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    January 20, 2022

    Three Handy Hacks

    I am not an IT guy and don’t play one on TV, but the hotel where I stayed last night had better pillows than the Holiday Inn Express, so I have that going for me.  Fortunately, I have a bunch of smart IT people on my team and am quick to punt the heavy lifting to them.

    Invariably though, IT issues come up in strategy or business partner conversations and we non-technical executives don’t always have the luxury of phoning a pocket protector friend. ‘Fake it til you make it’ might have been the past strategy, but Elizabeth Holmes killed that idea.

    I am here to help.  From three different conversations this week alone, here are three things to keep handy when the conversation turns to big IT spending decisions.

    First, a national retail primary care practice (big money behind it…you’d know the name) let the prior CIO make decisions with his ego and he decided to build a home-grown PM and EMR.  That drove them into a cul de sac that could not scale.  Hobbled the business. He is gone and now they are staring at an expensive proposition to back out and start over.

    Lesson: Never start the planning and decision-making with IT hand-waving and hocus pocus.  Business strategy drives IT.  The smart folks here knew how big this was going to get given the money being invested.  A flying DeLorean might be cool, but large companies don’t run on gadgets.

    Second, a medium-sized practice – about two-three years on their platform – was evaluating alternatives because the docs hated the EMR, and the finance people thought the PM was trash.  They were very close to signing a replacement deal when someone was bold enough to ask how the new one would be better since they had done nothing to address the problem of having no one in the practice to help manage implementation and ongoing optimization.

    Lesson: The software may suck – many are bad.  But more often than not, the frustrations are more due to all the poor work that must be done around the software.  Writing checks to the vendors is the easy part.

    Third, a dinner discussion got deep into the weeds about providing data to physicians – ‘business intelligence’ we call it to sound intelligent about business.  Charts and graphs, self-service reporting, mobile apps, real-time or periodic data…it was a robust discussion.  Then the air went out of the room when people began to confess of building great tools that the users never used (so why are they called ‘users’ and is it ironic that we have the same word for partakers of EMRs and illicit drugs?).  Then the truth came out. ‘They still just ask someone their question.’

    Lesson: Just because the technology ‘can’ doesn’t mean the users ‘will.’  Solutions go better when the users pull than when the IT folks push.

    Three good hacks to keep handy when your IT wizards start asking for a lot of money.

    And having a good pillow helps, too.

    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 13, 2022

    Do We Need Moving Vans?

    I have long been a fan of ‘States’ part of the ‘United States of America,’ liking the idea of 50 laboratories trying to figure out this messy thing we can democracy.  (The ‘united’ part is pretty important, too, but is a bit tattered right now.  But that is for another day.)

    Sure, that means we frequently get a lot of whacky experiments coming out of these diverse labs.  At times, we need Mom and Dad to step in say, ‘No, lighting the cat on fire and throwing him in the dryer is not a good way to get him dry, no matter how much you think this is a good idea.’

    And slavery…let’s shut that one down, too.  Really bad idea.

    But generally, I support the principle. This stuff is hard, there are over 350 million of us and we are fairly diverse lot.  We need to try different approaches, especially on the tough nuts to crack.

    Healthcare is one …important, complicated, expensive, some critical work that is not economically lucrative, lot of opinions on what matters most.  Definitely in need of innovation, so sure, let’s get 50 states working on different ways to skin the cat.

    Probably shouldn’t use that metaphor given the earlier paragraph.

    Then I read about the latest single payer, government-run proposal gaining steam (again) in California and my principals start to get personal.

    Right up front, I am not a single-payer guy.  Could give you 100 reasons for my position, but here is one: I frequently fly through the Denver airport.  30 years ago, the construction cost was a few billions over budget; the current remodel looks a lot like the original deal.  Enough said.

    But I prefer learning through real life experiments and single-payer advocates have their talking points.  But California ain’t North Dakota, or even Indiana for that matter.  Stuff there tends to impact the rest of us in big, unforeseen ways (see: Kardashians, yoga pants pandemic).

    This time, however, the idea was not news from a distant land.

    Many of ALN’s clients are physician practices in California.  Most don’t like this idea. Maybe we’ll soon have a lot more clients in Nevada or Arizona.

    Then I got to the funding mechanism to pay for this.

    Business tax for ‘the privilege of doing business in the state’ (yes, the legislation actually says that): Check

    Payroll tax if you have employees there: Check

    Additional income tax on many of our employees: Check

    I still have about 93 objections, one of which is that I live in Colorado and don’t get a say on this, but then again, I don’t have to drive on the 5.

    Let’s see how this plays out, but for those of you who like to make long-term, speculative bets, you might check out taking future options on office space in Primm, the first town in Nevada on the highway from Los Angeles to Vegas.

    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, 2022

    Intergenerational Knowledge Transfer

    The holidays were great at our house because all three kids were home.  Between them and their friends that hung out with us, the house was full of the energy and perspectives that 20-somethings bring.

    There was a lot of cross-generational learning going on.  Of course, most of the information flow was one-way.

    We old folks learned about Tik Tok influencers, fashion trends, crypto, Kanye and Elon. And because mom and dad bought the wine, the lessons were a lot more fun than high school algebra.  It was awesome and though my ‘hip factor’ will fade faster than New Year’s dieting resolutions, right now it is as high as it gets.

    ‘Girl, I see your new Christmas clothes.  You dripping!’

    Don’t press.  That is all I have got.

    There was also a little sharing that flowed the other way, some history flowing downstream to inform the present.  We talked a bit about Turducken, the Muscle Shoals music influence, and inflation.

    Inflation?  Really, Dad?  If you must, at least pass the wine.

    It is notable that anyone born after about 1970 has less understanding of inflation than I have of Charli D’Amelio.  My ignorance makes me dull at parties (OK, I was already dull…it reinforces my khaki pants persona), but the other means that every person in your organization under the age of 50 really has no idea about what happens when inflation shows up and sticks around.

    Take a second to take stock of who that includes at your place?

    Oh, did you also count all of your physicians under age 50?  How about the physician owners under 50, you know…the ones who get to keep what is left once all the bills are paid? Yeah, those conversations are getting real, aren’t they?

    A key discussion topic in the business and market news is about how cost increases due to inflation are being passed on to the consumer.  But what if you are in a market where you can’t pass on cost increases in your pricing?  Like physician practices.

    Anyone had any luck calling Medicare for a 5-8% price increase because your staff wages and supply costs are skyrocketing?


    How about the call to United or Anthem?  [I know, I know…they seem to be doing just fine raising prices, whether there is inflation or not.  A topic for another day…bring the wine for that one.]

    This is a hard economic reality that will continue to dog physician practices in 2022 (so much for starting the year with a dose of rainbows and butterflies).  Costs are going to rise, and prices mostly will not.  Heck, we call it ‘reimbursement rates’ instead of ‘pricing’ as if to drive home the predicament even more.

    Here is my learning from the holidays: leaders are going to need to have some patient but pointed educational conversations with their organizations about the impacts of inflation.

    Don’t leave it to Tik Tok; a glass of wine might help.

    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 16, 2021

    Microscopes and Telescopes

    I have a suspicion that I’ve used today’s story before, but I am too lazy to go back through the archives to check and am counting on the presumptions that a) you are not logging my blog topics, and b) whatever I might have said, whenever I might have said it was not so deeply profound that you burned it into your memory.

    So yes, I am confessing to recycling an idea that probably wasn’t that memorable the first time.  Consider today’s post the fruitcake of blogs.

    Years ago, the CEO of one of my consulting clients said something that did, actually, burn into my mind.  He noted that actionable strategic insight come in the intersection when information met perspective.

    He happened to be in the beverage industry and noted that his truck drivers schlepping in and out of stores and restaurants had real-time information about what was really going on out there.  He, a long-time and very smart industry veteran, had a great grasp of the tectonic forces changing the big landscape.  It was when – and if – the two came together that good stuff could happen, that the company could make a move to gain an advantage.

    As I was contemplating today’s topic, I found myself wandering between very micro, here-and-now type stuff (one more article on COVID, vaccines, worker shortages, wage increases) and the kind of large, systemic change kind of observations that we tend to miss because they happen slowly (over half of physicians now work for hospitals or corporations, some of the fastest growing franchises in the US are in some aspect of the home care space, the forecasted decade-long nursing shortage).

    Flipping quickly between microscopes and telescopes can give you vertigo, but it is a useful exercise as we try to find some insight in the intersection of perspective and information.  This is what leaders do as they steer their organization.

    So, here is my friendly encouragement as we head into the holiday season…

    2021, like 2020 before it, had a strong bias toward here-and-now information.  News came at us in torrents as we all tried to figure out what was happening, what we knew and what was just a hypothesis. We’ve been making decisions on the fly just to keep it all right-side up.  It has been heroic, but exhausting work.

    But in truth, we have been heavy on the information inputs and need to step back a bit and mix in a good dose of perspective and see what insights can emerge.

    I was going to get you a better gift for the holidays than a piece of advice, but you know…supply chain issues, stuff was out of stock, prices were high, etc.  Besides, I did not know your size.

    I can’t say thanks enough for you reading our thoughts each week.  Hopefully, there is occasionally some value in there for you.

    Have a great holiday and we’ll see you again after we flip the calendar.

    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 9, 2021

    The Insight of Sancho

    As I was driving across the Midwest earlier this week, I could sympathize with the confusion of Don Quixote.  The awkward, dramatically out of place, windmills turning slowly on the plains do look like attacking ferocious giants.

    Quixote, the main character in Miguel de Cervantes’ classic ‘The Ingenious Gentleman Don Quixote of La Mancha,’ has sort of lost his mind – attacking the windmills being just one piece of evidence.  Fortunately, Cervantes gives him a grounded sidekick, the humble farmer Sancho Panza to serve as the voice of wisdom in the novel.

    I need Sancho’s commentary on some news this week.

    See, UnitedHealth Group and TeamHealth are locked in a pitched legal battle.

    You need no context on United, but maybe a quick refresher on TeamHealth would help.  It is a roll-up of physician practice roll-ups, now a massive 15,000 clinician entity that was acquired by Blackstone Group, an even more massive private equity fund.

    Short story is TeamHealth has filed at least ten lawsuits across the country against United for underpayment and ‘oppressive claims practices.’ [Side note: those of us who work in RCM might consider that statement a bit redundant] United has countersued, accusing TeamHealth of filing over $100 million of fraudulent claims.

    Talk about the image of fighting windmills being appropriate.

    This week, a court in Nevada awarded TeamHealth $60 million. United will appeal. The fight will continue. We’ll all stay tuned. Lawyers will get rich.

    But there is another ironic connection to Don Quixote that led me to a wry smile.

    ‘That is like the pot calling the kettle black’ is one of the great idioms of all time and its origin is generally attributed to a dialogue between Quixote and Sancho. It is a favorite euphemism because the corrective rebuttal it offers is clear and cuts straight to the point.

    And that brings us to the statement from United about why, of course, they will be appealing this unrighteous decision by the court:

    “We will be appealing this decision immediately in order to protect our customers and members from private equity-backed physician staffing companies who demand egregious and anticompetitive rates for their services and drive up the cost of care for everyone.”

    Oh, that is rich.

    I’ll save you the Google search time – United’s earnings from operations in just Q3 of this year: $5.7 billion.

    If you want to fight the fight, then fight the fight. I am sure there are arguments on both sides. But spare us the self-righteous moralizing, please.

    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 18, 2021

    Do the Hustle

    The adage in New York is, ‘you know we are in a bubble when the cab drivers start giving stock tips.’

    I think we are in the same place with crypto because twice this past week I was at a dinner where passionate crypto advocates – redundant, I know – went deep into the weeds on blockchains; the philosophical fight among crypt-heads between the Bitcoin maximalists and those who think the 13,000  current digital currencies (real number) is a good idea; and whether using crypto in the metaverse is ‘really real,’ like how two negatives make a positive in math.  And both guys are within spitting distance of their 60th birthday, not youngsters playing The Beatles looking for a revolution.

    I just have one question:  Can I use my Shiba Inu to buy some Dogecoin?

    If you have no idea what that question even means, I am guessing you still have an actual $20 bill in your wallet.  Heck, you still have a wallet.

    I really don’t want to talk about crypto (Are you disappointed or glad? Tells you how you are going to navigate the Thanksgiving conversation with Crazy Uncle Joe, who you know is going to ruin someone’s holiday with conspiracy rant that Satoshi is some dude at the CIA.), but a different type of weird exchange going on these days.

    Random pivot…

    Last week I was talking to a friend who is an anesthesiologist.  He is in a big group that covers most every hospital in town, so he is a source of intel for me about how things are going in the ORs, the outlook on elective cases, and the future of Telsa sales to orthopedic surgeons.

    A few weeks ago, he noted how staffing shortages, not COVID protocols, had some facilities working at less than full room capacity.  ORs are money machines for hospitals, so that is a problem.

    Invariably, organizations start throwing money at the issue.  I happened to get my hands on a recent email from the CEO of one of the health systems he covers.  It went to all their employees and laid out what they were doing to increase employee pay.  The grab bag of goodies and incentives had more stuff thrown in there than a piece of Biden legislation.

    The other day he shared another tidbit with an ironic twist.

    Nurses from Hospital A, part of one big health system, were missing from Hospital A, but showing up at Hospital B, part of a competing system.  Likewise, nurses from Hospital B were now working at Hospital A.

    This was not some collaborative cultural exchange between competitors, but some savvy nurses taking advantage of the moment.

    They were reducing their hours at their primary employer and working as a traveling nurse at the other place, just a couple miles down the road.  Both hospitals are paying a steep premium for temporary travelers, but the net capacity added to the system was zero, if not a tad negative.

    How’s that for a side hustle?

    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.