Exactly

... 'cause so yeah, so we're, we are proceduralists.

We are involved in, in, in the care of a patient in a very limited window.

And yes, they'll say, well, there's decisions that I make in the operating room that have impact on 30-day mor- mortality and morbidity.

Okay.

Okay, that's fine.

But how are you qua- how are you identifying and quantifying those? Which is why, you know, they're moving towards intraoperative hypotension.

Uh, Ra- Randy, any thoughts here?

I see the No Surprises Act a lot.

Well, I mean, just to pull the thread on Tracy's comment, so zoom out and then we can zoom in.

So this is a, all of this, that's this IDR stuff, This these lawsuits that are targeting Halo, MD and other parties.

This is all second and third order consequences of no surprise billing.

So no surprise billing was passed in the 11th hour of the first Trump administration.

The rules were promulgated and the needle of leverage moved really far over to the commercial payers.

And Tracy, I think, did a very good job of describing how their behaviors changed after these rules were promulgated.

medical direction care team.

Randy, does mandatory reimbursement parity increase costs?

This whole set of comments were pretty underwhelming, period.

But, I mean, there are elements of his argument that I would say, like, okay, that's the way I would run at it, too, if I were them, in terms of the government intervening and regulating on what's happening from a commercial perspective on contracts.

I don't agree with this position, but that's exactly what I would say if I were him.

And then there are other elements of his arguments, which was just kind of complete nonsense.

So this idea that nurse anesthetists are not regulated, I feel pretty regulated as a nurse anesthetist.

From my state licensure all the way through to credentialing at a facility, I honestly feel like I'm overregulated in some aspects of my clinical practice.

Randy, how are you guys adjusting to the practice level? What are you advising other practices to do with this stuff?

Be careful.

Obviously, Tracy and I are much more aligned on this than I'm probably, I was signaling.

I think if you zoomed out a little bit even more, I think anesthesia is a big, fat, rich target for the UnitedHealthcares and the Aetnas and Blue Cross Blue Shields of the world for a variety of different reasons.

One is they know that there is a financial backstop, which is the hospitals and health systems in the United States.

They know that At the end of the day, if they're driving down reimbursement, someone else is going to have to pay for that.

It's not going to be the anesthesia clinicians, and it's not going to be the anesthesia groups that employ anesthesia clinicians.

It's all going to be passed through.

Randy, do you want to just finish your comment there, and then we'll go to Tracy for your reaction on this newsletter.

it's Randy at no, just keep,

it's fine.

I think it's, it's a really, like if we zoomed out and said, like, just looked at this from a macro perspective, I think it's a really interesting problem, right? So we, there is definitely a significant supply demand imbalance of CRNAs and anesthesiologists.

The anesthesiologist pipeline just cannot respond in the way that the CRNA pipeline is.

So you're seeing significant growth in the CRNA pipeline You're seeing significant growth in the year-over-year graduates of nurse anesthetists.

But, you know, you're also seeing the demand dynamics continue to change in a way that they're just gobbling up all of those new graduates.

So there is definitely a supply-demand.

they're much less market responsive.