Envision evaluating option for bankruptcy filing

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eikenhein said:
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.
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per hour and with time and a half for overtime the answer is yes in many cases.
 
46Long said:
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.
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I think this is a great idea. AA/PA will compete with CRNAs and help fill areas that need more coverage with physician supervision. Hospitals will end up saving money as AA/PA will be cheaper than CRNAs. Surgeons will be happy as they still have the expertise and safety of having a physician taking care of their patients. Anesthesiologists will continue to do what they're doing. CRNAs will find it harder being independent after all their wet taps and failed blocks (do not teach them how to do blocks) and will come back to ACT model. But by then, the fat has already been trimmed.
 
eikenhein said:
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.
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Well this is depressing.
 
"How few anesthesiologists can we get away with supervising a gaggle of CRNAs?"

That is the calculation going on everywhere.
 
dr doze said:
"How few anesthesiologists can we get away with supervising a gaggle of CRNAs?"

That is the calculation going on everywhere.
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Dont think this is limited to anesthesiology. At least we have CMS regs limiting ratios to 1:4. Other specialties aren’t so fortunate.
 
GASPER20 said:
I think this is a great idea. AA/PA will compete with CRNAs and help fill areas that need more coverage with physician supervision. Hospitals will end up saving money as AA/PA will be cheaper than CRNAs. Surgeons will be happy as they still have the expertise and safety of having a physician taking care of their patients. Anesthesiologists will continue to do what they're doing. CRNAs will find it harder being independent after all their wet taps and failed blocks (do not teach them how to do blocks) and will come back to ACT model. But by then, the fat has already been trimmed.
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PA is currently pushing for removal of supervision as well. This is a bad idea.

Before pushing for AA we need to cement iron-clad laws to prevent them from ever trying any of the NP/PA bs




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dannyboy1 said:
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.
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AAs have been around as long as PAs. The PAs are looking for independence. The AAs haven't and won't. The whole concept behind AAs is functioning in the care team environment with the anesthesiologist as the head of the team. That concept is also embedded firmly in both state law and federal regulations. We're not looking for independence nor do we have the desire to do so.
 
AdmiralChz said:
At the cost of a 25% billing cut, right? At least it is here. We do 0% QZ in our practice currently.
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Can someone comment on this for real? Who actually sees billing?
Had an encounter with someone with a big title for a national group recently told us, that is untrue. He claimed that you can still capture everything......
 
jwk said:
AAs have been around as long as PAs. The PAs are looking for independence. The AAs haven't and won't. The whole concept behind AAs is functioning in the care team environment with the anesthesiologist as the head of the team. That concept is also embedded firmly in both state law and federal regulations. We're not looking for independence nor do we have the desire to do so.
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I hope you’re right. But I feel that’s where crna was 30 years ago. They were nurses first. And they were trained to follow and dare I say respect doctors’ orders. They were not “allowed” to do epidurals, spinals or regionals.
Look where we are now?
 
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IMGASMD said:
Can someone comment on this for real? Who actually sees billing?
Had an encounter with someone with a big title for a national group recently told us, that is untrue. He claimed that you can still capture everything......
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Complicated issue. Depends on the local Medicare artist and individual pay or contracts.


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IMGASMD said:
I hope you’re right. But I feel that’s where crna was 30 years ago. They were nurses first. And they were trained to follow and dare I say respect doctors’ orders. They were not “allowed” to do epidurals, spinals or regionals.
Look where we are now?
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We all know where we are with CRNAs. I'm old enough to know exactly why we're there.

With CAAs - there is a broad scope of practice possible (really as broad as CRNAs, at least as far as what CRNAs SHOULD be doing, not what they ARE doing), and how much they're allowed to do is up to the anesthesiologist at the local level who is best positioned to observe the skills and competency of the CAA. There are a lot of CAAs that do spinals and epidurals and central lines. And there are a lot that don't. Regardless, that determination rests with the anesthesiologist, where it should be. THAT is the big difference between us and them.
 
dr doze said:
Complicated issue. Depends on the local Medicare artist and individual pay or contracts.


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I imagine it depends, but in my area Medicaid reimbursement (already bad) goes down 30% with QZ modifier. Our largest commercial carrier goes down 35% (!) I’m told with QZ. A few of the others reimburse the same or decrease 10% or so. It’s significant enough a difference that opening a 5th room at the local ASC became quite problematic for us - we ran the numbers when that came up and the decrease made it very impractical in terms of coverage.

It’s pretty complicated, but this website explains it. Some payers adjust payment based on modifiers and some do not. What Does the QZ Modifier Really Mean? | Anesthesia Business Consultants
 
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AdmiralChz said:
I imagine it depends, but in my area Medicaid reimbursement (already bad) goes down 30% with QZ modifier. Our largest commercial carrier goes down 35% (!) I’m told with QZ. A few of the others reimburse the same or decrease 10% or so. It’s significant enough a difference that opening a 5th room at the local ASC became quite problematic for us - we ran the numbers when that came up and the decrease made it very impractical in terms of coverage.

It’s pretty complicated, but this website explains it. Some payers adjust payment based on modifiers and some do not. What Does the QZ Modifier Really Mean? | Anesthesia Business Consultants
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Looks like carriers finally getting wise to all the practices who were billing QZ even though the anesthetic was actually AD


1588094095905.png
 
As private payers review and revise their fee schedules, CRNAs appear to be losing ground financially. Ironically, payers may be accepting the AANA argument that nurse anesthesia represents a more cost-effective option. A number of plans now pay less for QX and QZ than they do for AA and QK cases. QZ has become the emblem and beacon of an alternative model of care. None of us knows for sure where this will end up, but one thing is now very clear—there is no going back. QZ has become yet another layer of complexity in an already complex set of anesthesia management challenges.


What Does the QZ Modifier Really Mean? | Anesthesia Business Consultants

Communiqué is a professional quarterly publication dedicated to providing resourceful articles and advice to the anesthesia and pain management community.
www.anesthesiallc.com www.anesthesiallc.com
 
BLADEMDA said:
As private payers review and revise their fee schedules, CRNAs appear to be losing ground financially. Ironically, payers may be accepting the AANA argument that nurse anesthesia represents a more cost-effective option. A number of plans now pay less for QX and QZ than they do for AA and QK cases. QZ has become the emblem and beacon of an alternative model of care. None of us knows for sure where this will end up, but one thing is now very clear—there is no going back. QZ has become yet another layer of complexity in an already complex set of anesthesia management challenges.


What Does the QZ Modifier Really Mean? | Anesthesia Business Consultants

Communiqué is a professional quarterly publication dedicated to providing resourceful articles and advice to the anesthesia and pain management community.
www.anesthesiallc.com www.anesthesiallc.com
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The AANA and AANP are keenly working on expanding "reimbursement parity" state by state so that QZ = AA reimbursement is required by law.
 
When you own a business.. you should pay yourself LAST.
 
46Long said:
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?
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The nerve of those damn anesthesiologists just walking right in without even having an RN degree and thinking they are qualified to teach anything to a nurse! Pffft.
 
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sidefx said:
The nerve of those damn anesthesiologists thinking they can just walk right in without even having an RN degree and think they are qualified to teach nurses! Pffft.
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He wasn't even trying to teach the CRNAs he was teaching the SRNAs and was told to stand down.
 
sidefx said:
The nerve of those damn anesthesiologists just walking right in without even having an RN degree and thinking they are qualified to teach anything to a nurse! Pffft.
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46Long said:
He wasn't even trying to teach the CRNAs he was teaching the SRNAs and was told to stand down.
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To be fair, there are people on this board who say CRNAs should have no role in medical student or resident education. There are extremists on both sides.
 
Any further developments with this?

Will NAPA scoop this as well? Or will envision pull through?
 
nimbus said:
To be fair, there are people on this board who say CRNAs should have no role in medical student or resident education. There are extremists on both sides.
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They really shouldn't, except to teach monkey skills. Definitely not clinical judgment, with very few exceptions. Most of those are old school and close to retirement.

And any SRNA who has something between her ears would welcome the teachings of a much higher-educated physician.
 
nimbus said:
There’s definitely stuff that a medical student could learn from a CRNA.
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Perhaps. There’re stuff a medical student can learn from a competent RN too. Or even PCAs, but they shouldn’t have a formal responsibility of teaching nor be “given” the recognition from above.
 
Anyways back on subject. Envision KKR just wants to force their business debt down from the 9.9 billion dollar purchase. Aka restructure debt.
I think they owe like 8 billion.

it’s like a Buying a house 1 million and it’s worth 500k. And u owe 800k on the home. Depends how much the bond holders want to lose. It’s a game of who blinks first.
There is obviously a lot of money at stake for bond holders.

if you are ever in position to “invest” in private equity. This is the type of gamble you take. The financial guy selling u a stake will claim let’s go to buy this bond it will “guarantee” rate of 20% return. It’s all fine and dandy till KKR pulls a fast on and destroy ur investment with this BK filing.

always ask how secure the debt is before investment. Like buying preferred shares of a stock. The regular stock holders end up with nothing. Preferred share holders at least get something back.
 
This is why many businesses file for bankruptcy then continue business as usual.

Envision with 8 Bil in debt, files bankruptcy. They can turn that 8 bil debt into 4 bil, renegotiate EM doc contracts, etc. In a year, they go IPO again.

KKR gets to double dip on a second IPO once they polish their books.
 
If anyone buys into the KKR Envision model they are fools and deserve to lose their money. Envision is a money losing proposition as out of network billing disappears and insurance companies cut Envisions market leading rates. They are bloated with a lot of non workers and mid tier management people earning high salaries.

Once the playing field gets even remotely leveled with the national balanced billing/out of network law then Envision can no longer outcompete smaller groups or hospitals.
 
BLADEMDA said:
If anyone buys into the KKR Envision model they are fools and deserve to lose their money. Envision is a money losing proposition as out of network billing disappears and insurance companies cut Envisions market leading rates. They are bloated with a lot of non workers and mid tier management people earning high salaries.

Once the playing field gets even remotely leveled with the national balanced billing/out of network law then Envision can no longer outcompete smaller groups or hospitals.
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They don’t even need a law. Insurance companies are now cutting rates and really don’t care if you go OON. of course this will hurt the small PP as well....
 
dannyboy1 said:
They don’t even need a law. Insurance companies are now cutting rates and really don’t care if you go OON. of course this will hurt the small PP as well....
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they want you to go OON so they can "show" politicians how greedy those doctors are and that they need legislation to prevent you from doing so. They are intentionally low balling to try to drive people out of network.
 
Mman said:
they want you to go OON so they can "show" politicians how greedy those doctors are and that they need legislation to prevent you from doing so. They are intentionally low balling to try to drive people out of network.
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But we all know anesthesia billing for private insurance vs Medicare is way out whack

Can you imagine if surgeons got $500 for a gallbladder for Medicare and $2500 for private gallbladder?

but surgeons get 60% of Medicare vs private. Not 15% as anesthesia.

it would level the playing field if they increase Medicare rates. But we all know that won’t happen. Insurers want to push the reimbursements towards Medicare rates.
 
BIGphysician said:
I’ve been discussing jobs with two different Sheridan groups, owned by envision, they keep saying this is a rumor and they’re just restructuring corporate debt


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Lol. Inability to restructure corporate debt leads to BK filing.
If banks and bond holders don’t want to negotiate. Envision has two choices.

continue business as usual or BK filing.

it’s a game of chicken. Consider they are essentially a staffing company. They don’t own anything of intellectual value either. If I were the banks I’d play chicken with them.

The only complicated scheme I can see is what happens to their amsurg component. Many of you don’t know how amsurg works. They brought out usually a 51% stake in single speciality centers (usually GI centers). But it’s very complex. Because they “lease” back space from GI docs.

so if facility fee is $500 per procedure. Amsurg takes $251 and gi docs takes $249
and considering their lease back component. Gi Docs May get super screwed cause whoever inherited the amsurg component can stiff them on their pre arrange lease back deal.

gi Docs screwed. Anesthesia screwed in BK.
I love it.
 
Mad Jack said:
Hopefully this pandemic sees a good number of AMCs and CMGs go under
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They will just sell to some other AMC which has better financials or better private equity backing. (I.e. Mednax/NAPA) Rinse and repeat.
 
aneftp said:
Lol. Inability to restructure corporate debt leads to BK filing.
If banks and bond holders don’t want to negotiate. Envision has two choices.

continue business as usual or BK filing.

it’s a game of chicken. Consider they are essentially a staffing company. They don’t own anything of intellectual value either. If I were the banks I’d play chicken with them.

The only complicated scheme I can see is what happens to their amsurg component. Many of you don’t know how amsurg works. They brought out usually a 51% stake in single speciality centers (usually GI centers). But it’s very complex. Because they “lease” back space from GI docs.

so if facility fee is $500 per procedure. Amsurg takes $251 and gi docs takes $249
and considering their lease back component. Gi Docs May get super screwed cause whoever inherited the amsurg component can stiff them on their pre arrange lease back deal.

gi Docs screwed. Anesthesia screwed in BK.
I love it.
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I don’t feel bad for GI docs. Little sad for anesthesia docs.

GI docs knew what the deal is, hopefully they were profitable. Anestheia docs didn’t have a choice or may not know the deal.

It’s all about the Benjamins anyway.
 
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