of pressure on smaller groups to provide all the facets of you know of organizational endeavor that you mentioned, whether it's IT, quality reporting, just even communicating with the facility, it's a challenge for smaller groups for sure.

SPEAKER_00 30:03

Yeah, for sure. Yeah, absolutely.

SPEAKER_01 30:04

Yeah, and then payer contracting, you know, all of that. Um so um and I I think you guys do a really nice job um in terms of revenue cycle function within your organization as well, which is a key driver. Um so when folks are coming from other places, are they coming primarily from smaller anesthesia practices where they just wanted a change, or are they coming from employed environments where the hospital employed them in other cities, or is it a mixed bag?

SPEAKER_00 30:37

Uh I I I I mean, speaking just from where I am in Austin, I I would still say the majority, majority of our hires are new graduates. So they're they're they're coming out entering the workforce for the first time. We we do, and that's how it was historically. Like when I came in, geez, probably the the three and four years uh before me and after my class, we were all new grads coming straight out of you know residency or fellowship. Um over time that we've we've had people come out of practice, and the majority of those are coming from different different uh you know private practices. Um, some are some different transfers within within our company from from other geographies. Um, but like I mentioned for for staffing of our CRNAs, we've had to branch out into all facets. Uh same thing. You know, we we we just interviewed somebody, matter of fact, from Nashville, um, looking for a job to move to Austin. And and so she'd been out of practice for five plus years, if I can remember. And and so I mean, obviously, you're you're gonna get all types there.

SPEAKER_01 31:35

Yeah, wow, right. Um, interesting. Yeah. Um so uh, you know, we talked about efficiency a bit, scale matters. Um we're a vendor to you guys, you know, medaction. Um how does um how does the data and some of the tools that medaction provide, how does that aid in your communication with facilities or your drive for efficiency inside your organization?

SPEAKER_00 32:02

Yeah. Well, that's uh, I mean, if uh you meant you asked early on about how long we'd known each other. So back in 2014, and this is sort of pre a lot of the data push in anesthesia over the last 10 years, I'd say, um, we were fortunate enough to have some of my predecessors and leadership here say, hey, we we really need better data to try to figure out, you know, what exactly are we doing, how efficient we are, not efficient, and trying to, you know, look for different drivers of of uh hospital performance or anesthesia group performance and try to sort of prove it. You can say one thing, but if you can't prove it, then it's just your word against someone else's. And so uh we looked around at lots of different uh different vendors, like you mentioned, although I don't like that term, lots of different uh uh EMR partners, we'll call it. Um and and actually was was far and away the the choice at the time. We've been very, very happy in our 12 years uh using that. But but basically it allows us to do a couple of things. One, like you mentioned on the RCM side, um, all of the things that we used to do on paper before, um, charge capture quality, um, and then kind of starting the RCM process, um, that is obviously much better, more efficient, more fine-tuned. And um, when you talk about actually looking at data on refining that process, um, we're in a much better situation there. And then on the other side, when it comes to the actual running of a hospital or a surgery center and the operational part of that, seeing what uh certain utilization for an OR is from you know, prime time from 7 a.m. to 3 p.m. or overnight. And and so some of those we use for our relationship with our hospital partners or facility partners, so ASEs as well, of saying this is how efficient you are, this is what your turnover time is, this is what your first case sometime start is. I mean, not having that data easily available before was a hindrance. And so now uh, you know, you you can generate that in in five minutes, or you can have it auto-generated that just show up on your in your email inbox or your administrator's inbox every week or every month, whatever they want. Um, and so that's important as well. And on the on the on the third side, for us at least, you know, how how we run our practice is is very much dependent on um what different providers are doing. So, what do you do at night? How many, if you're on call, how many cases do you do on average? And so it allows us to sort of um uh figure out exactly what different sites are doing at different times of day. And sorry, my phone is going off here. I'll make it silent. Um, what do we do during different times of day um is is very helpful in keeping that culture up our practice. And so for all of them, it's a rubber, isn't it?

SPEAKER_01 34:47

It's a it's a common language. So there's no it it helps, I would imagine, and we hear this from other groups, with the potential misconceptions of people in one shop versus another. Oh, we're busier than they are. You can show them the numbers and disprove that.

SPEAKER_00 35:04

That's exactly right. And so, I mean, everybody only remembers their bad call nights, or the miniatures only remember the time where our our room was completely full, but they don't remember the things, the times that don't support their theory. Like you took a call and you did nothing, right? Of course, you don't you don't bring that one up again, or you uh opened an operating room and there was no cases in that, and yet we staffed it and things like that. And so going to them with the data, as long as they can they can believe the data and say, hey, this is this is this is where this data came from, this is what we've actually done at your site, or this is where you took all this of the cases you did for the last quarter, uh, people can't argue with that, right? And and so, not that we're trying to use a Trump car, but data's the data. And so um, that's the way I think it's the most successful if you want to drive change, is to show people what's happening and then make a make a change, make a make a choice of doing something. And then after that, you you test and say, did it make a difference? And and so you iterate that process over and over again to be more efficient or to staff things um with fewer people or or whatever that is. Yeah. So and without Medaxian, we would not have been able to do that.

SPEAKER_01 36:13

Well, and it's I would I would imagine too that it it having a common language with commonly agreed metrics uh allows you to tamp and manage the emotional response that you said. You know, people remember that that call night or the really, really busy set of days. Um you know, knowing um that that is an emotional response to those factors and then showing data that levels that out. I imagine that that helps with you know just culture management, just as you said, you said as much. I would imagine you guys have better data than the hospital does about the core metrics of how patients are flowing to the OR. Um there's a lot of variability on how hospitals measure utilization and what they think is efficient. Um sometimes they're not looking at the factors that matter to anesthesia. So you guys are in there educating them as to this, this, and this factor really matters, and here's why. Um, I think those are absolutely.

SPEAKER_00 37:18

And so, you know, we work with um hospitals that have different EMRs, not necessarily mean for anesthesia, but for the hospital part of that. And I promise you that data exists in those platforms somewhere, but extracting that data on a routine basis quickly and in a meaningful way is incredibly frustrating. So, yeah, you're exactly right. We will go to a hospital meeting and we can easily show data, even live time, and show data and say, here's what's happening in your operating room. And they're just astonished because if they wanted that same uh uh set of data, they would ask their IT or their EMR or whatever, and they'd be lucky if they got it in a week, whereas we can do it nearly live. Uh and so that's exactly right. And so if you can build the trust with an administrator, I would love them. I always love it when they say, Hey, can you send me data on X or skate time time starts or efficiency or whatever?

SPEAKER_02 38:11

For the data.

SPEAKER_00 38:12

They ask you for that. Absolutely, absolutely, especially like the operating directors. They know, like, hey, listen, I could go through my processes, it would take me, you know, two weeks to get that back. And then I don't even know how good the data is, but I can I can do it in, you know, in half a day and get it there. Um, and so, you know, and and that's that's the value add part of that. We don't we don't charge for that. We just say, hey, you know, it's it's these are the cases that we did in your hospital system. So it was our cases, you know, you had a surgeon and a patient in there and and you had staff and things. And so we just we just provide that to them. And so that that part is is the absolute value add. Um, that is that is great um for hospital um uh you know partners as well.

SPEAKER_01 38:52

Well, and and you guys are in enough facilities with enough variability that I would imagine that your ability within even just your local platform to normalize and say this is a normal set of operating parameters, and you guys are outside the norm there. Um, so giving perspective on how a facility might be out of step with staffing and coverage expectation patterns of other facilities, does that help as well?

SPEAKER_00 39:20

Does that come into and and exactly? And then the other thing that you talk about being part of a larger company nationally, um, there are definite best practices that we've picked up or we've passed on to other places. And so uh there might be a new hospital that we're opening and it's gonna be six ORs and it's gonna have L and D and whatever. We can actually say, well, this is how we've staffed this very similar sites, different places around the country that are also new hospitals. We did it in this way, and we can say what we learned, what we didn't learn. And so you can actually, I mean, we have actually a tool that actually compares different hospitals across the country that are of similar payer mix or uh you know, case volumes or sites covered or whatever to try to find their uh their their best ways to do things. And of course, every hospital says, well, we're special because of X, Y, and Z. Well, and that's fine, that's fine. But but we can at least come from a starting place and then make changes. Well, you you say you're you're special or you've got special circumstances because you're gonna cover a stroke service. Great. We can we can add we can tweak those things in. But again, it it all starts with with the data. We can say this is actually how we've run this exact site before or a very similar site, and then we can tweak it from there. But again, it comes back to the data.

SPEAKER_01 40:36

Yeah, because I think you guys, um, because the platform is so large that you guys can extrapolate across a large set of very similar, you can specify down cohorts that actually do match the particular hospital you're going into, right? You know, hospitals that that do trauma, that do cardiac, that might have, you know, special service lines. Well, you have other facilities in the platform that do that too.

SPEAKER_00 41:00

That's right, exactly.

SPEAKER_01 41:03

Um well uh Chris, thank you for the course today and the time today. Uh appreciate it. Hopefully see you um uh in Charleston, you know, uh last year in February. Maybe we're gonna do another uh summit in um at the end of February next year in Charleston.

SPEAKER_00 41:24

Are you gonna be at ASA or anything this fall?

SPEAKER_01 41:28

We are we're gonna be at the ASA um for sure. Um and I think a couple of other shows, you know.

SPEAKER_00 41:34

Okay, great. I'll be at the ASA. I'm actually I'm calling you for on the from San Diego right now. We're uh yeah, my my folks have a place here, so we're just on vacation, but it's back in San Diego in October, and so I'll I'll be here for that. I'm I'm speaking at that.

SPEAKER_01 41:49

So oh, fantastic. Good, awesome, Chris. Thank you so much.

SPEAKER_00 41:53

Hey, no problem, Jeff. I appreciate the time. Great, great catching up.

SPEAKER_01 41:57

Cheers, thank you.