Envision evaluating option for bankruptcy filing

[zizzer]

Envision Healthcare to Consider Bankruptcy Filing

It seems the Pandemic is hitting hard financially for Envision, who was already in debt following a leveraged buy-out. They've already delayed new hire emergency medicine physicians' and anesthesiologists' start date bonuses until Q4. How would this affect Envision AMCs? Some are very large. Would they buy themselves back out?

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[aneftp]

It’s very simply. KKR all took nice 20% transaction fees from the 9 billion buyout?!
So the firm probably netted easy millions from the buyout. Each private equity partner probably got 5-10 million.

than all the fake money leveraged. Of that 9 billion. How much did KKR actually invest? I’m guessing less than 500 million fake borrowed money from “investors”. The rest is borrowed.
The company envision. Is likely worth less than 4 billion at this point.

it’s like buying a house with almost no money down. And the home value is worth 50% less.

now kkr threatens BK to reduce the debt.

business 101.

winners KKR private equity partners.

 

[habibimarwan]

They build house on sand, house falls down. No problem! They sell house to rich man who use it for parking lot. Problem: doctors inside when house fall. Now they are parking lot. Wise man said, don't go in house with bad foundation!!!

 

[BLADEMDA]

Envision was a stock listed in the S and P 500. The stock was cratering, on the verge of bankruptcy before KKR stepped up and bought the company for more than the current price. That made no sense to me at all at the time since Envision was on the verge of collapse. Apparently, this was just a Shell game or Ponzi scheme by KKR to trick investors: It worked.

 

[BLADEMDA]

As a result of the completion of the merger, Envision has become a wholly owned subsidiary of funds affiliated with KKR, and Envision stockholders will receive an amount in cash equal to $46.00 per share of Envision common stock. As a result of the completion of the merger, shares of Envision's common stock ceased trading on the NYSE prior to the opening of the NYSE today.

At the time many analysts thought Envision was worth between $0 and $15 per share. Somehow KKR bought it for $46 per share.

 

[BLADEMDA]

Envision had dropped to $26 per share and likely heading lower in late 2017. But, there were rumors of a buyout which caused the stock to move up rather than down. At the time I remember many analysts thinking it was a $15 stock with many problems.

Why Envision Healthcare Is Spiraling Downward | The Motley Fool

It’s not just the disappointing third-quarter earnings. It’s also the lawsuits and the questionable business model.

www.fool.com

 

[apoondoc]

Good riddance. I hope that Envision, CEP, Vituity, Somnia, USAP, NAPA, and all the other efficiency-destroying "management" companies crash and burn.

If any hospital CEOs happen upon this thread wondering what value Anesthesia Management Companies add, let me spell it out: NONE. They only suck money out of the system, and add a layer of bureaucracy between hospitals and anesthesiologists, and between anesthesiologists and their patients. Nurses, surgeons, and patients all suffer when private practices (which are dedicated to individual hospitals and necessarily invested in the community and have long-term relationships with the surgeons, nurses, and administration) are taken over by "management" companies, who blab about efficiencies and business optimization while DECIMATING the physicians' investment in their practice and their profession.

Anybody who tells you otherwise is lying because he or she is getting paid (either with a cash buyout, a stock buyout, or a salary) to lie.

 

[dannyboy1]

Good riddance. I hope that Envision, CEP, Vituity, Somnia, USAP, NAPA, and all the other efficiency-destroying "management" companies crash and burn.

If any hospital CEOs happen upon this thread wondering what value Anesthesia Management Companies add, let me spell it out: NONE. They only suck money out of the system, and all a layer of bureaucracy between hospitals and anesthesiologists, and between anesthesiologists and their patients. Nurses, surgeons, and patients all suffer when private practices (which are dedicated to individual hospitals and necessarily invested in the community and have long-term relationships with the surgeons, nurses, and administration) are taken over by "management" companies, who blab about efficiencies and business optimization while DECIMATING the physicians' investment in their practice and their profession.

Anybody who tells you otherwise is lying because he or she is getting paid (either with a cash buyout, a stock buyout, or a salary) to lie.

All I know that in my job for an AMC I have been well paid with a reasonable work life balance. Somehow I don’t see a rebirth of the glory days of private practice if the AMC’s crash and burn. More likely it will be hospital/surgicenter employment with full CRNA independence because the hospital will be the one paying the salary AND dictating the Credentialing/scope of practice. In other words more work, less pay.

 

[Status Sciaticus]

All I know that in my job for an AMC I have been well paid with a reasonable work life balance. Somehow I don’t see a rebirth of the glory days of private practice if the AMC’s crash and burn. More likely it will be hospital/surgicenter employment with full CRNA independence because the hospital will be the one paying the salary AND dictating the Credentialing/scope of practice. In other words more work, less pay.

How is this different than AMCs? They too are. as you say, "more work, less pay" when you compare them to private practice. This is actually the prime time to restructure PP.

 

[Tony C anesthesia]

What's gonna happen to their anesthesiologists? All fired? Go on unemployment?

 

[dannyboy1]

What's gonna happen to their anesthesiologists? All fired? Go on unemployment?

Possibly in the short term. That being said the hospital will still exist and will need anesthesia services when cases return so they will either form a PP group or be hired by the hospital or another AMC that would take over the contract. Unlikely that the non compete would be an issue if the company can’t make payroll and dissolves.

 

[deleted171991]

If CRNAs become independent, watch the 90s come back roaring for the specialty. Except that, this times, there will be many CRNAs to fill the gap, and it will become a nursing specialty.

The hospitals will be even worse employers than AMCs. Many academic ones already are.

If we don't unionize fast, we'll be treated like commodity (which we became the moment we agreed to work with CRNAs, instead of walking out).

 

[2Fast2Des]

If CRNAs become independent, watch the 90s come back roaring for the specialty. Except that, this times, there will be many CRNAs to fill the gap, and it will become a nursing specialty.

The hospitals will be even worse employers than AMCs. Many academic ones already are.

If we don't unionize fast, we'll be treated like commodity (which we became the moment we agreed to work with CRNAs, instead of walking out).

I have a feeling that the CMS mandate that mid-levels can practice independently in setting of pandemic will stay in place for good, and the CRNAs will make sure it stays that way. I really hope you are wrong, but with hospitals bleeding and who knows when round 2 of Covid will be back, so they will definitely start counting pennies.

 

[dannyboy1]

If CRNAs become independent, watch the 90s come back roaring for the specialty. Except that, this times, there will be many CRNAs to fill the gap, and it will become a nursing specialty.

The hospitals will be even worse employers than AMCs. Many academic ones already are.

If we don't unionize fast, we'll be treated like commodity (which we became the moment we agreed to work with CRNAs, instead of walking out).

Yup. What the CRNA’s don’t seem to realize it that ironically they will likely be making less and working harder as well. Because if you have CRNA independence the docs still exist so you have just vastly increased supply of anesthesia providers without increased demand for services.....

 

[deleted941485]

Yup. What the CRNA’s don’t seem to realize it that ironically they will likely be making less and working harder as well. Because if you have CRNA independence the docs still exist so you have just vastly increased supply of anesthesia providers without increased demand for services.....

I think that’s lost on the Crna lobby. They get independence and then what? They’ll literally be sitting atop a huge pile of **** when it’s all over.

 

[46Long]

If any hospital CEOs happen upon this thread wondering what value Anesthesia Management Companies add, let me spell it out: NONE.

They must have some value(to somebody) otherwise they would not be around. We dont see it though.
Priot to the Management companies, hospitals had to deal with us directly. IT was fine when the billings were flush but when reimbursements spiralled down for professional services (intentionally) we were going to the hospitals for subsidies and stipends. Also Hospitals could not get rid of physician troublemakers who would essentially blow the whistle for unsafe practices, poor work conditions etc. SO enter management companies who promised NO stipend but in return they would get the exclusive contract for services. Hospitals also placed a no cause termination clause in all the contracts. And they got it. I always thought exclusive contracts were always a dirty way of playing since they could not assure a meritocracy. But those were conversations of 20 years ago. Its all about the money and here we are.

 

[46Long]

How is this different than AMCs? They too are. as you say, "more work, less pay" when you compare them to private practice. This is actually the prime time to restructure PP.

Dude Private Practice was a disaster too with the groups. They were top heavy and wicked crooked. Talk about DIRTY. I always felt that hospitals should credential all qualified Anesthesiologists and surgeons would dictate who they would consult. And if that didnt work there would be teams of 2-3 anesthesiologists in a group with 3-4 groups in a hospital depending on size. If you want to restructure PP this is how you should do it.

 

[deleted126335]

Yup. What the CRNA’s don’t seem to realize it that ironically they will likely be making less and working harder as well. Because if you have CRNA independence the docs still exist so you have just vastly increased supply of anesthesia providers without increased demand for services.....

You don’t get it. It is about autonomy, independence, professional standing as much or more than the $$. Not having to answer to an anesthesiologist is worth a lot to some of them. They hate our authority over them as much as we hate the positions and speech of AANA.


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[agammaglobulin]

Dude Private Practice was a disaster too with the groups. They were top heavy and wicked crooked. Talk about DIRTY. I always felt that hospitals should credential all qualified Anesthesiologists and surgeons would dictate who they would consult. And if that didnt work there would be teams of 2-3 anesthesiologists in a group with 3-4 groups in a hospital depending on size. If you want to restructure PP this is how you should do it.

Good idea in theory but surgeons would end up choosing the Anesthesiologists that give the least push back. Ok doing a spinal in a total joint with an INR of 2.5? You’re hired. Ok proceeding with AV Fistula with K of 6.5? Here’s a contract

 

[GravelRider]

Dude Private Practice was a disaster too with the groups. They were top heavy and wicked crooked. Talk about DIRTY. I always felt that hospitals should credential all qualified Anesthesiologists and surgeons would dictate who they would consult. And if that didnt work there would be teams of 2-3 anesthesiologists in a group with 3-4 groups in a hospital depending on size. If you want to restructure PP this is how you should do it.

Oh you. Stop with your silly talk of capitalism and free market competition. We all know that’s not how things work.

 

[GravelRider]

Good idea in theory but surgeons would end up choosing the Anesthesiologists that give the least push back. Ok doing a spinal in a total joint with an INR of 2.5? You’re hired. Ok proceeding with AV Fistula with K of 6.5? Here’s a contract

Not true. Good surgeons have a lower threshold to cancel than I do.

 

[coffeebythelake]

Not true. Good surgeons have a lower threshold to cancel than I do.

Where can we find some?

Jkjk

 

[Status Sciaticus]

Dude Private Practice was a disaster too with the groups. They were top heavy and wicked crooked. Talk about DIRTY. I always felt that hospitals should credential all qualified Anesthesiologists and surgeons would dictate who they would consult. And if that didnt work there would be teams of 2-3 anesthesiologists in a group with 3-4 groups in a hospital depending on size. If you want to restructure PP this is how you should do it.

Isnt this the exact premise of private practice? AKA independent contracting just on a smaller scale.

 

[aneftp]

envision and other amc do serve a purpose. There were many uneven private practice Ponzi schemes where “associates” or similar “junior members” took 200-300k less per year for 3-5 years as part of their buy in.

I’m know more of the late 1990s-2000s story but I know so many people who did not become “partner” after 3-5 years. They basically gave up 1-1.5 million in salary.

at least you know you are giving up 100k maybe 150k salary each year by working for an AMC.

So what’s worst? Doing 5 years like my sister (and it happened to 6 other docs also so it wasn’t just my sister) she gave up 1.5 million in lost revenues. Or working for 5 years and giving up $500-750k to an AMC?

working for same AMC

 

[C4C]

That's some weak praise, saying that AMCs are less bad than the very worst private practices. But, I guess you have a point.

Shame on residencies for training anesthesiologists without teaching them any business sense.
Shame on anesthesiologists for taking advantage of each other.
Shame on physicians for giving so much control of the business side of medicine to the insurance companies that doctors are powerless to look out for their own--or even their patients'--best interests.

 

[Tony C anesthesia]

Just curious to know what's going on in some ENVISION-run hospitals in California? Salary cuts there too? lay-offs? Anyone has heard or talked to people there? Thanks for the input.

 

[banister]

Just curious to know what's going on in some ENVISION-run hospitals in California? Salary cuts there too? lay-offs? Anyone has heard or talked to people there? Thanks for the input.

Salary cuts of 30%. No layoffs that I've heard of

 

[dannyboy1]

You don’t get it. It is about autonomy, independence, professional standing as much or more than the $$. Not having to answer to an anesthesiologist is worth a lot to some of them. They hate our authority over them as much as we hate the positions and speech of AANA.


Sent from my iPhone using SDN mobile

Maybe for some. The vast majority are clock punchers (not that there is anything wrong with that). I don’t think they realize that their leadership, who want independence, are willing to sacrifice the career of the rank and file to get it....

 

[Zekchar]

Maybe for some. The vast majority are clock punchers (not that there is anything wrong with that). I don’t think they realize that their leadership, who want independence, are willing to sacrifice the career of the rank and file to get it....

Agreed. Most CRNAs want to do a simple 8-12 hr shift while occupying a chair and have no drama. Aversion to making difficult decisions or dealing with challenges is the biggest difference maker. CRNAs I work with at an academic institution want someone else to make every major decision and while adjust the Sevo from 1.6 to 2.2 or give dilaudid instead of morphine. They will never admit it but they love that security blanket and are terrified of not having it. They love having a backup for every intubation and extubation and someone to help with patient moving and transport. I make their lives easy and they don't give me a hard time. I reserve the right to adjust their plans and make decisions about patient care that actually matter. Such is real life in medical supervision/direction.
`````````````
They want no part and especially no major responsibility to make difficult decisions. K+ of 5.4, defer to the doc. MP 3 and short chin but CMAC is tied up, defer to the doc. Neo drip high and patient HR is 45, defer to the doc. Cardiac stent 5 weeks ago but vision faltering, defer to doc on whether to proceed. That is where the value of a physician lies. I have the knowledge, confidence, and skills to make decisions and guide patients through the perioperative experience safely. CRNAs can do simple stuff, but so can a CA1. Surgeons recognize this. Those that don't are one bad intra-op outcome from learning that quickly.

 

[BLADEMDA]

To play Devil's Advocate, A hospital can hire 1 FFP and 26 CRNAs. The CRNAs are "independent" and do the preop, intraop and postop. The hospital insures the CRNAs. The hospital also has 3 hospitalists available during the day and 1 Critical Care trained Anesthesiologist named FFP. The CRNAs are told by administration to consult FFP or the hospitalists for any concerns regarding the patients prior to going to the O.R.

FFP is paid $550K by administration for his services. He is legally not responsible for intraop or postop care as spelled out in the consent.

This is one vision as seen by the AANA for the future of CRNAs in the USA. The other would be 3-4 Anesthesiologists doing their own cases (the sickest patients) while the CRNAs do the rest. The AANA is convinced this field belongs to Advanced Practice Nurses and Physician Anesthesiologists are not needed in this field of nursing.

 

[aneftp]

To play Devil's Advocate, A hospital can hire 1 FFP and 26 CRNAs. The CRNAs are "independent" and do the preop, intraop and postop. The hospital insures the CRNAs. The hospital also has 3 hospitalists available during the day and 1 Critical Care trained Anesthesiologist named FFP. The CRNAs are told by administration to consult FFP or the hospitalists for any concerns regarding the patients prior to going to the O.R.

FFP is paid $550K by administration for his services. He is legally not responsible for intraop or postop care as spelled out in the consent.

This is one vision as seen by the AANA for the future of CRNAs in the USA. The other would be 3-4 Anesthesiologists doing their own cases (the sickest patients) while the CRNAs do the rest. The AANA is convinced this field belongs to Advanced Practice Nurses and Physician Anesthesiologists are not needed in this field of nursing.

Agree for the most part

want to add

AANA wants crna to have the best of ALL WORLDS along with giving hospitals and facilities anything they want including giving MD a shell “director title”.

Crna can be supervise or independent even at the same facility.

That’s what they mean by the practice to the fullest level of their training.

AANA knows they just can’t replace docs. They want to be equal.

What about arnp taking over family medicine? Emergency medicine? It’s endless.

 

[dannyboy1]

To play Devil's Advocate, A hospital can hire 1 FFP and 26 CRNAs. The CRNAs are "independent" and do the preop, intraop and postop. The hospital insures the CRNAs. The hospital also has 3 hospitalists available during the day and 1 Critical Care trained Anesthesiologist named FFP. The CRNAs are told by administration to consult FFP or the hospitalists for any concerns regarding the patients prior to going to the O.R.

FFP is paid $550K by administration for his services. He is legally not responsible for intraop or postop care as spelled out in the consent.

Doc FFP is not gonna be paid 550k if the rest of his colleagues are unemployed. Supply/demand economics is a ruthless b!tch.

 

[AdmiralChz]

What about arnp taking over family medicine? Emergency medicine? It’s endless.

Bingo! FM has already mostly lost the independence battle to ARNPs and even PAs. EM is losing ground and hampered as they don’t have a “ratio” requirement spelled out by CMS. 5 years ago you might have 4 MDs and 2 midlevels running a large ER today that’s probably 2 MDs and 4 midlevels.

 

[aneftp]

So what do you guys think? Salary goes down for us? Salary goes up for crna?

I just can’t see hospital admin saying ok...crnas will get paid $250k to work 40 hours no nights and no weekends 4 days a week. Heck if they paying that. Might as well pay and MD. That’s what the crnas are magically thinking magically thinking.

The MDs taking calls q4-5 for 400k-450k at AMC working 55 hours. AMC will tell them to take 350k? If that’s the case you might as well take 250k and work 4 days a week with no calls and no weekends like Crna and moonlight elsewhere and make an addition 50-75k on your own terms.

 

[dannyboy1]

So what do you guys think? Salary goes down for us? Salary goes up for crna?

I just can’t see hospital admin saying ok...crnas will get paid $250k to work 40 hours no nights and no weekends 4 days a week. Heck if they paying that. Might as well pay and MD. That’s what the crnas are magically thinking magically thinking.

The MDs taking calls q4-5 for 400k-450k at AMC working 55 hours. AMC will tell them to take 350k? If that’s the case you might as well take 250k and work 4 days a week with no calls and no weekends like Crna and moonlight elsewhere and make an addition 50-75k on your own terms.

Problem is this: suppose a given area has around 1000 anesthestizing sites and 1000 CRNA’s with roughly 250 docs. At 4:1 coverage everyone has a job. If you suddenly have CRNA independence then you have 1250 providers competing for 1000 sites. In this scenario it will be whoever is willing to work the most for the least. Docs lose, CRNA’s lose, hospital wins.

 

[coffeebythelake]

So what do you guys think? Salary goes down for us? Salary goes up for crna?

The hourly pay for physician vs CRNA is already about the same. The difference at my institution is about $25/hour (for regular working hours we get paid $150/hr, they get paid $125/hr). We hold more responsibility, work more hours and take a lot more call.

 

[aneftp]

The hourly pay for physician vs CRNA is already about the same. The difference at my institution is about $25/hour (for regular working hours we get paid $150/hr, they get paid $125/hr). We hold more responsibility, work more hours and take a lot more call.

That’s exactly my point. There is very little cost savings

the only real spread difference the aana points out is the average md salary of 340k and average Crna salary is 160-170k. To the public that’s a huge difference but when you dive into details. Weekends. Nights. Etc. the spread isn’t as big as people think.

 

[46Long]

That’s exactly my point. There is very little cost savings

the only real spread difference the aana points out is the average md salary of 340k and average Crna salary is 160-170k. To the public that’s a huge difference but when you dive into details. Weekends. Nights. Etc. the spread isn’t as big as people think.

I don't get it..
Why do I have to continually apologize to this entire world for my salary?

 

[coffeebythelake]

I don't get it..
Why do I have to continually apologize to this entire world for my salary?

Because the AANA says that you are overpaid, as a way to push their agenda, while they conveniently disregard the fact they get paid the same despite having many years less training and education.

 

[deleted126335]

Because the AANA says that you are overpaid, as a way to push their agenda, while they conveniently disregard the fact they get paid the same despite having many years less training and education.

Depends on the market and the job.

 

[Southpaw]

To play Devil's Advocate, A hospital can hire 1 FFP and 26 CRNAs. The CRNAs are "independent" and do the preop, intraop and postop. The hospital insures the CRNAs. The hospital also has 3 hospitalists available during the day and 1 Critical Care trained Anesthesiologist named FFP. The CRNAs are told by administration to consult FFP or the hospitalists for any concerns regarding the patients prior to going to the O.R.

FFP is paid $550K by administration for his services. He is legally not responsible for intraop or postop care as spelled out in the consent.

This is one vision as seen by the AANA for the future of CRNAs in the USA. The other would be 3-4 Anesthesiologists doing their own cases (the sickest patients) while the CRNAs do the rest. The AANA is convinced this field belongs to Advanced Practice Nurses and Physician Anesthesiologists are not needed in this field of nursing.

What do these crnas make? How many hours do they work? Morning and afternoon break? 30 min lunch? 8 weeks vacation?

 

[aneftp]

I don't get it..
Why do I have to continually apologize to this entire world for my salary?

AANA attack for independence relies on these three major points

1. We are safe
2. We are cheaper
3. We have the same “years” of anesthesia training. ....we are cheaper to train cause medical education doesn’t count

So why just not use crnas as your main anesthesia “providers”

cut out the anesthesiologist who demand more money.

that is their logic

 

[Justice4all]

AANA might have some success in a small community hospital with that approach, but not in a tertiary center.

 

[46Long]

AANA attack for independence relies on these three major points

1. We are safe
2. We are cheaper
3. We have the same “years” of anesthesia training. ....we are cheaper to train cause medical education doesn’t count

So why just not use crnas as your main anesthesia “providers”

cut out the anesthesiologist who demand more money.

that is their logic

The large residency programs need to start advocating hugely for Anesthesiologist Assistants being licensed in every state and start mass producing them. You can also repurpose existing PAs to enter these programs. 18 months later. voila... A PA/AA that can give anesthesia. (A CRNA.... only smarter) It is clear that the CRNAs do not want to practice under a team model any longer. We either ramp up our numbers which is hard to do or start advocating for this heavy. THis is the time to do it. Take a page out of the CRNA playbook. Advance an agenda during a national emergency. This needs to be done. Just start phasing CRNAs out.

 

[Southpaw]

AANA attack for independence relies on these three major points

1. We are safe
2. We are cheaper
3. We have the same “years” of anesthesia training. ....we are cheaper to train cause medical education doesn’t count

So why just not use crnas as your main anesthesia “providers”

cut out the anesthesiologist who demand more money.

that is their logic

Leave out #3. All but a few of them realize that’s a disingenuous argument. Their main beef is simple - anesthesia isn’t that hard and doesn’t require a medical degree to do it.

In tiny shops and offices pushing propofol they get away with it. Most of the time. But corners are cut and people look the other way.

Patients benefit from care involving a BC anesthesiologist. Unfortunately it’s up to us to make them aware of it.

 

[46Long]

- anesthesia isn’t that hard

anesthesia isnt that hard, until it is..

 

[habibimarwan]

Simple:

CRNA push medication, push ETT

Anesthesiologist practice MEDICINE, they are PHYSICIAN, not syringe pusher procedure person. BIG DIFFERENCE.

Good luck to CRNA if they try to be doctor. They can't, they are nurses, NOT doctors!!!!

 

[dannyboy1]

The large residency programs need to start advocating hugely for Anesthesiologist Assistants being licensed in every state and start mass producing them. You can also repurpose existing PAs to enter these programs. 18 months later. voila... A PA/AA that can give anesthesia. (A CRNA.... only smarter) It is clear that the CRNAs do not want to practice under a team model any longer. We either ramp up our numbers which is hard to do or start advocating for this heavy. THis is the time to do it. Take a page out of the CRNA playbook. Advance an agenda during a national emergency. This needs to be done. Just start phasing CRNAs out.

Terrible idea. Your solution to to many mid levels is to make more mid levels ? One day these guys will also want independence. Also in most states CRNA’s already have independence as per state laws, they only need supervision by hospital bylaws and some insurance rules. If the labor market contracts for them they will definitely try for (and probably achieve) complete independence. Then you will be competing with them for the same job.

 

[zero0]

Terrible idea. Your solution to to many mid levels is to make more mid levels ? One day these guys will also want independence. Also in most states CRNA’s already have independence as per state laws, they only need supervision by hospital bylaws and some insurance rules. If the labor market contracts for them they will definitely try for (and probably achieve) complete independence. Then you will be competing with them for the same job.

But.. But AAs are licensed by the state medical board so they'll NEVER be able to practice independently.

And history repeats itself.

Seriously, the phrase "race to the bottom" gets thrown around a lot but holy ****. All that's going to happen in the end is CRNAs will be overworked and underpaid and they'll yearn for the long-forgotten glory days of physician supervision, but hey maybe they really do just hate physicians that much and it's worth it to them to have a worse job and not answer to anybody.

 

[46Long]

Terrible idea. Your solution to to many mid levels is to make more mid levels ? One day these guys will also want independence. Also in most states CRNA’s already have independence as per state laws, they only need supervision by hospital bylaws and some insurance rules. If the labor market contracts for them they will definitely try for (and probably achieve) complete independence. Then you will be competing with them for the same job.

It is not a terrible idea if you think about it. Bringing mid-levels under the board of medicine (PAs, AAs) will give us control over the quality of the midlevel market. CRNA training is all over the map. And we have no control over them. And will never have control over their quality. My friend was working in a heavy SRNA training place years ago. He tried to instruct them and was approached by a militant CRNA telling him NOT to ever instruct them. Can you believe it?