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    November 25, 2020

    A Little Extra Gravy

    Normally, the post for this week of the year is a brief holiday greeting because you are more focused on cooking a turkey than hearing from one.  We get in and get out quickly.

    But this year is far from normal, isn’t it?

    Eh, we need to grab hold of any normal we can, so we’ll hold any attempt at deeper thoughts for later.

    More than ever I am thankful for you who read along, who are willing to give me a couple minutes of your time each week.  I so appreciate it and hope to give you enough to think about to make it worth your time.

    Here’s a final treat for you before you start your holiday.  Rumor has it a second helping of gravy will shorten and reduce any COVID-related symptoms.  I am not a scientist, but clearly there are a lot of opinions flying around that are not based in science.  Is a little extra gravy for medicinal purposes crazier than some of the other things we’ve been doing?

    Have a happy socially distanced, mask protected, hand sanitized Thanksgiving.

    Tim Coan
    Tim Coan

    CEO and founder

    Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
    November 19, 2020

    The Hiroo Onoda of CMS

    In 1944, the Japanese Imperial Army sent a small band of intelligence officers to Lubang, an island in the Philippines, to spy on American forces in the area.  They were ordered to conduct guerrilla warfare and not die.  Who knew that ordering a soldier to not die was helpful instructions?

    As the victory by US forces became inevitable, most Japanese troops withdrew or surrendered, but Hiroo Onoda melted into the jungle to continue to the fight and follow his orders…for 29 more years.  Messages that the war was over were interpreted as trickeration by those sneaky Americans.  Of course they would say that to get him to surrender.

    Finally, in 1974 he was persuaded to come out of hiding.  Nearly three decades after Japan surrendered, so did Onoda, still in his tattered uniform as he handed his sword to his old commanding officer.

    I guess the cell service was not good in the jungle of Lubang.

    Onoda came to mind as I read the recent announcement from CMS about the release of the administration’s final rule on Transparency in Coverage, the executive order requiring payers to disclose negotiated rates with providers.

    Hey, did you guys hear there was an election?

    Oh wait, of course they are still fighting the good fight.  Their boss has not yet surrendered.

    Well, that shoots the analogy all to heck, but score one for government bureaucrats busy at work.

    It is worth keeping this on your radar, even though the deadline is an eternity away in 2022.  Executive Orders can be undone, but price transparency seems to be a somewhat bi-partisan idea so this might be a relic from the Trump era that the Biden team does not dismantle.

    In short, the rule requires payers to make a lot of data available online to their members – data that shows the actual negotiated rates with providers for an initial list of 500 ‘shoppable services’ and the member’s specific out-of-pocket financial exposure.  They will also have to provide downloadable files that show historical billed charges and payments made for out-of-network providers.

    Here are a couple of things you need to take away from this reminder, neither of which is new nor profound, sort of like being reminded to floss…

    The move toward price transparency is a big wave that is not dependent on politics.  Particulars may change, but the idea is going to march on.  How will your pricing look on some comparative shopping site?

    You living off an old out-of-network strategy?  You might want to think about how those payment amounts will play in the new world.

    Providing easy to access data to the world will be the price of admission.  If getting data out of your IT systems is harder than getting a Japanese soldier out of the jungle, it might be time to upgrade.  Lay down your sword and get some new clothes.

    Tim Coan
    Tim Coan

    CEO and founder

    Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
    November 12, 2020

    The Boilerplate Stuff

    Earlier I mentioned that I’ve been spending most of my summer and fall getting a couple of deals done, which has meant spending a lot of time with legal documents.  Which means I am running low on blue pens and bourbon.

    The latter comes in handy when you get back to the boilerplate language that the lawyers think is important. 2020 has validated why.

    Here’s one: The ‘Rona Age (I am bored typing COVID, so amuse myself with new names for the virus) has taught us that ‘force majeure’ has nothing to do with cow patties.  The parties to lots of contracts, lease agreements, and bank loans are arguing about how the force majeure clause does or does not apply.

    A friend of mine is with a specialty insurer who writes a lot of coverage for the live entertainment industry.  They cover artists, promoters, venues – everyone up and down the chain.  Everyone is suing everyone, and it is all about how you interpret force majeure.  Was this an ‘act of God’ or a covered business interruption?  Hello court backlog.

    Yesterday, we got another lesson about another boilerplate section – severability, that clause that says, ‘if one part of this contract is invalidated, the rest of it still applies.’ You thought it was a bunch of yada yada yada, but the nine folks in nice black bath robes seemed to think it is important.

    The Supreme Court heard oral arguments from Texas and the Trump Administration seeking to have the Affordable Care Act tossed.  The chain of their argument was: The ACA only stood because Congress has the authority to tax and the penalty for not having insurance was deemed to be a tax; now that the tax is gone, the entire law should be invalid.

    But questioning from the justices homed in on the severability concept.  Well, they are lawyers after all and took the Boilerplate 301 class.  It did not go well for the challengers.

    Chief Justice Roberts, who seems be a conservative in the vein of sticking to the Constitution as opposed to advancing the right’s policy agenda, noted, ‘I think it’s hard for you to argue that Congress intended the entire Act to fall if the mandate were struck down when the same Congress that lowered the penalty to zero did not even try to repeal the rest of the Act. I think, frankly, that they wanted the Court to do that. But that’s not our job.’

    Most scholars thought this latest run to the Court was a fool’s errand on the merits, and though the tone of oral arguments are not always indicative of the vote, yesterday’s line of inquiry strongly suggests the justices will conclude that the doctrine of severability applies.  Congress removed one part, but not the entire law, and thus intended it to stand.

    Unless Georgia changes everything, the ACA is likely to be the law for the foreseeable future, though bourbon should be covered as part of the wellness plan.

    Tim Coan
    Tim Coan

    CEO and founder

    Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
    November 6, 2020

    Don’t Step in It

    The blog is a little late this week as I mailed it through Georgia, and it seems things there are taking a little long to process.

    Someone asked me earlier this week when I’d have my blog post up about the election and I immediately thought of the old joke about two rednecks.  There are always two rednecks in these stories, aren’t there?

    They came upon a pile of what appeared to be the recent work of a dog.

    ‘Is that dog poop?’

    ‘Looks like it, for sure.’

    ‘Smell it.’

    Bending over to get close, the other inhaled, made a face and said, ‘Yep, smells it.’

    ‘Touch it.  Does it feel like dog poop?’

    Squeezing some in his hand, he replied, ‘Warm and gooey.  Yep, feels like it.’

    ‘Taste it. Does it taste like dog poop?’

     Pulling a dab with his finger, he put a little in his mouth. ‘Dang, sure enough tastes like dog poop, too.’

    The brighter of the two then pronounced, ‘Yes, it is dog poop.  Buddy make sure you don’t step in it.’

    Yes, this joke was only told by eight-year old boys who liked to say ‘poop’ a lot.  But I thought about the election and how we try to serve you each week here with our little blogging thing and concluded that mostly I need to just not step in it.

    As I write this, the long-term Airbnb rental on the west end of Pennsylvania Avenue likely will have some new folks moving in.  On the other end, Mitch and Chuck may have to wait until one, or maybe two, Georgia Senate runoffs are completed to see which of them gets to hold the gavel.  People often wonder what, exactly, the Vice President does other than go to funerals.  Well, there is a chance Kamala Harris will spend a lot of her time casting the deciding vote.

    Yes, we are about as divided as we could possibly get, and things are as tight as a scuba suit on a Sumo wrestler. 

    I could opine in 14 different directions about how we got here, how bad it is, what we need to get out of this place, or several other things, but I am guessing you’ve already read way too many of those pieces this week as you’ve spent too much time watching interactive maps that haven’t moved much.

    So, here’s one piece of data for you…

    Thus far this week the prospect of a divided government (maybe that was premature on the Senate) was good for healthcare stocks.  Said CNBC, ‘The lower possibility of rising regulatory zeal and unwelcome legislation plus pre-election positioning leaves Managed Care and Hospital stocks in better shape.’

    ‘Rising regulatory zeal.’

    Maybe no big changes come. 

    Which means, as we’ve been saying for years now, what matters to your practice is not Washington, but your vision, strategy, culture and execution.  That is where your vote matters even more.

    Tim Coan
    Tim Coan

    CEO and founder

    Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
    October 29, 2020

    Pick Your Truth

    A lot of us have new office mates now. Some are sharing their workspace and internet connections with 3rd graders who also hog the Crayons.

    Me?  I am sharing my office with our dog, especially this week since it snowed here in Colorado.  When you are a professional napper as he is, that warm spot on the rug in front of the fireplace is ideal.

    Generally, I am glad to have Moose hanging out with me, though I resent a bit when he gives me that pitiful look that comes when my call runs long and his lunch is a bit late.   Maybe he was trained by a nun, but man can he silently deliver guilt inducement.  Forgive me, dude, but I am working here.  How do you think we buy that food for you?  But it works…I get up and he gets fed.

    The other nagging reminder of my failure as a human has been that ‘write blog post’ item that sits atop my weekly TO DO list.  Forgive us for playing hooky the past couple of weeks.  In trying to get a couple of big deals across the finish line, we’ve had too many conversations on tax matters, obtuse legal issues, government regulations, and ‘in the weeds’ due diligence tasks to string together 500 thoughtful words worthy of two minutes of your time.

    But like Moose, that on the pad next to my computer has shamed me into action, even if late and maybe not up to your normal expectations.  Here goes…

    Though my attention to the world at large has been limited of late (I hear there is something big happening next Tuesday?) what I have been able to discern is that I have not been able to discern much.  In short, the data – almost regardless of what – seems to be mixed and inconsistent.

    Businesses are failing, but some are thriving and most just muddle along.  Deals are getting done, deals are not getting done.  Some are laying people off and others are hiring like crazy and facing upward wage pressure.

    Cognitive dysfunction reigns as we all can support our confirmation bias, regardless of our opinion.

    One quick example is relevant for readers here looking for every possible clue as to where healthcare utilization – physician volume, in particular – is headed.  Some data suggest we are back, or almost back, to pre-COVID levels.  Others say we are still a long way away.

    Which is true?  Probably both.  Some markets are doing better than others, some specialties are doing fine while others are very sluggish.

    I offer two thoughts for your consideration:

    Your particular circumstance is probably more unique than ever.  Divergence from the headlines could be likely.

    The tide is not steadily flowing in or out right now, so there is not a clear current to ride.  That means strategy and execution matter more than ever.

    Ponder those as I take the dog out to pee.

    Tim Coan
    Tim Coan

    CEO and founder

    Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.
    October 8, 2020

    Meanwhile, Back at the Ranch

    As the election cometh, we’ve spent the last few weeks exploring a specific policy idea – how we should navigate the mesh point between the government and the market, especially in healthcare.  It is a high form of intellectual denial, allowing us to say we are addressing an important election without having to actually think about the clown show.

    Quick digression for a pubic service announcement: As the debate commission ponders rule changes to improve candidate behavior, might we suggest they consider moving the debate to Weehawken, New Jersey, on the banks of the Hudson, but instead of pistols, give the candidates and their seconds a bag of Nerf bats and let them go at it (see Hamilton v Burr, 1804).

    The role of government in healthcare is always an election topic and all COVID has done is expand that.  Now the two vying campaigns are debating not only coverage of the uninsured and drug prices and anti-trust enforcement and employer mandates, but also public health strategies and vaccine approval stances.

    Then right on cue comes news to remind us not to get too focused over here and miss what is happening over there.

    Quick digression for some random trivia: Back in the early 1900s, silent movies would insert captions, later called sub-titles, between scenes to help the audience follow along.  There were some stock phrases that theater operators could insert, things like ‘A year had passed’ or ‘Later that day.’  One such reusable caption was, ‘Meanwhile, back at the ranch,’ which then meant a literal ranch.

    Meanwhile, back at the ranch (figurative kind) …now you know where that came from. You’re welcome.

    Walmart announced last week that it has joined with Clover Health to offer a Walmart-branded Medicare Advantage (MA) PPO plan in eight Georgia counties.

    If that sounds insignificant compared to the big national policy issues, let me reframe this for you:

    • There are almost 25 million MA enrollees, a number that grows substantially every year. By comparison, just over 8 million are covered by ACA plans.
    • Clover, the tech-enabled MA player, is about to be taken public with a $3.7 billion valuation. That ain’t nothing.
    • The eight Georgia counties surround the first location of the full-service Walmart Health facilities. The company has announced that they will have 22 of these operational by the end of 2021.
    • The Walmart MA plan will have zero-dollar monthly premiums; free primary care visits, lab tests, dental exams, and annual physicals; and access to the Walmart centers, 31 hospitals and over 8,000 providers.

    Two years ago, right after Haven Healthcare was formed by Amazon, Berkshire Hathaway and JP Morgan, I noted in a talk I gave that Walmart, not Haven, would be the company most disruptive to healthcare.

    I’ll double down on that and go one further…sure, keep an eye on what the government folks want to do, but back at the ranch market players are not snipping, but acting.  None more so than the big yellow asterisk from Bentonville, AR.

    Tim Coan
    Tim Coan

    CEO and founder

    Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.