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August 20, 2020

We Interrupt for a Longer Vista

As we have discussed here a time or two of late, one of the casualties of 2020 is the loss of the normal sense of time.

What day of the week is it?  [One or two days past when your blog is due.]

How long have we been in this thing? [Don’t change the subject. Where is your blog post?]

Is it time for dinner?  [No blog, no dinner.]

Fine, voice in my head, fine.  I am writing now, I promise.

Today we diverge from all things 2020 and look at a longer-term issue.

A recent study published in the Annals of Internal Medicine examined 142 million primary care visits from a large national commercial payer.  The data was from 2008-2016 and was for adults ages 18-64 years.  No kiddos, no Medicare.

It found some big trends that are troubling for primary care providers.

Visits to PCPs declined by 24% over the period, from 170 per year per 100 members down to 134.  In 2008, 38% of folks had no PCP visit in a given year.  That rose to 46% in 2016.

The drivers were what you might imagine…lower acuity visits were way down (almost half); visits by young people were off 28%; visits by those without a chronic condition dropped 26%; visits in low income areas were down 31%.

Young, relatively healthy, relatively poor folks aren’t going to see their doctor as much.  By a wide margin.

But maybe it was just the ‘their doctor’ part that is troubling because at the same time visits to alternative primary care venues like urgent care clinics increased by almost 50%.

In the ‘just in time’ world of the ubiquitous Amazon truck, in the ‘I want it fast’ world of 15 second TikTok videos, primary care seems to be viewed the same way by the next generation.

Throw in the news that at least one health plan is now including free, unlimited telehealth visits for their members and you see a big, long-term trend that does not bode well for primary care providers.

That the study found visits to specialists to be stable during the same time frame is noteworthy.  It was not physicians in general that saw a net outflow, just primary care providers.

This all raises two slightly rude, slightly inappropriate questions from me…

This was the timeframe when tons of PCPs left private practice to become health system employed providers.  Is that a factor in this trend at all?  Just asking.

Also, this was the time of great reform, of accountable care, of the elevation of primary care on many fronts.  So, after all this push, why does the consumer seem to be voting the opposite direction with their behavior?  Again, just asking.

Now can I go get a snack?

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.
August 12, 2020

Me and Elmer Fudd

I am suffering a pandemic.

Not COVID as I assume you knew about that one.

I mean the rabbits.

The friggin rabbits are destroying my yard.

Friggin is an acceptable form of profanity for good ol’ church going boys where I was raised, in the same vein as ‘dagnabit’ and ‘gosh darn it.’  Normally I reserve this pejorative adjective for Apple or Comcast (especially Comcast), but I have now added the rabbits to my cussing list.

We’ve always had a rabbit problem but this year it has escalated to pandemic proportions.  We can’t blame this on a Chinese wet market.  No, fault lies squarely with our little city.

Our house backs up to some wetlands with a walking trail through it.  It is great.

The Village, as we like to call ourselves as a way to pretend we are not just another non-descript Denver suburb, has a lot of money thanks to all of the tax-paying businesses along our commercial corridor.  We like our parks, so the area behind us is being converted from wild wetlands to improve wetlands.  It will be more great, and we can’t wait, but wait we must because the construction has been interminably long.  Which gets me to the coyotes…

Their ‘hood jacked up by dozers and backhoes, like other COVID nomads, they moved into an Airbnb and are riding this out somewhere else.  Which gets me to the rabbits…

Absent the coyotes, the rabbits are doing what rabbits do – breed, have babies, come sit all day and eat grass, leave a nice large pile of acidic pellets.

Thus, the battle is on.

Yes, we have a dog, but he’d have to work hard to catch a turtle.  He eats the pellets but is otherwise useless in this fight.

Were my redneck brothers (yes, there are multiple) reading along, they would be puzzled by my problem and wonder aloud when .22 rifles were banned in Colorado.

My neighbor just runs his sprinkler non-stop to see if that will run them off.

In a completely laughable act, I threw a shoe at a rabbit the other day.  Futile, but it felt good.

Since I can’t torture the rabbits, let’s at least torture the analogy.

Similarly, COVID has disrupted the natural flow of healthcare and we’re going to have consequences a lot worse than dead grass.  In particular, patients with chronic diseases or at risk of getting them are not getting the care they need.

If you know anything about the distribution of healthcare spending, you know that people with chronic diseases drive a disproportional share of the costs.  These bills will come due and when they do, they will be significant.

So, a strategic question for you to ponder: Is there something you should be doing to reach out to these patients to get them in to see you?  It will be good for their long-term health and your short-term finances.

Now back to my wascally wabbits.

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.
August 6, 2020

The Walking Dead

One of the many weird things about COVID is the loss of the sense of time.  If your Monday through Friday work attire looks a lot like what you wear to mow the lawn on Saturday, it is hard to remember what day of the week it is.

If bathing is now somewhat random, well, just keep that news to yourself.

It is not only the days of the week that get blurry, but the passage of time is as warped as a Dali clock.   Have we really only been in this thing for five months?  It seems like five years.

Way back in March, back when the government showed up at the scene and started spraying money like water on a fire, our sense of future time was best characterized as ‘temporary.’  Survive a couple of months, get to Easter, or at worst, the 4th of July, and then get back to the election or football or whatever your late summer pleasures.


Two of the primary injections aimed at small business in general and healthcare providers specifically – the PPP loan/grants and the advance Medicare payments – served their purpose to avert immediate disaster. But both were clearly conceptualized in the hopeful framework of the day that this all was temporary.


The PPP money is running out and those Medicare advance payments were a payday advance. Without some additional Congressional action, CMS will soon begin recouping those payments by applying the amount due against new claims.  See here.

Let’s translate that: If you took the advance payments them the claims you are about to submit are not going to get paid but will instead be applied to your ‘loan.’

Now to translate the translation: If you spent that money to survive the spring and summer, which was the plan, and if you are fairly dependent on Medicare, well dang, your cash planning is again about to get pretty binding.

I am not throwing stones at what the government did – we really had no choice – but temporary solutions for what is turning out to be a much longer-term problem leads to one unavoidable conclusion:


Not what you thought I was going to say?

It is sad, but it is true.  Many companies are already gone and there are many more that are dead and just haven’t fallen over yet, but soon will.  The math is inevitable.  Healthcare and physician practices are not immune to the economic gravity.

Mr. Sunshine today, huh?

First, I hope your practice is not a zombie.  Because unlike in the movies, they really are dead.

Second, and I realize I sound like a greedy pig in saying this, but when companies finally give up the ghost and keel over, there is opportunity for someone.  So, if you are not among the walking dead, be ready to move quickly into the soon to be vacated space because others will be.

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.
July 21, 2020

Dealing at the Deadline

I confess that I enjoy the distractions from real life that sports bring, but COVID has me a bit conflicted.  If ever we needed some mindless stuff to talk about that aren’t so heavy, it is now.  Loving or hating the Yankees or Cowboys or Lakers would be a relief.

Then again, it is sports we are talking about, not people dying; or caregivers who sleep in the basement to protect their families from the risks of their job; or the one in five people who are unemployed; or the 100,000 small businesses that may close forever.

But these are people and businesses and universities, too.

It makes my head hurt trying to decide if I am for or against.

That said, they are trying to make it happen and since they are, there is an analogy I want to steal.

In major league baseball, the trade deadline generally comes around late July, after they have played about four months.  Teams that have a chance of making the playoff are ‘buyers;’ those who are out of it are ‘sellers.’

What that means is that buyers trade the future – young prospects – to the sellers for players in their prime who can help them win now. General managers look hard at their team and decide if they should be buyers or sellers.  In this COVID-shortened season they will, virus willing, play only a third of the normal games, so the trade deadline comes quickly.  The decision to trade or hold will be even trickier, but no less important.

COVID may have shortened the baseball season, but the pandemic season just seems to be lengthening day by day.  Little did we know that ‘by Easter’ meant Easter 2021.  Physician practices, like every other business, may not be able to count on the quick return to normal strategy.  As such, it may be time to lean back in your chair and ask, ‘Am I good with our situation, our prospects, our chances…or should we be buyers or sellers?’

In the recent physician survey published by McKinsey and Company that we referenced a couple of weeks ago, half of the independent physicians were more likely to consider an employment option than they were pre-COVID.  I get it.  Getting to a safe harbor now might cause you to tolerate more employment hassles than you would have in the past, though it is worth noting that being employed by a health system did not, is not, may not provide as much security as you might have imagined six months ago.

Conversely, only one in four was more likely to think about partnering or selling now.

Let me encourage you to consider that option a little more.  Maybe it is time to be a buyer, or a seller, or both.  Maybe this is better than standing pat or just throwing in the towel and taking a J-O-B.

Times like can lead to some moves that create a much better future scenario.

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.
July 17, 2020

False Summits

My home state of Colorado boasts of 53 14ers, mountain peaks that rise above 14,000 feet.  Or maybe it is 58 if you don’t get too technical about how deep the saddle must be between peaks if you want to count them as two instead of one. If you schlepped up there and hit both peaks, count however you want.

For many, collecting 14ers is a life-life pursuit, a badge of honor. My buddy is on a similar mission, trying to see how many of our state’s craft beers he can drink.  Some people do both.

Rookie climbers experience the psychological letdown of ‘false summits,’ that belief that you are almost there, only to get to the top of a peak you’ve been eyeing and discover that there is more mountain – sometimes a lot more – left hiding behind it.

You are tired, your friends who told you this would be fun forgot to mention the blisters or how heavy a backpack starts to feel after a while, but you see your goal and trudge on.  Then the goal is a mirage that mocks you as the trail continues to ascend to the sky.  The real summit is still ahead, or is that another fake one?

I do have one piece of advice for first time hikers from the flatlands, wanting to come to Colorado and bag a 14er for bragging rights back home – take on Mt. Evans.  You can drive to the top and the parking lot is about 100 feet from the summit.  You don’t have to give all the details when you get back.

But like the hiking, the pandemic come with false summits and those can bring disappointment that must be managed, or it turns into discouragement.  That is a battle some of us are facing right now.

Like tired kids in the back seat during a cross-country trip, some are starting to whine, ‘Are we there yet?  When will this be over?  When will things get back to normal?’

It is a fair question, but repeatedly setting false milestones in this time can do more than lead to disappointment – it also offers a way out from having to face some really hard questions.

If there is a summit, a real one – this one or the next one, that implies, like hiking, that we eventually get to the top, take a selfie, turn around, head down, then resume our beer quest.

But COVID will not work that way, at least not entirely.  Some things are changed forever.

So, time for a hard question…is your hope for a return to normal just a way to avoid facing some hard decisions that you need to make to put your practice in position to be healthy in the future?

Sit atop a mountain peak (or just have a craft beer) and ponder.

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.
July 9, 2020

So Why Do We Still Have Car Crashes?

How good of a driver are you?  Better than average? Excellent?

Of course you are.

I know what you said because most Americans rate themselves as ‘excellent’ or ‘very good’ drivers.

We’re good at driving; math…not so much.  Like Lake Wobegon, 90% of the children are above average.

Psychologists could cite us many examples of our overconfidence, but the driver rating serves the purpose here because it is so universal.  Even though we admit to driving too fast, driving while tired or even intoxicated, and occasionally texting behind the wheel, most of us still think we’re excellent, especially if we are husbands.

And the accident…never our fault.

I bring this up to continue this line of thinking about our thinking when it comes to navigating our businesses through the restart.  Not only are we stumbling blindly down the hill with incomplete data and no friggin’ idea what the fall will bring, much less the next five years, but our thinking is as flawed as our information.

We have cognitive biases all over the place that screw up our thinking, but Daniel Kahneman, the best-selling author who introduced these ideas to the world at large, called overconfidence ‘the mother of all biases.’

We are infected and wearing a mask won’t help.

A recent McKinsey & Company survey found that most physicians believe that a year from now volume will be back to, if not slightly higher than, pre-COVID levels.

As someone whose business depends on the patient volume of our clients, that is awesome news.  As someone genetically predisposed to optimism, I’m ready to sign up for the scenario that says, ‘Hey, this is healthcare…we are doctors…this is life and health we are talking about…we’re special…we’ll bounce back first.’

For affirmation, another recent report by the very same smart folks at McKinsey agrees, showing ‘Healthcare and Social Assistance’ as the segment of small businesses that will return to pre-COVID levels the fastest.


But what if we are being a tad optimistic?  What if there is just enough fear, just enough friction, just enough governmental brake-tapping to drop things permanently to 90% of past levels?  How about 80%?

Not to be rude, but if large numbers of people having a heart attack during quarantine decided not to go to the ER, what makes us think there will be no long-term change in patient behavior?  Some stuff can wait, for some stuff just rub some dirt on it, some can be managed through that free telemedicine visit offered by my health plan.

There is one other interesting finding from the physician survey.  Pre-COVID about half of the practices had a month or more of cash on hand.  The other half either had less (23%) or had no idea how much they had (26%).  Now, only 30% have more than a month’s worth (probably inflated by PPP money) on hand.

So, we are very positive in our outlook even though our indicators are flashing a lot of risk.

Yes, we still have car crashes.

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.