Going Under: Anesthesia Answered with Dr. Brian Schmutzler
Going Under: Anesthesia Answered is a podcast with renowned physician and anesthesiologist Dr. Brian Schmutzler. Together with Award-Winning Co-Host and television journalist, Vahid Sadrzadeh, the podcast aims to answer not only your most pressing anesthesia questions but to provide the most up-to-date medical data available.
This weekly medical podcast will release a new episode every Thursday at 5 am. Thanks in advance for being a listener.
Don't forget to send your questions to Dr. Brian Schmutzler on social media and his website at www.drbrianschmutzler.com.
Going Under: Anesthesia Answered with Dr. Brian Schmutzler
Medicine on the Edge: The Impact of the 'Big Beautiful Bill'
The "Big Beautiful Bill" passed by Congress affects healthcare in multiple ways, with significant changes to Medicaid, Medicare payments, and how states implement healthcare policy.
In this special episode of Going Under: Anesthesia Answered, Dr. Brian Schmutzler and Vahid Sadrzadeh weigh the good and the bad of this new bill.
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this is going under anesthesia. Answered with dr brian schmutzler. I'm vahid sadarzadeh. We are brought to you by the butterfly network the butterfly network.
Speaker 2:all right, I'm going to let you in on something that's completely changed the way I practice. I've been using butterfly probes for years. It's a portable ultrasound that plugs directly into my compatible smartphone or tablet so I can start scanning at the bedside in minutes. If you use the older version, or even if you're new to the handheld ultrasound game, let me tell you why this new IQ3 is a game changer and really impressive. First off, having an ultrasound that literally fits in my pocket means I can move faster, whether it's vascular access, procedural guidance or just getting real-time insights from my patients.
Speaker 2:And the tech inside this tiny device is incredibly impressive. Biplane imaging lets me see short and long axis simultaneously, which is huge for procedural guidance and also for learners. The new needle-out-of-plane preset even shifts the scan plane digitally, so I can see the needle tip sooner, which makes a real difference when precision matters and the image quality. Honestly, the IQ3 holds up against some of the high-end cart-based systems I've used, and that's impressive for something this portable. If you're looking for a device that supports your practice, I can't recommend the Butterfly IQ3 enough, and right now they're running a special offer. You can get $750 off the latest IQ3. Check it out at ButterflyNetworkcom. Awesome Good check it out at butterfly networkcom.
Speaker 1:awesome, good to be back?
Speaker 2:absolutely yeah, special, special episode here, just because you know a lot of stuff going on a lot of stuff going on.
Speaker 1:It's mid-summer, uh, we're still going to be probably breaking until, I would say, august yeah, yeah, mid-august probably um, but something just uh passed congress last week, right, that is, on j July 4th. That is and was and still is controversial because it was really divided, we didn't really know where it was going to go and then, once it was signed, we're like let's do a podcast on it because I think it's really important in terms of the medical community.
Speaker 2:Yes, I was going to say that I am no expert on this bill. I am just trying to delve into what I know, which is the medical side of things. So, my goal is to give you a little bit of detail on the medical side of things, and I'll do this the way that I do everything that's controversial. Here's the positives, here's the negatives.
Speaker 1:Yeah, so take that away.
Speaker 2:Take that away.
Speaker 1:Don't think it's just one-sided.
Speaker 2:Exactly, it's both we are covering both sides here.
Speaker 1:So we're talking about the big beautiful bill, obviously, that passed by a margin of 218 to 214. What is the one?
Speaker 2:beautiful one, big beautiful the OBBB, OBBB.
Speaker 1:Yes, and included in that. So we're not talking about the taxes, we're not talking about any of that stuff.
Speaker 2:I am no expert. Neither one of us are an expert in that, not at all. So we're not going to get into any of that stuff.
Speaker 1:We're talking about. I am no expert Neither one of us are an expert in that, so we're not going to get into any of that, Not at all. We are going to talk about how it has an impact negatively and positively on the medical community, particularly in small towns, hospital system physicians and, of course, those on Medicaid and SNAP programs. And so let's just get into it. What is it covering in terms of the bill and how is it positively and negatively impacting the medical community?
Speaker 2:So I think the biggest change is going to be in how Medicaid is distributed across states, how Medicaid is instituted and all that sort of stuff, sort of stuff. So so let me first preface with as with any large bill that's thousands and thousands of pages long, the devil's in the detail, right? So it's not necessarily what's actually written in the bill, it's how it's implemented, because these bills don't don't take into account every possible scenario. So there's going to be a lot of implementations, things that will really matter, and so what? What probably is going to matter more than anything is not that you live in the United States, but what state you live in and how they implement these changes. So that's that's my preface. So the the bill basically addresses a lot of issues with Medicaid.
Speaker 2:I think we can all agree everyone in the medical field and even outside the medical field Medicaid is a totally broken system. I'm. Medicare is not much better, but Medicaid is a totally broken system. Medicare is not much better, but Medicaid is a very broken system. So, for those of you who don't know, medicare takes care of the elderly, meaning those over the age of 65 receive Medicare. Medicaid, for the most part, takes care of those who can't afford to take care of themselves. So we say that Medicare takes care of the elderly. Medicaid aids the poor. That's kind of the acronym, or what we learn in medical school.
Speaker 1:And 71, I just want to read the stat here 71 million people are on Medicaid, reported to be on Medicaid which expanded under the Affordable Care Act Correct, and 40 million use the SNAP program Gotcha. That's according to recent data.
Speaker 2:Data, yeah, and so probably the highest percentage of people on Medicaid are children of people with lower incomes, right? So, basically, unless you're on an employer program, most kids are on Medicaid. So, that being said, how does Medicaid? How is Medicaid initiated? So the federal government supplies money for Medicaid, but the states are the one who administer Medicaid, who decide what the qualifications are, who decide all that kind of stuff, right? So it's a combination the federal government pays in a percentage of monies to the state Medicaid and then Medicaid distributes it as they see fit.
Speaker 2:So, again, I think the biggest thing is going to be what state do you live in, right? So, in general, Indiana's Medicaid program is pretty well allocated and pretty well administered. There are some other states and I won't necessarily name them that are way leveraged with the number of Medicaid people. They have and don't have balanced state budgets, so they're already in debt. So there's a lot of issues that come in there. So what does it do, All, right? Well, it changes the qualifications for Medicaid, right? So there's and I can't remember all the exact specifics, and so I don't know if I call this a positive or negative, right? I'm just letting laying out what it is here because, again, it's how it's instituted. So if these, if somebody with in good faith looks at it and says, yeah, you have to do and I think the requirement was over the age of 20 or 18 or something you have to do 80 hours per month.
Speaker 1:So yeah, so the package.
Speaker 2:Sorry, yeah, go ahead.
Speaker 1:Yeah, so the package includes a new 80-hour-a-month work requirement, or or volunteer or you can do anything with those 80. Hours.
Speaker 2:It's just you have to do something that contributes to society with those 80 hours.
Speaker 1:So those are for the adults receiving Medicaid and food stamps, including older people up to age 65. Parents of children 14 and up would have to meet the program's new requirements. And while I'm at it, there's also a proposed new $35 copay that can be charged to patients using Medicaid services, which previously was not.
Speaker 2:Correct. So those are pretty fundamental changes. And again, do I agree or disagree? If you're able-bodied and you can get to work or volunteer and it doesn't say it has to be a specific volunteer, specific time I mean that could be from what I'm hearing that could be even going over to your neighbor's house and raking their leaves can count towards your 80 hours. So I don't think that's completely unreasonable. So that's number one. I think there is a push to remove those who are not American citizens from the roles. Again, I'm not making a comment whether that's good or bad, but I think that's part of it as well. But I think it also. The biggest thing that it does is it shifts the majority of the onus and and financial issues to the states. It takes it away from the federal government, moves it to the states. You could argue that's good. You could argue that's good. You could argue that's bad. Um, you know again, in indiana we're a pretty fiscally responsible and stable state. I don't think you're going to see a huge impact in the state of indiana.
Speaker 1:There will be states where there would be big impacts but under the trump administration, not saying bad or good, sure, under the Trump administration. That is how these medical decisions have been trending correct.
Speaker 2:Correct, yeah.
Speaker 1:Under the state's legislation and decision-making power to make these kinds of decisions.
Speaker 2:Yeah, trump is much more of a states' rights guy in terms of policy that he passes. Now his bluster is not so much that, but in terms of policy, pass is states' rights. So if the state wants to do something great, the state can do it. So I think that's probably one of the biggest issues. Now there's a lot of discussion about how rural hospitals are going to lose funding and there's going to be a loss of access. So I would say, in some ways yes, in some ways no.
Speaker 2:So I think in general, what the bill shows is that there's less Medicaid money probably going to go around because less people are going to qualify. Less of that money is going to be supplied by the federal government and if the state doesn't make up the difference, there's going to be less money in Medicaid. But critical access hospitals are funded via a different mechanism. So these are hospitals that are smaller than I think 26 beds or 27 beds or something like that and serve an area that's underserved. So, for instance, in our area, bremen Hospital is a critical access hospital. We know the president there very well and he actually came out on the news here and said we're going to be fine this is not going to cause any interruption in service.
Speaker 2:We're doing just fine. This won't change anything. So I think you have to separate out those rural and small community hospitals that are maybe 75 80 beds versus those that are critical access. So it's probably actually because of the way there's some shifting of funding. It's probably actually because of the way there's some shifting of funding. It's probably actually better for the critical access hospitals than the current system and probably worse for the small community hospitals and the rural hospitals that aren't critical access. There's also a shift in the provider tax, so the provider tax gets reduced.
Speaker 1:So I'm just reading Is this under physician owned or is this just in general, in general, in general Provider tax. Provider tax gets reduced. So I'm just reading here Is this under physician-owned or is this just in general, in general, in general Provider tax.
Speaker 2:Provider tax, a funding mechanism supporting Medicaid provider payments, drops from 6% to 3.5%. This downturn tightens hospital budgets, indirectly potentially impacting operating room.
Speaker 1:So budgets are falling 3%.
Speaker 2:Two and a half, two and a half percent.
Speaker 1:Yeah.
Speaker 2:So that's less money out of the provider's hands. I'm sorry, yeah, less money out of the provider's hands into the hospital hands. So there's more money to the providers. Again, positive or negative Depends who you are. If you're somebody supplying care, if you're a physician or an advanced practice nurse or something like that, probably better. If you're a hospital and you're counting on that money, probably worse.
Speaker 2:So one thing that I think almost everybody could agree with is a positive thing is the Medicare physician payment, doc, fix right. So there's something written in the bill ever since the mid-90s, when a certain first lady decided she wanted to get into the health care game, every year the federal government is supposed to decrease what Medicare pays physicians and advanced practice practitioners. They almost every year except this last year, of course, and the year before have said all right, we're just going to ignore that, we're going to write an amendment and just this year we're not going to deal with it. Well, the past two years they've cut back the reimbursement to physicians. This one actually creates in 2026 a 2.5% increase in Medicare payments to physicians.
Speaker 1:So good news for physicians, right and I know you've had some guests on the show that have talked specifically, yeah, about the doc fix, about the doc fix. Uh, even previously, before this was passed, yep, about what that could mean. Um, and so if you're a physician, that's, that's significant that's significant.
Speaker 2:Yeah, I mean, you think about it. If you bill out let's say your practice bills out a million dollars. 2% decrease, which is what it's been the past two years in a row, is still significant money and a 2.5% increase is really big if you've gone down 2% and then now you're up 2.5%.
Speaker 1:Does that? We've talked before about how healthcare is shifting to less family practice kind of systems and more this kind of entrepreneurial out-of-pocket kind of system Direct care, Direct care of system, direct direct care, direct care. Does this put momentum back into those kind of clinics and and and systems? Or, you know, do you still see long term because we're sitting here in 2025 right now? Correct how long to implement these for states in general?
Speaker 2:I think they have to start implementing right away. Yeah, I think by 2026,. January 2026, they have to be implemented. So I think the issue is that most direct care providers don't cater to the Medicaid population right, because the direct care providers are people who require some sort of payment. Right, and most medicaid patients have don't don't pay anything. Right, they don't pay anything for their care during the visit. They don't pay anything for the medicaid itself. So I don't think that's fundamental medicare uh, some medicare do yeah because everybody over 65.
Speaker 2:There's no income requirements for medicare right, so you could be a multi billionaire. Now you know, as Jeff Bezos over six. If Jeff Bezos is over 65, he still can get Medicare right. So it may affect Medicare patients, but not Medicaid patients for the most part.
Speaker 1:Yeah.
Speaker 2:You know it's interesting. I think I think it'll be very interesting to see how each state does it, but I think I think it's without question something had to be done right. And I think you can make the argument, on the other side, that the Affordable Care Act, as much as we disagree with parts of that and, you know, agree with parts of it and as much as we disagree with parts of this and agree with parts of it, there had to be something done because the healthcare system is is breaking. Now, was everything done that needed to be done? No, of course not, and with some of the good, some of the bad, yeah, same thing, Um, but at least it's an attempt, in my opinion, to move the needle a little bit on the uh, on the federally funded healthcare system.
Speaker 1:And not only the healthcare system, but you're talking about SNAP as well. Coincidentally, snap benefits. Currently the federal government funds all benefit costs. So under the bill states, right Beginning in 2028. Okay Will be required to contribute a set percentage of those costs in their payment error rate exceeding six percent. So payment errors include both under payments and over payments.
Speaker 2:Yeah, um, so the senate, a lot of bill. There's a lot of complexity right.
Speaker 1:A lot of complexity in this um, but in general, people who disagree have been very vocal about this particular part of the bill.
Speaker 2:Well, it's the same thing, though it's moving the financial responsibility back to the states. So if you're a state that has a balanced budget or has a surplus, this isn't going to hit you as hard as if you're a state who runs a gigantic deficit every year. Again, in Indiana probably not that big of a deal. In other states probably more of a big deal. I do wanna make the point, though, about SNAP. So I agree there needs to be a safety net, especially kids. They need to make sure that they have meals. Snap makes sense. What doesn't make sense is what's covered under SNAP, and we can talk about it. I think we talked about this before.
Speaker 2:We did a little bit a couple months ago. Yeah, the American Heart Association sends a lobbyist down to the state of Texas when they're talking about changing what's on SNAP and that guy argues that we shouldn't take away SNAP's payments for sugary cereals, sugar sodas, candy, all that sort of stuff.
Speaker 1:The American Heart Association. What is the argument for that?
Speaker 2:What's my opinion?
Speaker 1:Is it easier to get a hold of those items.
Speaker 2:So what's my opinion, or what did he say was the reason he said it. So what he said is the reason he said it is because, yeah, those are densely packed calories and for people who only have a certain amount of food, it makes sense to get densely packed calories. I think that's a red herring. I think that the AHA, the American Heart Association, is in the pocket of big food Sugar, corn syrup, all that kind of stuff.
Speaker 1:Even though they're going touting or whatever.
Speaker 2:Yeah, they're saying yeah we care about your heart health. I mean, what is the most most inflammatory, dangerous thing for somebody with heart disease? Sugar, of course, and you're promoting oh no, don't take away their candy and they're just, they're empty calories. As I drink a cheer wine which, by the way, cheer wine. Had no idea, I was in north carolina. It's like cherry coke, but better so yeah, it's flavorful.
Speaker 1:It's flavorful, it's great, packed with a lot of flavor, packed with a lot of flavor, and a fair amount of sugar. That's right.
Speaker 2:I'm counterbalancing with a sugar-free tea.
Speaker 1:It is so the balance of where the line is drawn. You know, yes, american Heart Association does some great things, but you know where's the money going?
Speaker 2:Right, where's their money coming from and where's it?
Speaker 1:coming from.
Speaker 2:Right, I mean, who's supporting these, right? I think I heard something that Cadbury.
Speaker 1:We talked about this, we talked about Cadbury.
Speaker 2:Cadbury is the biggest funder of the American Diabetes Association. I can't imagine why that would be. Oh, maybe because you want to buy that company for them not to say Cadbury eggs cause diabetes, right, don't eat so many Cadbury eggs. So I mean, there's a lot of shady things that go on, I think.
Speaker 1:Well, I'm excited to see the comments, because I think we're going to get a lot of There'll be some comments on this episode. We'll try to obviously get to every one of those comments, but the facts of the matter here are the bill is passed. It's up to the states to implement these bills. Now they have to. But what does the state look like in the first place?
Speaker 2:That's the biggest probably thing. And the other thing I would say I would caution everybody not to take a stance, positive or negative, until we see how it works out.
Speaker 2:Talk to your lawmakers, right, talk to your state reps Same reason we didn't take a full-on stance Even the AMA didn't take a full-on stance on the ACA, on Obamacare, until the implementation started. Because this bill is thousands of pages long and all we're doing what you and I are doing we're not attorneys, we're not lawmakers, we're looking at it and just taking somebody's interpretation from it. Right, but once it gets implemented you'll see how it actually works. So I would caution everybody not to freak out too much. Either way, hey, this is the best thing ever. Hey, this is the best thing ever. Hey, this is the worst thing ever. There's probably going to be a lot of things that work well and a lot of things that don't. But I also think it's disingenuous to say taking the Medicaid program and modifying it to make it less dysfunctional is a problem. Right, this may not be the right way to do it I don't know yet but Medicaid is a huge issue and needs to be fixed.
Speaker 1:And SNAP too, this be the right way to do it. I don't know yet, but medicaid is a huge issue and needs to be fixed. So and this is a snap too, but this is a shameless plug but um, actually yesterday, one of the local stations, um did a full 30 minute interview with governor mike braun.
Speaker 1:Oh nice, so I'm I'm going to link it below yeah and and usually the station is very kind of what we do both sides of the issue and so it's a good conversation. But they do talk about these SNAP benefits if you live in the state of Indiana.
Speaker 2:Yeah.
Speaker 1:And what do they say? Well, I think Governor Braun took the stance of it's up to the states Right and our state, you're not going to really see much changes, right?
Speaker 2:because we have a surplus.
Speaker 1:We have a surplus yeah, um, this in particular. Yeah, um, but don't take my word for it.
Speaker 2:Listen to the full interview.
Speaker 1:Um, I'll link it below, uh, because it's a good one, yeah, and he gets into a lot of those issues. So I mean, and that's the way to do it, right? Right, talk to your state reps, yeah, listen to what they have to say. Listen to what you know local leaders have to say about it well, this community.
Speaker 2:This is why local government is so important here too. Right, because that that person who lives five doors down from you, that's your state senator or your, you know, your state representative. They're the ones who are going to decide how to deal with this change. So, yeah, that's somebody, that's right, it's. It's not like oh, you know who's our, who are our senators?
Speaker 1:uh, senator, uh, rudy yackham, I know he's a congressman, anyway, it's not like your, your federal guys who spent a lot of their time in washington we should know these guys yeah, we should.
Speaker 2:Uh, I mean, I still, I still remember when it was like bye yeah, right, yeah well, brown was a senator. Yeah, brown was a senator, yeah, before he came, but became governor, yeah, so, um, it's uh todd young, todd young.
Speaker 1:Yes, I wanted to say roquita, but he's the ag.
Speaker 2:Yes, yeah, yeah, yeah so it's todd young, but there's another one two senators so, so, um, yes, so I mean, these are people that you can talk to and you can say hey, don't take away my snap, benefits, benefits, or you know, I still want my cheer wine.
Speaker 1:Like you know Well and to be honest I mean whether, whatever side you're on, you know again, here in town you have people going to their local congressperson's office every Tuesday.
Speaker 2:Oh yeah.
Speaker 1:Because that's what they believe in Open hours. Yes, that's what they believe in Open hours. Yes, that's what they they want to discuss. So I mean they're not going to turn you down to not chat with you. Yeah, and.
Speaker 2:Rudy Yacoum has been very. I've seen him on a plane 10 times Probably.
Speaker 1:We saw him together, yeah, right.
Speaker 2:He's a very affable guy, he'll. And speaking about Medicaid, so up until last year or the year before so we don't get paid well by the government by Medicare, but we were paid half that amount by Medicaid. So you're talking about it was about $22 a unit. It's $20 a unit now for Medicare, for anesthesia and Medicaid was like $11. So finally, last year or the year before they bumped up Medicaid reimbursement for anesthesia and Medicaid was like 11.
Speaker 2:So finally, last year, the year before they, they bumped up Medicaid reimbursement for anesthesia to what Medicare is. What else is interesting and this is another shameless argument for the state of Indiana dentists and dental anesthesiologists. So dentists who become anesthesiologists for dental cases or head and neck cases only they can negotiate with medicaid. But I as a physician mddo, can't negotiate with medicaid. So the dental anesthesiologists are making way more money from medicaid cases for the anesthesia but why?
Speaker 1:why is that? Who knows who put that into place and what? What does it?
Speaker 2:protect. So what happened was the dentist said we don't do emergency care. You can't force us to take Medicaid, so either you pay us what we deserve or we're not taking it. They can find somewhere else to get their teeth done, because that's not an emergency. The unfortunate thing is that I have to deal with emergencies right, so I can't say I don't take Medicaid. I guess I could, but it would be much harder for me to say I don't take Medicaid and Medicare as it does dentists?
Speaker 2:So that's what they've done. That's what they've done with the insurance companies too. So that's why, when you go to the dentist, you pay that bill up front and then you submit to insurance and maybe they pay you back or you get some small deduction, but essentially you're paying for your dental care and then it's between you and the insurance companies to get the money back.
Speaker 1:it's not how it works in medicine yes, and we said it before we came on the air and I'm gonna, before we came on the podcast, and I'm gonna say it again as we go out of the podcast we are not experts.
Speaker 2:we are strictly, you know, giving you the facts of, you know, what is included in this bill, how it's going to affect positively and negatively for those in the medical community, and I would call us highly competent in the medical community and the way this may affect the medical community and the way implementation can affect things in the medical community, based on this bill, but certainly not experts in the bill itself. So read up on it is what we're saying. And if you can understand it. Read the bill itself. I tried.
Speaker 1:There is a lot of complication.
Speaker 2:It's a lot of words, a lot of words.
Speaker 1:Summaries help Chat. Gpt. Right, yeah, right, all right. Well, we're brought to you by the Butterfly Network, but can you show off your belt bag? Sure, sure, the Butterfly Belt Bag Now available. I love this thing, by the way.
Speaker 2:Well, we can do an unboxing later, I guess. Yeah, so this is great.
Speaker 1:So it's actually Hold it up just a little bit. Oh sorry, yeah, yeah, yeah.
Speaker 2:So it's actually a little pack that you can put around your waist. Well, I don't know that we're allowed to say fanny packs.
Speaker 1:Is that an official thing?
Speaker 2:Okay, I think that's trademarked, but it's a pack that you put around your waist.
Speaker 1:It's similar to something like that form factor yes, correct. Where you can put it around your hips. Yes, correct correct.
Speaker 2:And then it's got several pockets on the inside. Ah nice, you can put your cords and your charger here clips around your waist, so it's like ultimate portability now.
Speaker 1:And you know I'm a bag nerd. There we go, so I know exactly that is a two-liter bag. Is it Yep, one or two liters?
Speaker 2:Two-liter bag.
Speaker 1:It's either a one or two liters. It seems taller. Does it say on there? No, no, it does not say on here it's either one or two liters.
Speaker 2:I can definitely tell because I own a lot of belt bags and it's got a very solid clip on it.
Speaker 1:Love it. Yeah, we'll do an unboxing.
Speaker 2:Yeah, we'll do an unboxing on the.
Speaker 1:What's in your butterfly belt bag? My butterfly.
Speaker 2:I'll leave my butterfly belt bag in the back. Nothing else. Nothing else. No, I mean all the cords and stuff for it. Maybe a small iPad or a phone in there. I might be able to fit a mini in there.
Speaker 1:So you can do the butterfly with your phone or iPad? Yeah, either one, so you could just put everything in there Wallet You're ready to roll?
Speaker 2:Ready to roll Awesome Right around your fanny.
Speaker 1:Well, we are brought to you by Butterfly Network and thank you all for listening and watching, of course, dr Brian Schmutzler across all platforms here YouTube, check him out on Facebook, instagram, tiktok and everything else, and the website as well.
Speaker 2:And please comment on this one. Like we said, we're just talking about what we perceive as positive and negative. We're not endorsing or unendorsing this bill. But yeah, give us a shout, Let us know what you think about our conversation today.
Speaker 1:Awesome. Well, thank you so much. We'll see you in the next one, which would be probably four to six weeks. That sounds about right. I'm just guessing. Yeah, all right, we'll see you for the next season of Going Under Anesthesia. Answered with Dr Brian Schmutzler. I'm Vahid Sadrassadeh.
