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lasers and upgraded lenses, pretty soon it'll be hip and knee replace- ments." Mr. MacKinnon expects anesthesia providers to have to work harder for the same reimbursements, thanks to an aging population and "an obesity epidemic" that will "shift the population from private insurance to Medicare and Medicaid." MDs vs. CRNAs The future of the sometimes prickly relationship between anesthesiol- ogists and CRNAs is also up for discussion, and it's one that, perhaps not surprisingly, looks different to different practitioners as they turn their gazes forward. "I foresee greater usage of CRNAs in anesthesia staffing," says Mr. Horowitz, citing a record of both "safety and cost effectiveness." Mr. Horowitz wonders, in fact, whether anesthesiologists will eventually be priced out of the market. "I think they'll increasingly be used more as OR hospitalists and in research," he says. "The specialty will become less attractive to med school graduates and anesthesia assis- tants will disappear." Mr. MacKinnon also expects to see "erosion of the anesthesia care team," as CRNAs expand into independent and autonomous practices. "As the economic belt of health care tightens, all providers will be expected to work to the top of their scope of practice and license," he says. As such, private practices will follow the lead of the U.S. Department of Veterans Affairs, which is proposing to give full practice authority to APRNs. The combined factors will lead to the "dying of all MDA practices," he says. But the advent of the perioperative surgical home — a team-based model created by anesthesiologists and designed to align with the oft- stated goals of value, patient satisfaction and reduced costs — may 6 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 6