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43 Executive Briefing Sponsored by: GI Anesthesia Partnerships and the Changing Landscape of GI Anesthesia D eclining reimbursement and regulatory uncertainties have become prevalent in healthcare today. Jay Kreger, President of CRH Anesthesia, discusses how these changes have affected gastroenterology, as well as how partnering with experts in GI anesthesia can help to overcome current challenges and mitigate future risk. Before joining CRH Anesthesia, you were the VP of Development at HCA in the ambulatory surgery division. What motivated you to make the change and join CRH Anesthesia (CRH Medical Corporation)? I really enjoyed my work at HCA as we grew a network of more than 130 ASCs through acquisition and various partnership models. The attraction to CRH Medical came as a result of what they were doing within the GI community. They had been providing value to gastroenterologists for almost a decade through the CRH O'Regan Hemorrhoid Banding System, and now they were seemingly at the forefront of GI anesthesia. CRH Anesthesia has been able to apply their knowledge of GI and leverage their relationships in the community to develop an outstanding value proposition for gastroenterologists. This idea of physicians partnering with proven experts in the field, managing operations of ancillaries was very appealing. It allows physicians to focus on the clinical aspects of their practices and drive patient satisfaction. That, along with all the other changes taking place in the GI industry, made CRH the ideal company for me. I knew I would be able to apply my skills to help further benefit CRH, their GI partners and their patients. Based on your more than 10 years of experience in the healthcare field, what changes have you seen in the GI space, and where do you see the industry going? There have been countless changes in healthcare — and, more specifically, gastroenterology — over the past decade. The Affordable Care Act is of course what most people think of first. Ever-increasing reimbursement pressures and rising deductibles impact both physicians and patients. Additionally, regulatory concerns have sometimes made the healthcare arena difficult to navigate. These challenges have specifically impacted the GI community, putting undue pressure on practices to remain profitable while maintaining the same high quality of care. Demand for colon cancer screening has increased due to both the aging population and the push for the colonoscopy as a preventative procedure. This comes at a time when the continued decline in reimbursement for endoscopy procedures has led some gastroenterologists to retire early or opt out of Medicare, putting even more strain on GI practices. The trend is continuing in 2018, with yet another cut to colonoscopy reimbursement scheduled. As it relates to GI anesthesia, there has been a trend from conscious sedation toward Propofol as the standard of care. More than half of all colonoscopy patients are now being sedated by an anesthesia professional, whereas less than 20 percent used deep sedation just 10 years ago. Due to these dynamics, GIs are increasingly seeking avenues through which they can improve patient care within their busy practices, introduce ancillary revenue streams to offset reimbursement cuts, and mitigate the risk of any further cuts or regulatory uncertainties in the future. What has CRH Anesthesia been doing to help meet anesthesia needs in the GI realm? CRH Anesthesia completed its first anesthesia acquisition in December 2014, and since then [at the time of this interview] has completed 14 additional transactions. We now service 35 ASCs across seven states, performing over 235,000 procedures annually. We have also recently launched a new MAC development program, thus entering an eighth state, whereby we are converting several ASCs from conscious sedation to Propofol. We have the ability to partner with both independent and ASC-partnered physician groups nationwide, through a variety of anesthesia business models. We work with groups that already own their own anesthesia business and are interested in monetizing a portion of it. We also work with those that currently outsource their anesthesia, or use conscious sedation, and yet want to bring an anesthesia program in-house. We take over the day-to-day operations of the anesthesia business, allowing our physician partners to focus on their patients, rather than managing their anesthesia business. CRH Anesthesia is focused on GI anesthesia, so the groups we work with benefit from our operational expertise and quality programs, as well as our billing and collections management. This also allows them to monetize some of the equity they've built up in their anesthesia business, while mitigating the risks of future declining reimbursement. Can you elaborate on the operational and billing expertise CRH Anesthesia offers? Why would a practice choose to partner with CRH Anesthesia rather than retain 100 percent ownership of their anesthesia business?

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