Advanced practice providers can solve plenty of capacity challenges and they're critical to implementing population health strategies. But the secret to success is not having them on staff – it's in their management.
This article appears in the September issue of HealthLeaders magazine.
Hospitals and health systems are under unprecedented pressure to remove waste from healthcare, whether it stems from using too many expensive services or having high patient readmissions or poor quality. There are dozens of other bogeys out there that waste resources, but much of the waste lies in ineffective management and inconsistent approaches to care.
As a concept, team-based care has emerged as a critical element for removing waste and other inefficiencies in healthcare. It's essential for health systems that intend to deflect the effect of declining reimbursements and seek to improve patient care and quality—and meanwhile grow volumes. An important aspect of these efforts resides in the advanced practice provider group, otherwise known as nurse practitioners and physician assistants.
While most hospitals and health systems employ advanced practice providers to one degree or another, the organizations often have not invested in management of the group as a whole. Instead, many times, management of advanced practice providers is left to the individual physicians with whom they work.
That's where many problems can crop up, says James Leonard, MD, president and CEO of Urbana, Ill.–based Carle Foundation Hospital, who, in his 25-year career as both a family practice physician and an administrator, has had plenty of experience with the APP provider class.
"As we came together three years ago with Carle Clinic, we have tried to make strides of inclusion—bringing people together so that there's really one bowling shirt we all wear," he says. "This group is really involved in a new day in providing care, so they need a place at the table. This is incredibly important."
Making progress
Carle Foundation Hospital, a 345-staffed-bed regional care hospital, acquired Carle Clinic Association (the formerly independent 350-physician Carle Clinic) three years ago, and since then one of the key cultural transformations has been the management of APPs.
Until about 18 months ago, when Carle implemented the new management philosophy, training oversight and activities of APPs were based on individual physician preferences, leading to significant variation in quality and productivity. With no consistent oversight, as a group, APPs really had no voice, and compensation varied significantly within specialties and across the organization.
As part of that culture, Leonard recognized individual physician management of APPs can create inconsistency in relationships, oversight, and how things are done from one physician or division to the next.
"Those inconsistencies can be helpful," he says. "They're part of the art of medicine, but often they are not advantageous and create risk and inefficiencies."
Thanks to health insurance exchanges and Medicaid expansion, which will happen by 2014, many health systems are about to have a lot more patients to deal with, and a lot of the organizations are unprepared to meet those volumes. Count Carle among that group, says John Snyder, the system's chief operating officer, who, with Chief Nursing Officer Pamela Bigler, was charged with implementing a new management philosophy with APPs.
"Carle Clinic was a for-profit physician group. Primary care was a loser and wasn't high on their list of recruitment," says Snyder. "You can't blame them, given their business model, but that meant everyone was doing their own thing and it was a nightmare to figure out where to fit a patient in."
So access, already a challenge prior to the expected volume of newly insured patients, was seen as becoming a major problem. For example, waits for patients to see an OB-GYN ranged up to eight weeks, and many patients trying to access primary care just went to the emergency room in frustration with the inability to arrange a timely appointment.
In addition, individual physician management, says Bigler, led to inconsistent quality, compensation discrepancies, performance incentives that didn't line up with organizational goals, and inconsistent scope, among other issues, from reporting structure to inconsistent billing practices. And with plans to hire in the next few years approximately 70 physicians, with a significant number in primary care, and up to 50 APPs, the problem at Carle could have gotten worse without reform.
Uncommon approach
Josh Bennett, MD, a family practitioner by training, is a principal with Premier Inc., the Charlotte, N.C.–based member-owned group purchasing and consulting organization. He says Carle's approach is not yet common—he sees how it could work, but adds there are potential land mines in the shift because it puts APPs technically in the position of serving two masters, the individual physician with whom they work, and the health system.
"Some friction could take place there, but if you've done a good job of screening it could be very effective," he says. "It is an interesting concept because it takes some of the pressure off physicians on a day-to-day basis."
While he doesn't have much experience with Carle's approach, Bennett says the healthcare system nationally has a strong need for APPs, and better management of them.
"We're going to need them in the new scheme of things to see a lot of the walking well," he says. "They'll see those who need to be seen for some minor complaints or chronic diseases that are stable and allow the physicians to see the highly complex cases."
Regardless, even though the dominant model is still composed of a lot of one-on-one oversight, Bennett says the physician still needs input on the interview side.
"Once they get hired, regardless of who's managing, that means sitting down on day one on what they can and can't do and setting up some guidelines right off the bat. As conflicts arise, I advise physicians not to be confrontational but also not uncomfortable advising the midlevel as opposed to not saying anything, which is what physicians sometimes do."
Doing their homework
Literature on this kind of management change is scarce, Bigler says, so Carle did a nationwide peer survey with 12 organizations to gain a deeper understanding of best practices with APPs, she says.
"Once you do that and talk to other organizations who work with as many APPs as we did, you don't have to re-create the wheel, and you can go forward knowing others have done it successfully," says Snyder.
High-performing organizations, Bigler says, had clearly defined and standardized APP roles. For instance, were they a practice extender, collaborative provider, or independent provider? They also had to develop governance structures and a centralized forum for practices and policies.
"We had to develop governance structures, because you don't want some of your most valuable people wondering where they fit in," she says.
At Carle, as with other systems, APPs are used not just in primary care, but all over: in surgery, rounding, screenings, consults, acute care, ED, convenient care, and case management, for example.
"There's a lot they can do, and we needed to push those roles to a coordinated team delivery model," she says.
To implement best practices they learned, Snyder says they were helped by a "strong dyad medical director VP structure" with physician leadership fully integrated into operations.
"In other words, we have docs leading other docs," he says. "When you have that dynamic you can be effective."
Holes in evidence-based medicine
Leonard, Carle's president and CEO, is comfortable with the change because to him it doesn't mean that physicians don't have input into management of their APPs, it just means they do it as a group, and not individually. And management of the group as a whole doesn't mean necessarily always following treatment protocols and evidence-based medicine guidelines that may not fit a particular patient's diagnosis.
Yet he did face some resistance.
"What I heard is that 'If it's working for me, why do we want to change it?' " he says of discussions with fellow physicians who were hesitant to give up some control in managing their APPs. "I just had conversations with them and we agreed that in the long run it's advantageous to all of us because healthcare is more and more of a team sport."
The other thing to realize if you are considering a similar management change, says Leonard, is that not everything is contained in policy, explaining further that he makes the case with his physicians that the change is not an attempt to "control the world, only some parameters and consistency," he says.
The access issue is even more compelling. "We're preparing for bringing a large group of people into our system as patients and as providers, and if you don't have established direction and culture, [then] you have more chaos than you expect to have."
Above all, he says, communication—in some cases overcommunication—is the best approach when implementing such a big change, no matter whether it's in compensation, management of APPs, or integrating a merger.
"The most difficult thing for CEOs is that your good intentions aren't always clear in this kind of project," he says. "Be consistent and really transparent about what you're trying to do. The APP people are undergoing tremendous change in expectations in healthcare. Roles, scope of practice, compensation, and benefits are all on a wild ride, so you have to recognize that in the middle of such change, that is disconcerting to a lot of people."
Reprint HLR0913-5
This article appears in the September issue of HealthLeaders magazine.
If you're in charge of running a hospital or health system, managing the passive risk of payment reform is a given. To push your organization ahead, you'll need to take on the bigger risk that comes from being truly innovative.
For many hospital and health system chief executives, the embodiment of taking risk as it pertains to their organizations means talking about the new payment paradigm. This is the one under which government and commercial payers work with health systems to derive better value from their purchase of healthcare services. In other words, value-based care.
As opposed to fee-for-service payment, value-based payment puts the hospital, health system, or physician "at risk" for lower payment depending on a variety of metrics that attempt to measure the value of the patient outcome.
This is a very inexact science at this time, and that's one reason it's taking so long to figure out ways to incorporate risk into payment methodologies for commercial and government payers alike. Incidentally, despite all the fretting about risk-based payment, fee-for-service is still the dominant payment mechanism for the vast majority of hospitals and health systems.
Some regions are seeing the evolution in payment models more quickly than others, but the key is that it's changing very slowly. Of course any health system that incorporates a health plan into its business entities is already familiar with the gaps in information and analytical tools that would truly allow them to place a value on a health provider's services from a quality of care or efficiency standpoint.
Another, perhaps more productive way to take risk involves the risk that's inherent in any innovation. The risk of building a standalone emergency department, is one example. The risk of employing and managing care coordinators to help keep patients out of the hospital, is another.
In other words, this is a type of risk you'd take in trying to grow any other business, but a type of risk with which much of healthcare is unfamiliar.
To use a gambling analogy, providers of healthcare services are not used to betting on the come in this fashion. Instead, for the past several decades, the customer—whether you define the customer as the government, other payers, employers, or individuals—have paid the freight of the risk-taking, which, predictably, has proven unsustainable in the long term.
Think of the last time you green lighted a capital-intensive project like a heart or cancer center. Did you already know that the fees it would generate would make it successful, or was there a big element of uncertainty? The answer, in many cases, is that it was a no-brainer.
But some organizations are embracing these opportunities to innovate where success is far from guaranteed, and that fact was made apparent to me at a recent Roundtable discussion we hosted here in Nashville (for the November issue of HealthLeaders magazine). In contrast to risk-based payment, rather than worrying about what is being done to you by others, isn't it more exciting and interesting to figure out a better way yourself?
That's the kind of risk I'm most interested in discussing with CEOs, such as my recent conversation with a CEO who told me he's seen great success in getting people treated in the right place at the right time through their new off-site and standalone emergency room. It was an expensive investment, and risky, but it paid off.
Never mind that he's gotten high-cost patients out of the hospital's main ER, and never mind that he feels like he and his team are better incorporating their mission of providing the right type of care to the community. He has the satisfaction of actually doing something rather than having something done to him. The very real feeling of powerlessness in facing powerful outside forces is pervasive in healthcare, so I try to seek out those who don't use that as an excuse not to execute.
Another one of our guests spent a lot of our time together insisting that "I'm not a healthcare guy, but…"Almost always, his "but" was followed by a description of some innovative project his hospital is undertaking (a hospital which was on the verge of bankruptcy and closure just four or five years ago).
The risks he's taking include a variety of diverse business opportunities that will keep this community hospital at the center of where the community seeks care, and not just acute care. Part of his vision includes the hospital as a landlord.
By developing close contractual relationships with those who provide care outside the hospital's walls, from primary care to skilled nursing, he's not only strengthening his organization's position of leadership in the community, he's providing a physical location for smaller organizations to collaborate with each other and his hospital.
That's the kind of vision that will save many hospitals that, no question, are facing difficult financial times ahead. They're seeing shrinking reimbursements and regulatory burdens expand as organizations try to get a handle on waste and quality problems that still plague healthcare to an unconscionable degree.
And he thinks that vision will also keep it independent.
Uncertainty about the evolution of healthcare payment is well-founded. Just don't let it get in the way of what you and your team can do to adapt, and even thrive. You have to take risks. Real risks.
As competition for volume increases among hospitals and health systems, employers are seeking high-value partners.
This article appears in the July/August issue of HealthLeaders magazine.
Mercy, the nation's sixth-largest Catholic health system, is by all accounts a thriving and innovative 32-hospital health system that is based in Chesterfield, Mo., and operates in four states. But Alan Scarrow, MD, is under no illusions. It will have to compete hard to remain so.
The neurosurgeon and president of Mercy Springfield (Mo.) Communities, which includes Mercy Hospital Springfield, is competing with dozens of hospitals and health systems, not just locally but across the country and beyond over what he and many others see as a shrinking revenue pie. Innovation and transparency, he says, are the key tools in that competition. Better defining and distinguishing itself through value will be the key differentiator.
"We're the high-value folks now, but there will be more competition in this space," he says.
Scarrow was integral in involving Mercy in local demonstrations about the value the organization could provide large employers, thanks to reams of data about outcomes and utilization compared to other healthcare institutions.
Further, he says, Mercy demonstrated a commitment to giving employers what they want—a measure of cost certainty when it comes to expensive procedures. Mercy's effort, which started locally in Springfield nearly eight years ago, culminated late last year in a medical destination agreement with Wal-Mart Stores Inc., which employs 1.4 million associates in the United States.
Walmart's Centers of Excellence program calls for the retail giant to send employees who may need spine, heart, and transplant care to Mercy Springfield, which has 866 acute licensed beds and posted a 2011 total operating revenue of $866 million. Along with Cleveland Clinic, Geisinger Medical Center, Mayo Clinic, Virginia Mason Medical Center, and Scott & White Healthcare, Mercy has agreed to treat Walmart employees who may need these procedures for a single price for the entire episode of care.
Patients still have a choice, but the carrots Walmart and other employers are starting to dangle in front of them are alluring. In return for choosing one of these organizations for their care, Walmart employees are subject to no out-of-pocket healthcare costs for the care and the procedures that result from their condition.
Scarrow sees the program as a way for progressive healthcare organizations to drive patients to their organizations in an era where many in the industry expect reduced volume. Indeed, volumes are soft nationwide, especially in some of the most expensive, and therefore most profitable, services hospitals and health systems offer. Walmart's Centers of Excellence program, Scarrow says, is only the beginning of a move toward price and quality transparency. Hospitals and health systems can either embrace that demand or slowly wither.
What is value?
Proxies for value are often price and quality, but value can be difficult to discover where prices are obscured by the third-party payer system, among many other factors peculiar to healthcare. Quality often can be determined only by measuring factors that aren't clear until long after service is rendered, if ever. But science and intelligence based on data is getting better.
"We are on the path of understanding how information needs to be presented to affect how people make decisions," says Anne-Marie Audet, MD, vice president for health system quality and efficiency at the Commonwealth Fund, a New York City–based private foundation that focuses on access and quality. On the individual consumer level, she says, much of the work is currently in behavioral economics, noting the fact that some healthcare consumers perceive that higher prices indicate higher quality. There is no correlation, but because of this belief, it's "really important how we present data."
On the employer side, things are progressing much more rapidly, she says, but even though employers have much more sophisticated ways of measuring value, there is still a concern about who is determining value: namely, an entity that has a vested interest in cost savings.
"Employers can play a big role in directing consumers to high value," she says. "But now of course we have the exchanges that will be coming up, and people will have to select their coverage and providers, and that's another big opportunity to steer to high value."
Robert Pryor, MD, MBA, president and CEO of Scott & White Healthcare in Temple, Texas, which is one of the approved facilities in the Walmart program, says linking pricing to value can be misleading because, especially in healthcare, cost and quality are not always linked. He also notes that pricing is based on a complex set of factors that may include where a procedure is performed, the number of similar procedures an organization performs, and variations with the pricing of products necessary for a particular intervention.
Getting to high-value care, at least for Scott & White—a nonprofit healthcare system that includes 12 acute care hospitals, 140 clinics, and a health plan—is dependent more on producing a quality outcome than lower prices.
"We find through the proper application of medical judgment and skill, we are able to provide the best solution to the patient's medical need and avoid unnecessary or inappropriate procedures that can increase cost … hence, right care, right place, right time," he says.
And volume is a key factor in that strategy.
"Our agreement with Walmart enables us to treat patients from outside Scott & White's normal catchment area," he says.
He adds that the organization's involvement in the Walmart plan has attracted interest from multiple employer groups but has had little impact on traditional local insurer negotiations. He sees this type of "shopping" growing in importance strategically for hospitals and health systems—more on the employer level than with individual patients.
Though it's also in the Walmart program, Cleveland Clinic has also made strides with a handful of other national employers looking for high quality, high volumes, and a package price for care.
"Boeing, Walmart, and Lowe's are all significant clients, but we have many others in the pipeline," says Michael McMillan, executive director of market and network services with Cleveland Clinic, a nonprofit academic medical center with 4,450 beds systemwide. "We have good relationships with other employers for second-opinion services."
And Cleveland Clinic sees such value propositions as a key growth area.
"We haven't reached capacity," he says. "We can serve a significant chunk of this employer population."
Only the beginning
The Centers of Excellence program grew out of a similar program that Walmart has conducted for organ transplants for about a decade. In nearly all scenarios involving group health benefits, a small number of people account for most of the healthcare costs incurred.
Tom Emerick, a vice president for global benefits for Walmart who left six years ago to consult with employer clients that wanted to develop similar transplant programs, says that in many employer health plans, between 6% and 7% of employees generate 80% of the costs. If the employer could get a handle on increasing the value of the high-dollar procedures its employees needed, that could make a drastic difference in its annual outlays for health coverage—never mind the benefits to patients who were receiving unnecessary transplant surgery.
In studying transplants, Emerick and Walmart discovered that there was wide variation on utilization around transplants—certainly one of the riskiest and most expensive procedures known to healthcare.
In 1996, Walmart chose Mayo as its partner for transplants.
The eye-opening statistic, he says, is that they found that a significant number of patients, 40%, after being examined by Mayo physicians, did not need transplants. That data has held firm as he's helped set up similar programs in recent years for other employers.
"Over those years, four in 10 people who were told they needed a transplant clearly did not need one," Emerick says. "It's astonishing that it's happening at that rate. And some of these transplants are utterly inappropriate. For some of my clients, it's as much as 60%."
Walmart's spine and heart programs are based on the transplant Centers of Excellence program—with a wider choice of health systems. Emerick says Walmart, after seeing the success of the transplant program, clearly set out to discover what other high-cost healthcare diagnoses were driving up their healthcare costs. Beginning in 2005, Scarrow and his colleagues were seeking that answer as well with an idea that they could compete with other providers on value.
"We knew the high cost of spine care, and we would go out to local businesses to talk about value and utilization using our own outcomes data," says Scarrow.
What Mercy Springfield had, they soon realized, was a resource that many other healthcare organizations lacked, because the financial payoff for outcomes data in 2005 was uncertain.
"We had been doing outcomes for surgery patients since 2005," Scarrow says. "But no one gets paid more for outcomes at the 90th percentile than at the 50th. As a result, most hospitals and health systems have not invested a lot in outcomes. We had that data."
Mercy made the investment in data because it thought local large employers would be interested. The data was compelling. Scarrow says Mercy surgeons (all employed) noticed how widely the costs for spine treatment varied, and it wasn't based on severity of illness.
"There is a twentyfold difference in lumbar spine costs," he says, "but it's impossible that there is a twentyfold difference in incidence of disease between the highest and lowest utilization area. The question we were trying to answer was what level of utilization is reasonable?"
Overutilization, while especially prevalent in spine care, is an industrywide problem, says Scarrow, and a key factor in healthcare costs that continue to outstrip the rate of inflation for the rest of the economy. He says to provide cost-effective treatment and prevent overutilization, a hospital or health system has to combine three factors: highly ethical care, high-quality outcomes, and a reasonable price. Until recently, most hospitals and physicians haven't been interested in cutting utilization because it has the pernicious effect of cutting their reimbursement. But employers and payers are getting smart about this problem, and hospitals and health systems that can effectively manage utilization have a huge head start on their peers.
"There is an ethical overlay to this," Scarrow says, regarding surgical intervention, especially in heart and spine care. "You can justify a number of things to do interventionally, but what is really evidence-based for that patient?"
Big savings
In Walmart's Centers of Excellence program, Mercy has consulted on 39 patients. Of those, physicians told 17 to not even bother getting on a plane because they would recommend against surgery. Some 22 have traveled to Springfield. Of those, Mercy physicians have performed spine surgery on 11 and told another 11 that surgery was not their best solution. Previously, all 39 would have probably ended up with spine surgery, which is risky to begin with, and which may have actually harmed them.
"The best hospitals should be the ones who put themselves out of business, right?" says Scarrow, half-jokingly, referring to the revenue Mercy could have earned from this group of patients. "We ran into this same thing with the Medicare demonstration project, managing patients with congestive heart failure and diabetes in a proactive way to keep them out of the hospital. We were successful. Our reward was we made less money."
Yet that fact does not deter Mercy's leaders from pursuing such affiliations with employers and payers. Mercy pioneered value-based deals with local employers such as Bass Pro Shops and O'Reilly Auto Parts. And though it can lead to second-guessing as the health system turns away patients for whom it could easily perform expensive procedures of uncertain benefit, Scarrow puts it in the context of the big picture.
"We're $16.5 trillion in debt already, and the largest demographic group in history [the Baby Boom generation] is coming into their prime consuming years as they hit Medicare. There's no way we can sustain this, so we have to find better answers."
There is a silver lining. As a top performer in quality and evidence-based medicine, Mercy gets additional patient volume for its efforts. Scarrow is hopeful that will continue and that Mercy will remain a leader, because "it's about ethics, quality, and price, and when you allow the market to sort that problem out and decide winners and losers, you'll get a more efficient solution."
But he's under no illusions about employers. They're doing this to save as well as improve care.
"If we don't have these things in spades, they will go to someone else. They'll treat us like any other vendor. The market is choosing who does this well, and that is where patients will gravitate."
He says as a nonprofit health system, Mercy Springfield has an emergency room that sees 100,000 patients annually, and it treats all payers.
"The price we pay for that is that we have to make money off the commercially insured to subsidize," he says. "For-profits getting into medical destination could undercut our price significantly. That is one potential problem we will have to solve somehow if we are going to stay in this line of business."
Reprint HLR070813-5
This article appears in the July/August issue of HealthLeaders magazine.
Years ago, with his office in chaos, Peter Anderson, MD, looked for a better way to practice primary care. He found it by developing "family team care," a model that looks a lot like what we call today the patient centered medical home.
Peter Anderson, MD, would have quit medicine in 2002 if he'd had an alternative.
Run ragged by his role as a primary care physician who served as a "gatekeeper" to his patients, frustrated by having invested early in electronic medical records yet working longer and harder, and getting poorer as he added staffing to comply with administrative responsibilities foisted upon him by payers, he was depressed and looking for an exit strategy.
"When I went on an EMR, that cut my productivity by 35%, and I was paying $2,500 a month for that privilege," he says. "I knew EMRs were the future, and I didn't go to medical school to get creamed by a machine, but that's what happened."
Instead of practicing efficient and effective healthcare, Anderson says his goal became "seeing as many patients as I could without making a mistake."
Even that was not enough. His office was in chaos, two of his nurses were openly threatening to quit, and his patients were dissatisfied. Besides that, he didn't know them.
"I had to focus more attention on the EMR than on the patient and lost patient interaction," he says. "That loss of connection was disheartening, but you lived and died by that EMR chart."
Far from a technology Luddite, Anderson was adept at using an EMR Hilton Family Practice way back in 1998 as part of the Riverside Medical group, a network of more than 80 practice locations and 325 board certified physicians and other providers in Newport News, VA.
But the EMR in his practice was adding workload without any increase in patient throughput. He had a Eureka moment one night while reviewing charts at 3 a.m. He realized it wasn't technology and the payer systems that were dragging him down—at least not fully. It was his lack of foresight in changing his practice's processes. Anderson, like many of his colleagues, knew there had to be a better way.
"This has created a tremendous amount of burnout in physicians today," he says.
He began experimenting with creating a better way to practice primary care, and it began by letting go a little bit. By now his techniques are common knowledge and frequently implemented in the journey toward patient centered medical home status, but in 2003, when he began to transfer more authority to his nurses through a team-driven approach to primary care, he was on the cutting edge, along with Paul Grundy, MD, and Michael Sepulveda, MD, who at the same time were working on the same problem for IBM.
Grundy has since become known as the "godfather" of the patient centered medical home, and, in a gross oversimplification, has pioneered physician practice transformation that focuses on the patient and delegates tasks that used to be the exclusive territory of MDs to non-physicians. The PCMH model also puts a lot of emphasis on the power of preventive medicine.
The key to Anderson's plan was simple in theory if difficult in practice: Give back some time to the physician so that he or she could focus more on the patients and less on routine activities.
Others were empowered to enter information in the electronic medical record, for example. Nurses were given increased responsibility in the exam room. In short, Anderson was creating aspects of the medical home concurrently with the more famous authors of the system, although he didn't know it at the time.
His goal was simply rediscover the enjoyment of practicing medicine before being driven to quit it altogether. He wanted more quality time with his family, he wanted to know his patients, and he didn't want his nurses to quit because of "chaos."
The morning after those two nurses, who had been with him for 20 years, said they were going to leave, he asked them both to give him six months to redesign the practice. If they still wanted to leave after that, he said he'd probably walk out the door with them. They agreed.
"The key to medicine is having a physician who knows you and sees you when you need to be seen," says Anderson, who in his darkest hour in 2003, couldn't even guarantee that his practice would be able to open the next day, given his nurses' frustration. His book on this journey, The Familiar Physician, explores the transformation in depth and provides hope for the downtrodden primary care physician.
The familiar physician is a play on the old concept of the family physician, which he says went away with the advent of managed care.
"Primary care physicians became the gatekeepers. Instead of getting patients closer to primary care, which is more cost effective, the exact opposite happened," he says. "Instead of increasing the value of primary care, the system made it so you had to get through the primary care doctor before you get the 'real care' you needed, which led to a crisis in identity and value."
In an effort to get back to what made medicine attractive to him initially, consulting, cajoling, and helping his patients, he had to delegate, which is one of the main tenets of Grundy's patient centered medical home concept.
Anderson says he just paid attention to his instincts. He came up with what he called "family team care," and taught his nurses to do everything in the exam room that a physician did not have to do.
"It cut my time in the room in half and yet gave us a better product," he says.
The first full year, his collections went up by $100,000. Given that his practice had been losing $80,000 a year, that put it back into the black. But the bigger transformation was among his staff's morale as well as his own.
For the first six months, the whole team had a special meeting each week to redesign how care was delivered in the practice. Though detailed, the meetings essentially took everything away from him except practicing medicine.
Yet 10 years after his practice made the transformation, he says too many physicians are failing to understand the power of it.
"I was in Connecticut last week and the docs are still ignoring the reality that things have to change," he says. "Their office visit looks the same as 50 years ago. What other business would still be around if that were the case?"
He says he engaged in conversation with a dermatologist, for example, who had just purchased his practice for a million dollars.
"He doesn't realize he's not going to be as busy. People won't be free to go to any derm they want to," says Anderson, who asked whether the physician was looking at trying to join any ACOs in his area. Many ACOs require PCMH designation to be included in their network, but Anderson says the physician's response was, effectively, "what's an ACO?"
"He will be in the position of being surrounded by strong ACOs and if [he doesn't] get into one quickly, he might have to declare bankruptcy," says Anderson. "That's what the system is struggling with—individual physicians. The leadership physicians get it, but the grass roots physician is working pretty hard to ignore it."
Healthcare consolidation is changing and eliminating the role of the hospital CEO. But there are still opportunities for strong leaders—they're just not always going to come with the title of CEO attached to them.
I wrote several weeks ago about the disappearing hospital CEO, and the column struck a bit of a nerve. Though I didn't have much more than anecdotal material to back up my claim that CEO jobs are getting scarce, I hit a nerve. Others who are observing the same phenomena started to get in touch with me.
I spoke with one headhunter who told me that it's scary out there for those who are looking to lead hospitals as consolidation really takes hold. Lots of good jobs are going away or transitioning into something different than how they've been defined for decades. Before you're overcome with the doom and gloom, however, there are still opportunities for strong leaders—they're just not always going to come with the title of CEO attached to them.
Can you handle that, especially if you've already been to the mountaintop, so to speak?
"I was having lunch with a CEO of a system that has 10,000 employees," says Andrew Chastain, managing partner of the southeast region for executive search firm Witt/Kieffer, who says at least in that person's instance, that title, and many of the responsibilities that go with it, is going away.
"He told me 'we'll be a subset of a larger system. And my job will be employee relations.'"
Too Young to Retire That can be a tough pill to swallow, especially for someone who's been the leader of his or her own hospital or health system for a number of years. For many, it's the signal to retire or change jobs. But some CEOs aren't fortunate enough to be able to retire young, and almost certainly there won't be the number of available jobs at the CEO level as they might expect.
They might have to tough it out with what many see as a reduction of responsibilities and status.
For some, the title might remain, but day-to-day life will change dramatically, says Chastain. Where once you were master of your organization's destiny, now you might just be a cog in a bigger system's executive framework.
"There will be fewer and fewer of those positions," Chastain says, adding that as an executive recruiter, he's struggled along with his clients to define a way forward for those who have always defined success as attaining the CEO job at a hospital or regional health system.
"What's the ray of hope? The best I've come up with is we'll have to redefine what success looks like," says Chastain.
Not exactly the most satisfying of answers.
Matrixed Management Structures It's almost like managing a franchise, instead of managing a company, he adds. If that's the case, success might mean something else going forward indeed.
Larry Tyler, chairman and CEO of Tyler & Co., an executive search firm specializing in healthcare, says he's seeing a lot more interest by boards at growing health systems in matrixed management structures, where the titles may be widely variable, but also where title is not nearly as important as the number of pieces of the enterprise that report to the executive on a dotted-line basis.
"We're seeing a lot of matrixed operations. As they're trying to flatten the management structure and take out the overhead, you're getting people in concurrent positions, so they are combining jobs," Tyler says. "I was in a health system last week and their chief nursing officer is also the COO."
It's part of the mandate to take costs out of the system wherever and whenever possible, he adds.
Another sign of hope: Many systems are experimenting and reorganizing along the capabilities of the individual involved instead of the other way around. The system's not necessarily going to follow the established c-suite pecking order, and the division of duties, including whom reports to whom, is much more variable.
'A Lot of Analysis' Tyler relates recent experience in job searches for organizations that are very different from those he was getting just a year or two ago. For instance, he conducted a vice president of finance/operations search for a large hospital that's part of a system, in which the duties once associated with the CFO position have been removed from the job description. Revenue cycle and payroll, for example, are not there. But what is there is a lot of analysis, and the directors of the cardiology and ED service lines, just to name two, report to this vice president.
"The org structure starts looking really strange," he says. "You might report to somebody you wouldn't normally think of. In that sense, it's a good trend because it gets people out of the silos and helps broaden them so they understand what life's like in a different area.
In the end, Tyler's recommending a new definition of success for the hospital or health system executive too.
"You can't necessarily aspire to be the CEO anymore because there aren't enough jobs," says Tyler. "Not long ago, if you had a master's in health administration, you automatically had a job and most were CEOs by age 40. The most many can aspire to now is being a vice president, because [there just aren't] those job opportunities."
Opening the research center is part of a strategic plan to move Texas Health Resources squarely into a leadership role in the transition from fee-based healthcare to a value-based reimbursement model, says CEO Douglas Hawthorne.
Texas Health Resources has opened a research center intended to establish best practices for population health strategies that are intended to shift the giant health system's business model from fee-for-service to a value-based model.
Douglas Hawthorne, CEO of Texas Health Resources
It named Tricia Nguyen, MD, to lead the new Population Health, Education & Innovation Center. The health system, one of the largest in the state and billing itself as the largest in its north Texas home area, has spent the past seven years trying to make a transition from sick care to a value-and population health enterprise, as have many other health systems dealing with the challenge of healthcare reform.
A press release announcing the center's creation says it will be the nexus for sharing best practices, disseminating information about innovative approaches, leading physician-directed population health initiatives and coordinating community-based well-being collaboration.
It's all part of a strategic plan to move Texas Health squarely into a leadership role in the transition from fee-based healthcare to a value-based reimbursement model, says CEO Douglas Hawthorne.
"We did this to be able to bring together the pieces that would allow us to convert thinking into execution. Rather than going from pillar to post to find pieces that would make our value case, we're organizing the pieces around innovation and improving the population's wellbeing," he says. "This will allow us to move more swiftly yet deliberately."
The Center is intended to remake incentives that push caregivers to provide specific interventions reimbursed as part of a care episode into incentives that favor prevention, well-being, and better management of chronic disease and post-acute care.
It will house Texas Health's research and medical education activities as well as technology initiatives for interdisciplinary clinical research, analytics, predictive modeling, data management and remote patient monitoring. Community health and faith-based outreach activities will also be coordinated through the Center.
One example of an initiative that will be coordinated by the Center is the recently launched Blue Zone Project with the city of Fort Worth. The Blue Zone Project aims to improve the overall well-being of the community by creating collaborative efforts involving local government agencies, businesses, nonprofit organizations, educational institutions and community-based organizations. The Blue Zone Project was launched in partnership with Healthways Inc., a provider of well-being improvement solutions with which Texas Health already has a 10-year cooperative contract. Texas Health funded the initial assessment of Fort Worth as a possible Blue Zone Project city.
"It's taking hold," Hawthorne says. "Fort Worth's mayor and city council have said 'bring it on,' and we think that will change the dynamic. It really is a whole evolution of changing mindsets about how we engage people earlier in life around staying healthy versus waiting for them to appear at the ED or front door."
A big part of that change in mindset, and indeed, the entire organization's business model, involves working closely with physicians who "get it," Hawthorne says. "This is not just about diagnosis and treatment, but it's also about prevention and helping people avoid the ICU or ED."
Before joining Texas Health, Nguyen was with Banner Health, another large integrated delivery system in Phoenix, where she was involved in accountable care organization strategies and clinical integration and population health work across the physician network.
"We see this as something that will allow for faster execution in bringing resources together in single place rather than in a multitude," Hawthorne says. "There's risk in doing something like this, you cut new ice, and you begin to take on something that doesn't have a model. But we think this will be a model for others rather than something that struggles."
Consolidation in the healthcare industry will do nothing to stop the upward march of spending. In fact, consolidation should exacerbate it. So says a hospital chief in a major market who shall remain anonymous—for now.
I talked to a CEO this week who has some surprising opinions about the overriding result we'll see from the wave of consolidation that's sweeping through healthcare.
Though improvements in quality of care and care coordination, as well as elimination of waste, are often the first benefits cited by CEOs who are attempting to put a hospital or health system merger together, this guy happens to think those are all secondary. In short, he thinks it's mostly about the profit motive and regional monopolies.
Take that, Federal Trade Commission. Here's one hospital CEO who says consolidation is going to do nothing to stop the inexorable march of healthcare spending higher and in fact, should exacerbate it.
This CEO, who will remain nameless until our 2013 HealthLeaders 20 are unveiled in December, reflects but one opinion among many differing ones in healthcare, and indeed, his opinion is shaped by his own local market, where the variables that determine reimbursement are as different from one area to another as annual rainfall amounts.
His opinion is also shaped by the fact that he is, relatively, as head of a standalone hospital in a major market, a minnow swimming in a sea of barracudas, and trying to compete for a slice of the same reimbursement pie—at least on the commercial side.
The fact is that some hospitals and health systems can reap reimbursement as much as 50% higher than a competitor with similar quality and outcomes results, simply because it has a network insurers feel they can't do without.
So what's wrong with that? Make sure your customers can't do without you, and charge them accordingly. That's capitalism.
Of course that's a dramatic oversimplification of the highly complex beast that is healthcare. Healthcare is different from other markets in that it's near-impossible for those who are making treatment decisions, (customers) especially if they're patients, to make any kind of value comparison, and thus, choose the lower cost option—even if quality and outcomes are similar.
If Panasonic wants to sell me a TV at 50% less than Samsung, and it has similar quality, that's easy for me to discover and to make a decision on whether that extra 50% for the Samsung is well spent. Consumers, and with certain exceptions, employers, can't make that call, and insurers aren't helping them much.
This CEO's argument, which holds a lot of weight with me, is that the lack of transparency in healthcare means that all the demonstration projects, all the cost-cutting exercises, indeed, all the vertical and horizontal consolidation going on in healthcare won't lead to lower prices.
Obviously, whether or not the CEO I interviewed is right remains to be seen, but he makes compelling arguments that the trend bears further examination before we conclude that consolidation in healthcare is “good” for patients or “good” for our country.
On a macro scale, healthcare's already squeezing out other competing priorities that we all must pay for, in one way or another, such as food, shelter, defense, education, and other spending priorities.
For instance, this CEO contends, insurers, at least in his market, aren't really that interested in lowering the cost of healthcare because they've been content to pass higher costs onto their clients: large employers, and increasingly, patients themselves.
Hospitals and health systems are precluded, through contractual “gag” orders, from disclosing what they are paid by commercial insurers for a variety of procedures. Not that most of them would be willing to disclose their reimbursement even if they weren't contractually prohibited, he claims, because the biggest and most comprehensive are getting sweetheart deals because of their negotiating clout.
As head of a major employer himself, this CEO finds this particular prohibition unfair and contends it inhibits his ability to offer his employees fair wages and benefits, never mind the cost to our nation as a whole. As competition recedes, prices go up. And healthcare consolidation is no different than any other industry consolidation. The consumer pays.
He's not sitting still for it. In fact, he's working on a dramatic way to shine the light on insurer negotiations with health systems and the results they bring.
From an economic standpoint, the transparency in pricing for employers and employees and insurers is in the crosshairs of affordability in healthcare, he told me..
Makes sense to me. We have the Patient Protection and Affordable Care Act, like it or not. If anything, the cost of healthcare will likely continue to rise as the PPACA is implemented, and many on both sides of the debate on federal healthcare reform have long derided the “affordable” claim in the Affordable Care Act.
Truly affordable care requires transparency. Despite the ACA, there's still precious little of it in healthcare now. Where are the lawmakers when you really need them?
Chief financial officers from some of the country's top hospitals and health systems meeting at HealthLeaders Media's third annual CFO Exchange shared the exciting and often frustrating adaptations they're making to accommodate healthcare reform.
For a hospital or health system CFO, there's a lot to fear in today's marketplace. Volumes are down. Governments, employers, and payers are ratcheting back reimbursement. Hospitals and health systems are becoming the focal point for disdain for many patients as more of their healthcare is being paid for out of their own pocket.
Providers face daunting information technology investments—in some cases reinvestment. They must manage sometimes contentious relationships with clinicians who have to get used to a new, more accountable way to practice medicine. Finally, consolidation threatening their jobs is the cherry on top of an unappetizing sundae.
But where there is great challenge, there is also great opportunity, and as the second and final day of HealthLeaders Media's third annual CFO Exchange wrapped up in Colorado Springs Friday, most of the CFOs in attendance sounded notes of optimism in spite of the challenges they face.
In group discussions, the event's nearly 40 participants shared with each other and HealthLeaders Media's editorial staff the exciting, arduous, and often frustrating adaptations they're making to their business models in the midst of healthcare reform.
That term in itself has become fraught with so many different meanings that it's difficult to convey how much and how quickly change is coming to the financial side of the C-suite. No longer are CFOs locked away in their ivory tower of financial analysis, devoid of context to the value of their work as it relates to actual patient care.
Indeed, they are asked to work collaboratively with groups they have infrequently collaborated in the past. From reimbursement changes to labor costs to capital projects, little is familiar anymore.
Some organizations are transitioning to taking on actuarial risk, but whether they are or not, the risk of change itself is never far from the forefront of their minds. Often, they're expected to integrate the financials of many hitherto disparate parts of the healthcare continuum into systems that have never had to manage, for example, a skilled nursing facility and its labor and capital needs.
They're wondering how best to collect from a patient population that is bearing the first-dollar cost of their healthcare expenditures as never before. They're trying to influence physician decision-making, always an exercise fraught with professional peril.
But no matter the challenge, the leaders who gathered in Colorado Springs last week aren't doing it alone. Collaborating and sharing solutions, problems and successes with their peers is more important than ever before, which, after all, is the reason why this event is so important.
A sampling of the attitude of collaboration and innovation exhibited among this year's participants can provide a snapshot of the challenges and opportunities ahead.
On taking risk:
"We think our biggest organizational risk is thinking like a hospital system. Lots of health problems are socioeconomic. If we're going to take risk, we have to go beyond the medical stuff." – Dennis Dahlen, CFO, Banner Health
On the patient's growing role and emergence as a critical "payer" as deductibles and coinsurance makes up a greater part of each healthcare bill:
"We won't schedule an elective procedure anymore until we figure out how they will pay, and we're changing the formula for physicians so they have a vested interest in getting that collection tool into practice."—Kendall Johnson, CFO, Baton Rouge General Medical Center
On the often exorbitant cost of investment in the electronic medical record:
"The biggest miss we've had as an industry is not standardizing the EMR across the country. —Linda Hoff, CFO, Meriter Health Services
On the debut of the health insurance exchanges:
"Payers know they will take a big haircut on exchanges as [they are] fee-for-service. That's why so many in our state decided not to participate. Because the healthy young won't join and older people will at lower price than their risk. Whoever decides to do it for market share is taking a huge gamble." —Rich Rothberger, CFO, Scripps Health
Today's CFOs identified numerous challenges, but they're not just cataloguing those challenges—they're doing their best to implement solutions. Through this kind of information sharing, HealthLeaders is doing its best to help facilitate the transfer of knowledge in perhaps the most challenging time not only for healthcare CFOs, but for the entire healthcare system.
Healthcare is changing rapidly, and CFOs aren't standing still—they're racing to innovate.
Many hospitals and health systems aren't waiting for insurers to implement risk sharing into their contracts. Instead, providers are experimenting on their own—especially those that already own health plans.
As the third annual HealthLeaders Media CFO Exchange in Colorado Springs winds down to a close, I am struck by the wide variety of experience around the country surrounding population health initiatives and risk sharing for hospitals and health systems.
Before I go on, there's nearly universal agreement that healthcare takes up too much of the nation's GDP, and that outside of rationing care, which is unlikely to happen even in the long-term, risk sharing is likely the best way to reduce cost growth.
By risk sharing, I mean that at least part of hospital and physician payment is "at risk" based on how well providers meet certain targets on processes, overutilization, readmissions and other metrics.
In some geographical areas, health plans are being innovative. But in most areas, they don't seem to be, not on a broad scale, that is. Instead, with the consent of employers, payers are content to offload risk onto patients through high deductible health plans.
And guess who's at the end of that chain of responsibility? Health systems, as they seek to obtain the patient's portion of the responsibility for the bill, which seemingly grows each year with higher copays, deductibles and "coinsurance." That strategy, if you can call it that, has a limited shelf-life.
One CFO told me that high deductible health plans are generating not only declining volumes for a variety of inpatient and outpatient services, but also "a level of hate" from patients toward the hospital or health system, which is left to collect the patient's share of the bill.
Indeed, hospitals, physicians, and outpatient facilities are often obligated through their commercial contracts to attempt to collect that portion.
Not that hospitals and health systems are particularly enthused about moving from fee-for-service reimbursement to sharing risk on quality, utilization and outcomes, among other metrics, but in many geographical areas, they seem to be getting little cooperation from payers in testing risk-based payment strategies.
Why? According to hospital and health system CFOs, payers say they aren't ready.
The lack of progress isn't attributable to the hospitals and health systems themselves. Indeed, many aren't waiting for insurers to implement risk sharing into their contracts, and instead, they're experimenting on their own—especially those that already own health plans.
Knowing that taking risk on reimbursement is coming, they're hoping to build momentum by implementing population health strategies with their own employees, for example. They're also implementing their own narrow networks with local employers, in many cases.
But when it comes to negotiations with insurers, too often it's the same old game of negotiating fee-for-service contracts. Even the federal government, with its Medicare Shared Savings program and even the Pioneer program, seems to be moving faster.
Insurers, on the other hand, seem to want to slow-play the game of implementing risk on the facilities they pay, whether they be huge hospital systems or physician practices.
In some cases, these companies, which are presumably being pressured by employers to lower the rate of healthcare cost inflation, are making do with small, limited scope experiments in encouraging pay for performance and risk-based contracting. They're making a reasoned bet that they don't know enough about how risk sharing will pan out to implement it nationwide.
All healthcare is local, it's true, and what works in one geographical area won't necessarily work in another, but employers and patients are getting wise to how much healthcare costs them. They won't wait on insurers forever.
Many independent hospitals are joining with bigger systems in search of access to capital, scale, and survival. But that doesn't mean acquisition is right for everyone, says the CEO of Lodi (CA) Health.
Joseph Harrington has been a hospital CEO for 38 years, and he's been president and CEO of Lodi Memorial Hospital, a 214-bed community hospital in California's Central Valley, along with the new umbrella organization Lodi Health, for the last 20 years. He's witnessed a lot of change during the course of his career, but it seems that most of it has come during the past three years, as the federal, state, and local governments, not to mention payers and employers, have begun to push back hard on healthcare cost growth.
Harrington knows is his executive and clinical teams have to do a better job of managing down their costs so that the hospital can continue to survive in a low-cost environment. Hospitals themselves are the highest cost center in healthcare, so they're first on the chopping block. Because they're less diversified and don't have the economies of scale of the big systems, the nation's small, independent hospitals are less able to absorb some of the belt-tightening that's necessary.
As he moves toward the end of his career, Harrington estimates that Lodi Health needs to cut $600 in cost per adjusted bed day over a two-year period to be able to survive on Medicare reimbursement rates. Many formerly independent hospitals have given up the fight—and local control—by affiliating or being acquired by larger systems.
I spoke recently with Harrington about his strategic thinking and recent tactics. It might happen that Lodi Health is eventually acquired by a bigger player, but neither Harrington nor his board is shutting the door on independence just yet.
HealthLeaders Media: Lodi Health is reinventing itself from a patient care point of view. You have added cardiac rehab facilities, primary care clinics, you've invested heavily in follow-up care, and you've added a multitude of programs to adapt to a value-based reimbursement system. How have you chosen your investments?
Harrington: We have a series of clinics, about 14—mostly primary care—and we're trying to organize all of the physicians into a medical group. The group is formed, but we're working on the governance issues. About 4–5 physician leaders are taking the lead on determining compensation. One other initiative we're doing is a private ACO with Blue Shield. They're partnering with local IPAs and Dignity Health. We've been talking for about eight to nine months about doing a shared savings program for CalPERS [California Public Employee Retirement System] retirees. There are about 16,000 enrollees in the county, so this is kind of a narrow network shared savings model. What it means is we're getting our feet wet without a bunch of risk involved.
HealthLeaders: So it looks like you're doing all the right things, but with Medicare and Medi-Cal reimbursements trending downward, what's your strategy for replacing that expected lost revenue?
Harrington: We hope to have a number of very philanthropic donors who will give us millions of dollars! Seriously though, we look at ourselves in the mirror and know our limitations. We decided we were going to try the CMS bundled payment initiatives. We chose total joints [replacements]. We do 130–150 of those a year, and about half are for Medicare patients. It's an opportunity to learn and redesign care without a bunch of exposure, and through it, we're trying to get experience in how to handle a bundled payment.
We actually joined an advanced payment model ACO based out of Sacramento County as well. Eight of our primary care physicians put in applications, starting January 2014. It's the only one in California, but it appears they still have a lot to do get the work going. These kinds of projects are becoming the norm. About two years ago, we were starting to see reimbursements ratchet down, and at the same time we were trying to figure out what we need to do to downsize our operations and expenses in order to be at that Medicare reimbursement level or below to survive. We figured we had about $600 per adjusted bed day to cut down over a two-year period.
HealthLeaders: Do you feel you have the right pieces to thrive in a value-based environment? If not, what's missing?
Harrington: At that time [two years ago], we were looking at a lower census and asking ourselves what's causing this and how low will it go. We think that got answered last year. This year, our numbers are up substantially. ER volumes continue to be strong. We're still growing at 13%–17% in the ER. But a big question is why aren't these guys hooking up with a primary care physician instead of using the ED?
One of the reasons we believe we're getting busier is that a lot of the physicians tell their patients if they get sick, to go to the ED. What they should be telling [patients] is that they will deal with their issue. It's a convenience issue because it's a lot easier for them to just tell [patients] to go to the ED. And what's surprising about it is we have our own urgent care, too.
Those numbers are climbing as well. We've brought on more midlevels in the last three years than in the past 10 years prior, and we have a significant number of mature physicians who are now 70 or so and still working. That's good for us. We're competing with the Kaisers, and it's very difficult if you don't have shift work available for your physicians. The medical foundation model is what we're forming. We're trying to move all our docs into that which will create the foundation in 6–9 months.
We think that's important for integration. So to answer your question, I do think we have the pieces but I don't have a real high confidence level. I'm always thinking: do I have enough backup strategies in place? It's more of a feeling than knowing for sure, and it's not unique to us. Is what's happening evolutionary or revolutionary? We think evolutionary. We'll have a number of people in the exchange by '14, but in our county, 20% of the population is uninsured, and another percentage consists of illegals who still won't be covered, so we'll continue our free clinic. We're going to need more primary care physicians but we're competing with heavy hitters.
HealthLeaders: Independent hospitals are being gobbled up left and right. What path have you decided to follow at Lodi Health?
Harrington: We have had over the years a number of conversations about this. We're making sure we talk regularly with different consulting groups who can take an assessment of us and tell us the future. Every time we've done that—with different groups over three years—they've told us we don't have excellent numbers, but we're fine. Our [board members] aren't diehard independents, but they believe there are a lot of advantages to being independent. We have the ability to make a timely decision, for example.
But if the landscape changes, it's our job to make sure there's hospital services here, but it doesn't need to be independent. We have a discussion about the landscape about every other board meeting. We've had a bunch of consolidation around us. We've seen different affiliations. We're talking with Dignity about the ACO and we have an ongoing relationship with UC Davis. If we ever needed to get more serious, we could get to a decision pretty quickly.
HealthLeaders: Some say that the time to affiliate or be acquired is when you are at a position of financial and operational strength, as your negotiating position is better. Do you worry about becoming less attractive as time goes on?
Harrington: As long as we're making our money and have capital left over for tomorrow, we're good for two to three years. We've got a pretty good handle on the finances right now. That's why it's constantly on our calendar now. If we see certain ratios on our bond covenants, we project that out two years. Our board members are pretty sharp to look at these numbers. If they see a small tilt, they're quick to say 'What are you doing about it?' We feel like we have a pretty good sense on this, and we're ready to move if things start to deteriorate or if we do see a trend that way.
Fortunately the last few months have been better on those numbers, as we predicted they would be. Last year was the worst on that. We were very close to making a decision on independence, but the board members trust us. We predicted the numbers would get better. The good news is when you say something like that, and it comes true, the trust level doubles.
