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    January 21, 2021

    Serve Yourself, Save Five Cents

    You know, it was a big day in Washington yesterday, one with a lot of firsts – and hopefully some lasts as well.  There are a lot of directions we could go reflecting on what a day like that means, so…let’s talk about the evolution of the gas station.

    I have no explanation for that level of randomness.  I am like the guy who lives next to the airport and painted ‘Welcome to Cleveland’ on the roof of his house to greet landing passengers.  Thing is, he lives in Milwaukee.

    You’ve probably heard and read enough regarding DC for one week, but meanwhile back at the day job ranch, the way we deliver care is changing rapidly and doesn’t pause every four years just because there is a new guy called POTUS.  So, let’s look at the history of the ‘filling station’ to get our thinking rolling.

    Fittingly, Mrs. Bertha Benz (yes, that Benz) got the first car from her husband and business partner Karl, which she filled up the first time at the pharmacy in Wiesloch, Germany in 1888.  The early filling stations were run by the pharmacies, an interesting foreshadowing of something, I am sure.

    (Mr. Biden, if your speech writing team needs some historical research, you know where to find me.)

    The first one in the US was a Gulf station in Pittsburgh.  Growth was explosive over the next three decades as the automobile took over the country.  There were over 230,000 US gas stations by 1940, with attendants who would pump the gas, wash the windshield, check the air and oil, and give you a little local gossip as you waited.

    Pumps improved over time, but the first big innovation was just a business model change.  In 1947, Los Angeles station owner Frank Ulrich hung a sign that said, ‘Serve yourself, save five cents. Why pay more?’  With that, the self-service movement began.

    We pause here because our readers in New Jersey and parts of Oregon have no idea what we are talking about.  ‘Self-serve gas?  What? That is a thing?’

    Two other key technology advances then took us to where we are today – the system that allowed the pump to be controlled from inside the store, and then the pay-at-the-pump credit card – no human contact required.  Filling stations were leading the way on social distancing for years.  Who says fossil fuels are archaic?

    In a short 35 years, the job of gas station attendant was invented, exploded, then was virtually eliminated.

    Now, those squatty little charging stations are starting to spring up at places like the airport and the mall.

    The process is predictable, relentless, repetitive…

    • Big, underlying demographic and societal trends drive demand.
    • Technology of all sorts gradually improves, then accumulates to make a big jump to enable something completely new.
    • Then someone has a new idea and asks, ‘Do we have to do it that way? Why not this way?’
    • Customers get new value and the game forever changes.

    This is us now.

    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.
    January 18, 2021

    Sizzle Fizzle

    Most weeks, I write the post first and then figure out the title.  But this time, knowing what we wanted to address, the title came to mind immediately as the dog and I were taking a walk over the weekend.

    Sizzle Fizzle.

    How could I not like that?

    But I then had to think about a catchy intro, an opening before I pivoted to the real content.  So, I searched for the etymology of ‘fizzle’ thinking that might prompt a clever idea.

    Fizzle (v.) From the 1530s, meaning ‘to break wind without noise.’

    Really? OK, we’ll just skip all those middle school boy ideas and cut straight to today’s subject.

    We have to talk about the failure of the Haven joint venture before it quietly fades to a footnote in history.  You remember Haven, that much ballyhooed joint venture between Amazon, Berkshire Hathaway and JPMorgan Chase that disbanded at the beginning of the year after a non-descript three-year run?

    It would be easy to Monday Morning Quarterback this deal, kick dirt on them now.  So, in the spirit of ‘accountable journalism’ (Yes, I know, that phrase is almost funny these days.  And Lord knows we don’t even pretend that we are journalists here…only a bloviating blogger with an occasional insight.), we went back through the archives to see what we actually wrote about this deal.

    In January 2018, right after the announcement of the JV, we observed that the financial markets thought it was a big deal as Wall Street pummeled many healthcare stocks that week.  Then again, Warren Buffet is the patron saint of investing, Jamie Dimon runs a really big bank, and Jeff Bezos, well, he has more money than…anyone.  Of course, this deal would be big.  Of course, other healthcare companies were dead and didn’t know it.

    We wrote about again in April of that year with skepticism and dripping sarcasm (Who? Me?  What? Never).  We mocked the JV for such ground-breaking insights as the need to align incentives, eliminate waste, empower employees, find costly and over-utilized treatments, and rethink what we spend on end-of-life care.

    Friggin’ brilliant.  Why didn’t we think of those things?

    See, I am not sarcastic.

    Three years later, they are done and selling the press release machine at a garage sale.  I guess creating real change in healthcare is hard.

    We did note in that post that while the three dancing elephants did not scare us as a group, one of them, by itself, did.  We cautioned that anyone in healthcare should be on guard against the folks from Seattle with the cardboard boxes, that cloud technology thing, and everything else ‘Bezos, the Bond Villain’ could bring to bear against many segments of the industry.

    Three years later, we’ll stand by that warning.

    Adieu, Haven. You broke wind, but made little noise, much less impact.

    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.
    January 6, 2021

    The Georgia Runoff

    We open 2021 with a tight Georgia race, one that is too close to call.

    Which is the best Georgia song – the 1925 jazz hit ‘Sweet Georgia Brown,’ popularized by the Harlem Globetrotters who adopted it as their theme song in 1952, or ‘Georgia On My Mind,’ most noted for the 1960 Ray Charles album and later designated as the official song of the Peach State in 1979?

    Yes, it is close.

    You thought I was talking about that other vote still going on in Georgia?  Oh.

    Well, yes, that other vote matters a bit more.  As we write this, one of the two Georgia Senate races remains too close to call.  About 15,000 of 4.4 million votes separate the candidates.  The Senate hangs in the balance; the power of President-elect Biden to more easily implement his agenda turns on this; well, you know the rest.

    Just because I am learning my lesson to generally focus less on Washington does not mean that Washington doesn’t matter.  It does, a lot.  If the current trends hold, what comes out of DC on all matters, but especially healthcare, will be a lot different than what we’ve seen in the past four years.

    And yet…

    Ironically, I was a guest on a podcast yesterday where I got to talk about our belief in independent physician practices.  I was asked why I was so committed to the importance of independent physician practices, why I was bullish on their future.

    The host put the ball on the tee for me and offered me the chance to hit one of my favorite rants.  That the Georgia races and the fate of Congress was hanging in the background was perfect.  That Haven, the much-ballyhooed joint venture between Amazon, Berkshire Hathaway and JPMorgan Chase, had just announced that it was folding up shop (more on this to come) was the piece de resistance.

    In short, this is what we believe, what we are all about here, what we will be talking about even more in 2021…

    Yes, healthcare is, and must be, dominated by extremely large organizations, none more so than the US government.  There are important functions that only the government can do, even if it can’t do them well.  And yes, though we don’t like them, economic dynamics mean that we need really big payers and really big health systems and really big pharmaceutical companies.  Some things just need the size and scale of elephants.  That we must deal with elephant dung is just a necessary evil.

    But, but, but…I’ll still bet on the agile, ‘right here, right now’ focus of a thousand independent physician practices, working away every day in markets all over the country.

    Washington gets the headlines, but what practices do to take care of their patients, to advance their business, to make some innovation collectively matters more.

    So regardless of how you feel about Georgia – whether you prefer Ray or Meadowlark Lemon – the real story is out in the markets.

    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.
    December 21, 2020

    Even the Sign-Off is Weird

    Normally, our last post of a year is a bit of a sentimental send off.  Knowing that anyone still reading with us in the second half of December probably opened the blog by accident, thinking it was a coupon for last minute holiday shopping, we typically have kept it short and sweet, thanking you, dear reader, for being a dear reader and wishing you the best in the final days of the year.   We hoped you imagined failing snowflakes and nostalgic music in the background as you read.  We effectively outsourced the yearend post to Hallmark.

    Then we come to the end of 2020…

    It feels it would be more appropriate to send something of a survival sticker, a twisted participation trophy.  Hey kids, everyone is a winner!

    Or a funny ‘get the heck out of here 2020 and don’t let the door hit your mask on the way out’ rant.  Though that is pretty overplayed already, isn’t it? Almost everything in 2020 feels way overdone because COVID’s bizarre time warping has made every day the same.   What, that was just your pants.  Anything we’ve thought this year, we’ve thought a million times.

    Let’s just say I am looking forward to being invited to a mask burning bonfire sometime in 2021.  Fortunately, I know plenty of rednecks, so 100% guarantee that party is going to happen.

    Or I could ride an electric bicycle to California and toss my mask collection into a composting bin made from recycled iPhones where rare worms from New Guinea will eat the masks and poop out something that will be used to fertilize an organic beet whose juice serves as the basis for a new bio-degradable hand sanitizer.

    Either way works.

    A time or two at year end, we offered some deeply insightful outlook on what to expect in healthcare over the coming year.  The only way you pondered that was if you got button-holed at dinner by your mother-in-law, with her telling you again about her bursitis. ‘Will CMS use the same RVU conversion factor telehealth visits, or create a special code?’

    So, we’ll give you all three and you pick the one you want…

    Sentimental Option: We do appreciate you and thanks for reading along.  Mostly glad that you are still upright.

    Funny Option: If after all the stupid things I have done in my life I die because I touched my face, I am going to be really mad.

    Work Option: How healthcare gets delivered has been evolving, but 2020 really blew it up and the near-term future is going to be way different.  Let’s see what Coan says about that next year.

    Have a wonderful Christmas and we’ll see you next year.  It has to be better, right?  Right?

    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.
    December 15, 2020

    Fluid Metaphors

    As regular readers know, my education and early career work was in organizational psychology with a focus at the intersection of change, culture, leadership and strategy.  That was a nice amorphous glob of fuzzy stuff that allowed me to get away with tossing out metaphors, stories and analogies as a way to sound smart without having to do real work.   Actually, that is a pretty good description of what I still do every day.

    One of my best such efforts, if I do say so myself, was in a presentation that I did back in 2013.  We were on the front end of the HITECH frenzy and were implementing EMRs and EHRs at the speed of heat.  Everyone was all twitterpated with software demos and deciding if we were going to put laptops on carts or in the exam room.

    My presentation at that conference actually included a picture of Bachmann-Turner Overdrive’s 1983 ‘You Ain’t Seen Nothing Yet’ album cover.  That was a perfect fuzzy story-teller thing to do.

    I laid out a three-phase journey that healthcare was starting.  It was nothing original on my part, just an observation from what happened in every other industry that has gone before us…which is almost everyone.  An advantage of being the laggard is having the breadcrumbs.

    First, everyone must digitize their data.  We need bits and bytes, not paper and file folders.

    Then we start to exchange and share the data across organizations.

    Finally, the industry starts to change.  Disrupters can disrupt; progress comes.

    For that middle stage, I coined (OK, I stole it from someone, but since I can’t remember who we will pretend it was my idea) the phase ‘data liquidity.’  The data would flow.  It made me sound like such a visionary, which is like a rock star without the money, drugs, groupies, or cool hair.

    Well, that was a long time ago and it is time to update the metaphor, though fortunately, we get to stay in the realm of water.

    Your new metaphor is the ‘data lake’ and clearly, it is not my idea.   Credit any number of tech wizards, or specifically Amazon, who recently announced their HealthLake offering, a part of their AWS business.

    What is a ‘data lake’ you ask?

    Here’s the not quite technical definition: a big ‘ol pile of raw data gathered together in the cloud, just waiting for someone to do something with it.

    Amazon’s clients (Cerner was one of the first to sign on) dump all sorts of data into their lake and AWS does its aggregation/standardization magic in minutes instead of weeks, getting it cleaned up and into the Fast Healthcare Interoperability Resource (FHIR) format so people can begin to use it and make sense of it.  Analysts fish in the lake, I guess.

    So, impress your friends and start throwing ‘data lake’ around in your conversations.  And know that this is how giants like Amazon and Google are going to march into our industry.

    We ain’t seen nothing yet.

    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.
    December 10, 2020

    Watch the Ground Game

    In 1991, back when everyone still flipped on CNN when something big was breaking, Storming Norman was preparing to unleash ‘Shock and Awe’ on Saddam (you have to say that with the George W accent) in Desert Storm.

    It was our first ‘televised live’ war.  We had surreal news coverage leading up to the battle, almost like the pre-game show before a Sunday NFL game.  Commentators were breaking down the strengths and weaknesses of both teams as B roll footage of fighter planes and Scud missiles played over their shoulder in the background.  Had Fan Duel been around then, the money line for General Schwarzkopf’s team would have been -950.

    Because they had a lot of time to fill before kick-off, I mean the bombing to start, best-selling author Tom Clancy was being interviewed.  He was asked about the superior US firepower from the air and sea.  I expected him to break out the telestratetor and explain how the US offense would score 50 points against the Iraqi Republican Guard defense before halftime.

    Hey, it’s a commercial…make some more nachos.

    Instead, Clancy noted the speed of the victory would depend on the boring ground game, not exploding things that made for great TV.  It was more about the effectiveness of the non-sexy stuff happening behind the scenes, things like the speed of logistics and the ability to stand up the Army’s infrastructure in the wake of the advancing troops.

    It was so boring.

    More nighttime footage of F-15s hitting Baghdad, please.  And how about some chicken wings?

    Similarly, four years ago, when all post-election healthcare hyperventilation centered on the policy fight around ObamaCare – would it be overturned? repealed? – we noted that President Trump’s appointment of Seema Verma to head CMS, while not nearly as attention-grabbing as a Supreme Court fight, would be far more impactful on the healthcare industry.

    Reflecting on the changes implemented by CMS during these years, that might have been one of the smartest things we ever wrote.  Granted, it is a short list of even remotely smart things we’ve ever said, but still.

    In honor of the Clancy principle of battle commentary, we would be advised to pay more attention to President-elect Biden’s administrative team than the more glamorous policy stories, especially if one of the two Georgia Senate seats stay in Republican hands.  If that happens, we’ll again likely have little legislative change but a lot of Executive branch actions.

    Biden’s healthcare team will be led by California Attorney General Xavier Becerra, the nominee to head the Department of Health and Human Services. Where Verma came in with an extensive history that clearly pointed to what she would do, Becerra has little healthcare experience makes it harder to project his priorities, though his thin resume means something.  Time will tell what.

    Stay focused on the ground game.  That is what will matter.

    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.