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Community, connection, purpose: these values are almost palpable even in a virtual conversation with Dr. Susan Rogers. Dr. Rogers is an internist, educator, and activist on behalf of those who suffer when profit motives bulldoze the institutions that are meant to serve the public. A neon example of a public good which has been targeted by profiteers is traditional Medicare. As president of Physicians for a National Health Program, Dr. Rogers is fighting back against the shape-shifting strategies launched by insurance companies and private equity firms to cash in on Medicare. She fills us in on the importance of preserving the choice of traditional Medicare, and talks about her work to inform the public and Congress about the âpredatory DCEsâ or Direct Contracting Entities.
She was shaped by growing up in a uniquely integrated community in Chicago as well as by the activism of the 1960s. When she was in middle school, her mom took her to a march led by Martin Luther King, Jr. protesting the state of the public schools in Chicago. She trained at Cook County Hospital in Chicago and then went on to hold leadership and teaching positions there as an attending. While she did defect temporarily to work in other settings in Chicago, she missed the camaraderie and like-minded passion of her Cook County colleagues. She emphasizes the importance of community with colleagues and the significance of a physicianâs long-term relationships with patients.
Dr. Rogers is exasperated at the privatization of healthcare by people who know nothing about the practice and profession of medicine. She describes the total disconnect when decisions are made by financially-driven business people: âThere should be no role for them.â
âResources arenât placed where theyâre neededâ
theyâre placed where they can generate more money.â
She compares the inroads of private equity firms in healthcare to the debacle of private equity firms and charter schools siphoning funds away from public schools in poor communities. As in healthcare, the motives are not to provide the needed services to the publicâbut to amass profits for investors. Rural hospitals that are acquired and then closed by large healthcare systems are another example of decision-making by those seeking to maximize profit, not community benefit.
Dr. Rogers and other representatives from Physicians for a National Health Program had success on Capitol Hill when they petitioned Congress and HHS to reject DCEs. While PNHPâs efforts were influential regarding DCEs, she describes how it didnât take long for a new acronym and strategy to emerge. âSame shirt, different color,â she says about ACO REACH (ACO Realizing Equity, Access, and Community Health). She emphasizes the remarkable lack of oversight by Congress for this program that can be hoisted on patients without patients realizing that their traditional Medicare decision has been overruled.
Also in this episode:
â˘The powerful impact of a high school biology teacher
â˘Activism in the time of role model Angela Davis
â˘A Tuskegee airman who exemplified the bond between physician and patient
â˘She was able to see patients as people: âThey shared their lives with meâ
â˘âAre you going to open your own office?â a question rarely posed to medical students now that 70%+ physicians are employed
â˘Burgeoning full-service hospitals arising in close proximity are as logical as putting a townâs four fire stations on facing corners.
Meet Susan Rogers, MD
Dr. Susan Rogers is president of Physicians for a National Health Program, a national organization with over 23,000 physician members, whose mission is to advocate for Single Payer/Medicare for All.
Dr. Rogers received her medical degree from the University of Illinois College of Medicine and completed her residency in Internal Medicine at Cook County Hospital in Chicago. She spent most of her career at Cook County Hospital (now Stroger Hospital of Cook County), where she practiced internal medicine in a neighborhood clinic before becoming a hospitalist and Director of Medical Student Programs for the Department of Medicine. She has also worked at the Lakeside VA hospital in Chicago affiliated with Northwestern and was a prior Medical Director at Near North Health Services, an FQHC in Chicago.
She retired in 2014 but remains a voluntary attending at Stroger Hospital and continues as active faculty at Rush University in Chicago as an Assistant Professor of Medicine.
Dr. Rogers is a Fellow of the American College of Physicians, and a member of the National Medical Association.
Resources
Physicians for a National Health Program: https://pnhp.org/
Protect Medicare: https://protectmedicare.net/
Twitter: @rgrsssn @PNHP #M4A and #BLM
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McGill Business Professor Henry Mintzberg is the author of 20 books on management, creator of two revolutionary international management programs, and the recipient of a mountain of accolades and honors for his thought leadership in the business world. Mintzberg minces no words in his pointed criticism of current approaches to management training and the behavior of those in management and leadership positions. In this interview, Professor Mintzberg comments on the value of an MBA in providing management skills:
âAnybody who comes out of a business school should have a stamp on his or her foreheadâlike a skull and crossbonesâthat says Warning! Not Prepared to Manage.â
He explains how managers get distorted during traditional business education. Management is a practice where art, craft and science intersect. Because the art and craft cannot be taught in a business school setting, the âscienceâ has become the focus of graduate business education. Thus, MBAs emerge with skills in marketing, finance, and accounting but lack the very âessenceâ of managementâthe art and the craft.
He explains why âremote control managersâ are dangerous. These are people who manage by the numbers, with monitoring and measuring substituting for actually knowing whatâs going on in the business. This lack of understanding has implications for the success and capacity of the organization and disconnection from the ground floor of the organization impairs innovation.
Professor Mintzberg says healthcare should not be run like a business. In fact, he states, âmost businesses should not be run like a business.â He makes it clear that this is especially true in professions and in services like medicine and healthcare. Healthcare is not a business, itâs a calling.
Professor Mintzberg points to the pros and cons of various groups such as physicians, nurses, MBAs, accountants and others who seek to lead healthcare institutions. He believes managers must know and understand the services being offered, be unequivocally collaborative, and humble enough to learn. Physicians who succeed in business are those who collaborate and build relationships.
Mintzberg, an internationally recognized iconoclast, believes jail is the most appropriate destination for board members who approve super-sized CEO salaries and for the executives who accept them. He states that huge salaries are dysfunctional nonsense and the opposite of leadership that leads to âa kind of narcissism.â When asked about incentives for physicians, Professor Mintzberg exudes enthusiasm. âYes! A patient whose life has been saved and who is appreciative is a terrific incentive!â But treating physicians like caged pigeons and giving them little rewards for their work is just silliness.
Professor Mintzberg talks about the structure, purpose, and successes of the International Masters for Health Leadership program which he co-founded. And he shares a high level overview of his important work focused on the need to rebalance society. An imbalance in three sectors, the public, private and what he calls the plural sector, are at the root of many of societyâs most harmful and dysfunctional patterns. This is so relevant to healthcare, which is being destroyed by inroads by the profit-driven private sector.
In this episode:
â˘Why Professor Mintzbergâs quadruple bypass cost $2.50
â˘How beaver artists find gallery space
â˘The Supreme Court legalized bribery in the Citizens United decision
â˘Mintzbergâs Masters Program, Ebola Virus, and Doctors Without Borders
â˘Dulcie and the Infinite List of Positive Characteristics
Meet Henry Mintzberg
Henry Mintzberg, PhD, is a professor in the Desautels Faculty of Management at McGill University in Montreal. He sits in the Cleghorn Chair of Management Studies and has had extensive visiting professorships at INSEAD in France and the London Business School in England.
As an internationally renowned author and educator, he has received an avalanche of honorary degrees, awards, and recognition for his iconoclastic thought leadership in the realm of business. He has authored 20 books and nearly 200 articles, and speaks frequently on podcasts and regularly publishes a TWOG (Tweet to Blog) which he calls âprovocative fun.â
He co-founded and remains active in the International Masters Program for Managers and the International Masters for Health Leadership as well as the venture CoachingOurselves.com. These are all novel, successful, and highly regarded initiatives for managers to learn together from their own experience, with CoachingOurselves.com occurring in the participantsâ own workplace.
Professor Mintzberg is also an outdoorsman and collector of peculiar beaver sculptures, which he enthusiastically discusses in this episode.
Resources:
â˘Website: https://mintzberg.org/
â˘Newest Book: https://mintzberg.org/books/bedtime-stories-for-managers
â˘Website: https://rebalancingsociety.org/
â˘Twitter: @mintzberg141
â˘International Masters Program for Managers: https://impm.org/
â˘International Masters for Health Leadership: https://www.mcgill.ca/desautels/programs/international-masters-health-leadership
Photo credit: Owen Egan
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Author and certified lifestyle medicine physician, Iris Schrijver, MD, describes a fulfilling and fast-paced academic career at Stanford as a full professor of pathology and director of a molecular genetics research lab. A few years ago, in an unlikely turn of events, an opportunity to design a leadership project ignited her long simmering interest in wellbeing.
That project culminated in a 2016 research article An Exploration of Key Issues and Potential Solutions that Impact Physician Wellbeing and Professional Fulfilment at an Academic Center. I give you the details here because this is the article that led me to reach out to Dr. Schrijver. I had read everything and everyone with a scholarly approach to physician burnout in preparation for several podcasts. Dr. Schrijverâs article was one of the most outstanding and useful of the scores of articles I read. In our conversation, she describes how important it was for her to have the credibility of being a physician as she interviewed her colleagues about the underpinnings of burnout. She also describes how extrinsic factors, such as restricted autonomy, dominated the findings which contributed to physician burnout.
She and her husband, an astrophysicist, decided there was more they wanted to accomplish and experience beyond their fulfilling but all-consuming careers. The magnificent Oregon landscape was pulling them away.
Dr. Schrijver describes how she consciously made changes to create the life she wanted. She decided to pursue a certificate in lifestyle medicine, write a book on wellbeing, and contribute to medicine and patients in a different way. They moved to Clackamas County, Oregon, and she began volunteer work at the Clackamas Volunteers in Medicine Clinicâincluding a stint as medical director and a board member. Now she is developing a lifestyle medicine service for the Clinic. She finds the work remarkably rewarding. As she says, âPoverty is not a crime, and it is a privilege to provide good medical care for this population.â She continues to serve as adjunct pathology faculty at Stanford.
Dr. Schrijver describes an interaction with a mentor early in her career who gave her a pointed introduction to her leadership accountabilities as a physician. It served her well. She has served in academic and national leadership roles, including as the President of the Association for Molecular Pathology.
She connects the scientific method, physician leadership, and physician wellbeing to the important task of promulgating accurate and useful information to the public. Dr. Schrijver makes a compelling case in her book and in our conversation that we can take steps to improve wellbeing. We can envision and create a more fulfilling life for ourselves and guide our patients to greater wellbeing as well.
Also in this episode:
â˘The Six Principles of Lifestyle Medicine
â˘Mentoring advice to physicians making their first career move
â˘Does Press Ganey turn doctors into Nordstrom clerks?
â˘How alliances can serve physicians in attaining wellbeing
â˘Seeking resilience is aiming too lowâaim to thrive
Meet Iris Schrijver, MD
Iris Schrijver is a certified lifestyle medicine physician, also specialized in clinical pathology and molecular genetics. She is an adjunct clinical professor of pathology at the Stanford University School of Medicine and a past president of the Association for Molecular Pathology. Dr. Schrijver served as medical director of Clackamas Volunteers in Medicine, and is now developing a lifestyle medicine service there, because she believes that healthcare is a basic human right.
Her dedication to patients and to medical progress through science has resulted in the publication of many original research articles, book chapters, and books. Together with her husband, an astrophysicist, she wrote âLiving with the Starsâ, a popular science book about connections between the human body and the Universe. Her passion for lifestyle medicine, science, education, and the possibility of wellbeing for everyone sparked her latest work: "On the Path to Health, Wellbeing, and Fulfilment: To Your Health".
This book investigates the basis of what we think we know about healthy living, and reveals the influences on the use and understanding of health information. It shows how scientific breakthroughs shed light on health, causes of disease, and overall wellbeing throughout life.
Iris lives and works near Portland, Oregon, and enjoys the great outdoors of the Pacific Northwest.
Learn more about Iris and her new book at lifestyleforhealthandwellness.com.
Other Resources:
Website: https://lifestyleforhealthandwellness.com/
Book: https://www.amazon.com/dp/B0B7X269S5
Clackamas Volunteers in Medicine https://clackamasvim.org/
An Exploration of Key Issues and Potential Solutions that Impact Physician Wellbeing and Professional Fulfillment at an Academic Center https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4793321/
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Attorney and author Dennis Hursh helps physicians navigate their employment contracts. He describes his shock early on in his career when he saw the lopsided language in the contracts offered to his highly trained physician clients. He points out that no hospital executive would ever agree to such contractual language for themselves.
A sampling of items Mr. Hursh considers âinsaneâ:
- 24 hour call shifts (and by the way, you will work the next day, too)
- The employer will decide if youâre disabled and has the right to terminate you if you canât do the job
- No paycheck for you if you canât navigate their complex credentialing process by your start date AND they reserve the right to terminate you if you arenât fully credentialed by your start date
- Punitive non-compete clauses (a.k.a., restrictive covenants) that wreak professional and personal havoc rather than simply limit the loss of patients who might follow you when you leave
- âBrutalâ provisions in the contract that the administration promises they wonât enforce (but nonetheless they wonât remove the language)
- Low starting pay with a promise (but no contractual language) of partnership to come
- âIntegrationâ documents that provide explanations and promises related to the formal contract (but alas, they are not enforceable unless they are in the formal contract)
In this episode, Mr. Hursh exposes the risks lurking in several areas typically included in physician employment contracts (beware if these points are not explicitly addressed!):
CREDENTIALING: Flexibility can be built into the contract to allow a physician to begin a narrower scope of work if certain hospital credentials or other privileges are still delayed at the start date.
RESTRICTIVE COVENANTS (noncompete clauses): This refers to contractual language that prohibits a departing physician from practicing within a specified distance of the former employer for some period of time. Mr. Hursh draws attention to several issues regarding the distance that is specified and what is being measured: Is it the distance between the physicianâs previous office and the office with the future employer? From a specific hospital or the organizational headquarters? Or from any of the employerâs sites anywhere?
MALPRACTICE INSURANCE: He describes the critical difference between Occurrence vs. Claims-Made insurance policies. Red alert if the contract simply says âmalpractice insurance is provided.â If you donât know the difference you could be saddled with expensive âtail insuranceâ when you hightail it out of there.
COMPENSATION, CALL, DUTY HOURS and LOCATION: Ambiguity is not the physicianâs friend when it comes to an employment contract. Exquisite clarity about compensation and call is critical. If your future employer thinks full-time means 40 jam-packed patient-contact hours then, in reality, you could end up with a 60-hour workweek. Similarly, itâs critical to have clarity and security about your office and hospital location.
Mr. Hursh advises physicians to hire an attorney who has experience working with physician agreements and who has the needed resources (e.g., MGMA database, up-to-date Stark regulations). An advantage of hiring an attorney is that shelling out the money for an attorney signals that the physician is taking the offer seriously. Also, contractual challenges can be raised by the attorney so that the physician doesnât have to directly challenge a potential employer.
Also in this episode:
â˘We discuss my guestâs article âAre Hospitals Evil? A Physician Contract Attorney Explainsâ
â˘How hospitals protect themselves while circumventing the bans on Corporate Practice of Medicine
â˘The Business School Mindset (BSM) and its many manifestations in healthcare systems
â˘How disdain for physicians leaks out in the language, action, and inaction of management
â˘Patient care and collegiality are harmed when competition is the primary motivator
Meet Dennis Hursh, Esq.
Dennis Hursh, a veteran physiciansâ lawyer, with over 35 years of health-law experience is a frequent lecturer on physician contracts to residency and fellowship programs, and has spoken at events sponsored by the White Coat Investor, the Pennsylvania Medical Society, the Hershey Medical Center, UPMC, Geisinger Health System, the Pennsylvania Society of Cardiology, the WellSpan Health System, the Hospital of the University of Pennsylvania, and the American Podiatry Association. A former contributing editor to Physicians News Digest, Dennis has authored several published articles on physician contractual matters, and has literally âwritten the bookâ on physician employment agreement negotiation - âThe Final Hurdle - A Physiciansâ Guide to Negotiating a Fair Employment Agreementâ.
Dennis represents physicians in all 50 states in reviewing and negotiating employment agreements to protect physicians in one of the biggest transactions of their careers.
Dennis has also published information you may find useful in his Physician Contracts Blog, at: https://pahealthlaw.com/physician-contracts-blog/
Website: https://pahealthlaw.com/
Book: The Final Hurdle: A Physician's Guide to Negotiating a Fair Employment Agreement
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In response to listener questions and comments, we dive into two topics in this episode. The first is influence, especially when managing âupâ or when dealing with a high profile colleague. The second topic is incentives. Podcast episode #35 featured Alfie Kohn who surprised listeners when he described the negative impact of incentives on intrinsic motivation.
We discuss a model of influence from the work of Jay Conger, who wrote extensively on the topic of influence including his bestselling book Winning âEm Over. Linked below is a worksheet that we use in our leadership programs. Conger describes four components of influence that can be useful when trying to persuade an audience to align with your point of view:
⢠Credibility
⢠Compelling Evidence
⢠Common Ground
⢠Connecting Emotionally
In this episode, as in our leadership programs, we zero in on Credibility as an important foundation for influence. It is comprised of two components: your expertise as perceived by the other party (or your audience) as well as the relationships you have already built with those you are seeking to influence.
Of the other three elements of influence, one that physicians may be tempted to overuse is Compelling Evidence or bringing data to the conversation. Finding Common Ground means walking in the shoes of your audience for a spell. The last one is Connecting Emotionally by appealing to someoneâs values and leaning in with your own heart. Unlike the use of logic, emotional connection is often evoked by stories and has a lasting effect.
After we wrap up the influence section, we turn to feedback about the podcast conversation with Alfie Kohn (#35). Based on the questions and comments we received, this incentives episode had an unsettling effect on listeners. We discuss the misguided use of incentives in healthcare and the use of incentives in mundane and repetitive tasks. We raise the possibility that steering away from incentives might steer us into better outcomes and more empowering approaches to leadership. And Lynn makes the point that we must not confuse incentives with an important and often overlooked leadership behavior: the expression of genuine appreciation.
â˘Influence Worksheet: https://bit.ly/InfluenceWorksheet
â˘Jay A. Conger, Winning âEm Over: A New Model for Management in the Age of Persuasion
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Christopher Obetz, MD, is the CEO of an organization which started with a handful of physicians 30 years ago, and now they have over 150 physicians and APPs. The group staffs nine emergency rooms in the Minneapolis St. Paul area. One year ago, Dr. Obetz was my guest on Episode #15 (Title: Emergency Care Consultants CEO: The Incalculable Value of Physician Careers). At the time, the ECC leader and his organization were faced with a trio of crises:
â˘The Covid pandemic and sequelae in Emergency Medicine
â˘Unexpected closure of a hospital with resultant overstaffing
â˘The George Floyd murder devastated the community around ECCâs flagship hospital
Patient volumes dropped by 40-50% during the early months of the pandemic as patients stayed clear of hospitals in order to avoid infection by Covid. ECC, which was already generously staffed, faced overstaffing as a result of reduced volumes and the hospital closure. When I spoke to Dr. Obetz last year, he wasnât sure if the values of the organization or even the organization itself would survive. Could they get through an unprecedented nosedive in income? Could they honor the employment agreements with physicians scheduled to start in the spring of 2021? And in the aftermath of George Floydâs death, could they examine their own biases and emerge as a trusted source of care in their stricken community?
Dr. Obetz describes how the impact of the pandemic evolved: from the initial emptied-out emergency departments to a swelling tide of patients overwhelming their EDs. The current âboarding crisisâ resulted from greatly increased demand for ED visits and inpatient beds. One reason is the pent-up demand and more advanced disease because care was delayed for typical medical conditions. The second is prolonged hospital stays for critically ill patients suffering from Covid. Patients are âboardedâ when there is no ICU or regular hospital beds available and they end up receiving critical care, sometimes for days, in the emergency department. The effect on doctors and nurses and others is âbruisingâ as they scramble to care for patients on ventilators or crowded in the hallways, still working behind N-95 masks, gloves, and gowns.
The organization has navigated through two years of an unpredictable and seemingly unending pandemic. Dr. Obetz describes the strategy that has underpinned their success: âWe are democratic to a fault.â In fact, hiring decisions include an assessment of whether a physician will embrace the hard work, time investment, and collaborative nature of participative decision-making. Listen in as Dr. Obetz specifies how their three core values, their principles, have served the large emergency medicine group. And when it comes to the importance of physician ownership and physician leadership, Dr. Obetz is a believer.
In this episode:
â˘The expertise of previous podcast guest Alfie Kohn is invoked
â˘ECCâs prime directive is the overriding priority of outstanding patient care
â˘The importance of physician expertise in decision-making echoes the research of âfriend of the podcastâ and two-time guest, Dr. Amanda Goodall
â˘The real meaning of Shift Nirvana is spelled out
â˘Do ECC physicians defect to work for competitors? âIt has never happenedâ
Meet Christopher Obetz, MD:
Dr. Christopher Obetz, an emergency medicine physician, is the President and CEO of Emergency Care Consultants (ECC) in Minneapolis, Minnesota. ECC is a âphysician-owned, independent, and democraticâ organization responsible for both outstanding emergency care and outstanding emergency medicine careers in nine hospitals in the Twin Cities area. Dr. Obetz has been leading ECC for the last decade, a period marked by significant organizational growth.
The organization is known for its consistent high quality care and service, excellent business outcomes and sustained high satisfaction among physicians and staff. Innovation is fueled by ECCâs high physician involvement model and purposeful collaboration with all stakeholders. One such innovation is the comprehensive scribe program implemented early in the era of electronic medical records.
(known as Topher by family, friends and colleagues)
Resources:
Emergency Care Consultants: https://www.eccemergency.com/
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Dr. Keith Smith cofounded the remarkably successful and wonderfully disruptive Surgery Center of Oklahoma. He and fellow anesthesiologist, Dr. Steven Lantier, left their hospital-based practices in 1997 to launch a physician-owned surgery center promising high quality care at a fair, transparent, and all-inclusive price. They had become fed up watching hospital administrators profit mightily while those who were actually caring for patients struggled. The inequitable and often outrageous billing practices of the hospital, the low Medicare reimbursement to physicians, and the cost-shifting to compensate for poor government reimbursement were all affronts to their values.
Dr. Smith is clear on the ethics of medicine (excellent quality at a fair price), the ethics of business (a mutually beneficial exchange between parties) and the importance of free market forces establishing the pricing and the success of an organization. He describes the morass created by government policies that harm patients while offering fertile ground for the ârising administrative classâ to step in and profit from the chaos. He doesnât mince words in his criticism of influence-peddling in Washington, D.C.
Currently, the Surgery Center has 36 physician owners, 107 physicians on staff, 42 employees, and is internationally renowned. Healthcare institutions, including UCLA, have copied the Surgery Centerâs transparent pricing webpage with its human form and drop-down menu of prices.
The Surgery Center accepts no insurance or government reimbursement and their prices are often one-sixth to one-tenth the prices patients are quoted elsewhere. This means that patients come from all over the US and beyond for high quality care at a price that is often much lower than what they would pay with their (allegedly) âfull insuranceâ coverage. Dr. Smith describes several examples of the financial foul play patients are faced with when they believe they have insurance coverage but their deductible and co-insurance can bankrupt them.
The uninsured and underinsured (maybe we should call them pseudo-insured) greatly benefit from fair, clear, and transparent pricing. Self-insured employers, who pay employeesâ healthcare costs out of their operating revenue, quickly understand the benefits of partnering with the Surgery Center. In this episode, Dr. Smith describes the good will that develops when he passes vendorsâ price reductions on to patients and self-insured corporate clients.
This innovation is being replicated and Dr. Smith fans the flames at the Free Market Medical Association, an organization he cofounded.
This means that patients come from all over the US and beyond for high quality care at a price that is often much lower than what they would pay with their (allegedly) âfull insuranceâ coverage.
In This Episode:
â˘Non-Profit, Not-for-Profit, Tax-Exempt means "Donât Pay Tax"
â˘Dr. Smith walks through The Scam: the Charge Master obfuscation which allows collusion between insurance companies and hospitals to profit mightily and do harm
â˘"And then there were four: BUCA (Blue Cross, United, Cigna, Aetna)"
â˘Regarding government programs and BUCA: "We didnât so much tackle themâwe seceded"
â˘Physician leadership + strong operating principles = superb organizational culture
â˘"We all need our boundariesâso insurance companies are not a part of my day"
Meet G. Keith Smith MD
Dr. G. Keith Smith, a board certified anesthesiologist, cofounded The Surgery Center of Oklahoma in 1997. Dr. Smith serves as the medical director, CEO and managing partner of the Surgery Center while maintaining an active anesthesia practice.
In 2009, Dr. Smith launched a website displaying all-inclusive pricing for various surgical procedures, a move that has gained him and the facility, national and even international attention. Many Canadians, uninsured Americans and beneficiaries of self-funded health plans have been treated at his facility, taking advantage of the low and transparent pricing available. The Surgery Center, located in Oklahoma City, Oklahoma, has gained the endorsement of policymakers and legislators nationally. In 2014, he co-founded the Free Market Medical Association, an organization whose mission is to promote the application of free market principles. Self-funded insurance plans take advantage of Dr. Smithâs pricing model because it results in significant savings to their employee health plans.
He has made many appearances on an array of national television programs and has been featured in Forbes, Time Magazine, the New York Times and other print media.
Surgery Center of Oklahoma https://surgerycenterok.com/
@SurgeryCenterOK https://twitter.com/SurgeryCenterOK
Free Market Medical Association https://fmma.org/
Atlas Billing Company https://atlasbillingcompany.com/
Episode 3: "The Story of the $100 hospital aspirin" | Surgery Center of Oklahoma https://www.youtube.com/watch?v=y9H0CGgMnAM
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Alfie Kohn is a prolific author and expert on the psychological and organizational effects of rewards, incentives and competition. As a longtime fan of his thinking and writing, it was a huge treat (no pun intended) for me to talk with him about the counterproductive impact of incentive systems in the workplace. In 2018, the 25th Anniversary Edition of Kohnâs superb book, Punished by RewardsâThe Trouble with Gold Stars, Incentive Plans, Aâs, Praise, and Other Bribes was released. In the years since the original publication, other experts piled on scholarly articles and best-selling books confirming the deleterious effects of financial rewardsâespecially when critical thinking, creativity, and collaboration are needed. But alas, organizational leaders continue to fuel the swarms of compensation consultants who promise to tweak the organizationâs existing incentive system into an even better incentive-based compensation scheme. You know, into one that actually worksâŚ
We discuss intrinsic motivation, which is when motivation arises from within and there is inherent satisfaction in performing a task. And Mr. Kohn contrasts that with extrinsic motivation, when behavior is performed because of outside causes such as rewards or to avoid punishment. Rewards, like punishment, increase compliance and diminish intrinsic motivation which creates reliance on extrinsic motivation in order to perform.
Alfie Kohn points to the fact that attaching an incentive signals the undesirability of a task and thus devalues it. Incentives or rewards are also control mechanisms, and people inherently do not like being controlled by others or manipulated into performing tasks.
And how does a BSM (business school mindset) contribute to the prevalence of incentive compensation systems? By definition, the BSM relies on control, measurement and comparison. Alfie Kohn describes a parallel in the education sector with increased reliance on the sterile formulations of economists to apply measurement and mathematical models to teachers and students. He rails against this relentless tendency of those in charge to âdo things toâ people instead of choosing more democratic methods of âworking withâ others in an organization.
In This Episode:
â˘Gadflyâa person who interferes with the status quo of a society or community by posing novel, potentially upsetting questions, usually directed at those in power
â˘Perverse incentiveâan incentive that results in making the issue worse (if youâre in healthcare youâll have no difficulty coming up with examples)
â˘Rewards do motivate because they motivate people to go after more rewards (see perverse incentivesâŚ)
â˘Competitionâin order for one person to âwinâ he must defeat another and this is deadly for collaboration
â˘Frederick HerzbergâAlfie Kohn cites this author of one of my favorite classic articles (One More TimeâHow Do You Motivate Employees? Harvard Business Review)
Meet Alfie Kohn
Alfie Kohn is the author of 14 books, including NO CONTEST: The Case Against Competition and PUNISHED BY REWARDS. In addition to his many writings on education and parenting, his articles on management include "Why Incentive Plans Cannot Work" in the Harvard Business Review and "Competition versus Excellence" in the New York Times. Fortune magazine has called Kohn âAmericaâs most biting critic of money as motivator.â He has keynoted conferences across North America and abroad, as well as presenting at such organizations as AT&T, BMW, Dial, Mattel, NASA, and Pfizer. Kohn lives (actually) in the Boston area and (virtually) at alfiekohn.org.
Alfie Kohn's Website: https://www.alfiekohn.org/
Alfie Kohnâs appearance on Oprah with a demonstration of the effects of incentives on teenagers: https://www.youtube.com/watch?v=_6wwReKUYmw
One More TimeâHow Do You Motivate Employees? https://drive.google.com/file/d/1yOLNSj54DG8GDPJbGBn93RR3lhoXMR7r/view?usp=sharing
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My guest is Dr. Roger Fowler, Vice President, and Chief Medical Director of Quality, Performance and Innovation with CHRISTUS Health in Irving, Texas.
As an expert in population health, quality, and healthcare reform, Dr. Fowler offers a rich perspective on the historical events that underpin our current state of U.S. healthcare. His belief is that we must move away from payment systems that reward the quantity of procedures performed, and move toward those programs that reward excellent outcomes for patients and the community.
Dr. Fowler describes how quality measures themselves have their origins in the way insurance companies ranked desirable vs. undesirable physicians based on each physicianâs claims data. It was all about costs. The use of the term Medical Loss Ratio (MLR) is an important reminder of the insurance industryâs perspective about medicine vs. the perspective we as physicians have. MLR means that the resources spent on providing medical care for patients is the Loss referred to in this acronym. A family medicine physician for 40 years, Dr. Fowler says when he first heard medical care referred to as a loss it was like fingernails on a blackboard for him.
Dr. Fowler has compelling stories of how the healthcare system goes haywire. He talks about the unintended consequences of early âhospitalization insuranceâ and EMTALA regulations and he laments the various ways unscrupulous characters cash in on patientsâ vulnerabilities.
His expertise and patience almost meet their match with my ignorance about Medicare programs. He labors to help me understand some of the key points of Medicare Advantage, Traditional Medicare, ACOs, Shared Savings programs, and more. After we finished our conversation, I requested a CME certificate.
As a patient advocate and expert on population health and quality, he is passionate about getting to a reasonable level of spending on primary care (currently only 5-6% of U.S. healthcare spending is on primary care). He believes doubling the dollars spent on primary care would make significant inroads to address U.S. cost and quality woes.
See the newsletter episode #34 for a glossary of some of the terms discussed: https://bit.ly/LTLmoreinfo
Meet Roger Fowler, MD
Dr. Fowler is the Vice President and Chief Medical Director of Quality, Performance and Innovation with CHRISTUS Health, an international not-for-profit health system with hospitals, clinics, physicians and staff in five states and in Latin America.
Dr. Fowler envisioned, launched and provided leadership for the department of Population Health for the Trinity Clinic in Tyler, Texas, before that organization merged with CHRISTUS Health. Ultimately, he became the Chief Medical Director of Population Health and Health Plans, and CMO for the CHRISTUS Health Quality Care Alliance (ACO) and CHRISTUS Quality Network (CIN). Most recently Dr. Fowler assumed leadership for the Pharmacy and Quality Improvement departments for the health plan and the Medical Management Department.
Dr. Fowler has a broad history of administrative and governance roles, including chairman of the Trinity Clinic board for five years. He began his career as a family medicine physician in a solo practice in 1981 in Kilgore, Texas, providing full spectrum family medicine care. He is a husband, father, grandfather and has been a runner for 43 years.
https://www.linkedin.com/in/roger-n-fowler-md-faafp-14513236/
[email protected]
https://bit.ly/JAMAarticleEP34
https://bit.ly/AAFP_articleEP34
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Leah Houston, MD is a serial entrepreneur, emergency medicine physician, and activist. She is the founder of: HPEC: Humanistic Physician Empowerment Community is a platform physicians can use to own and store their own digital identity and credentials. A secure, self-sovereign identity is the foundation for restoring physician autonomy. (Find out why!)
EverCred: The system used by institutions to manage certification data and issue physician credentials that puts physicians in control of the primary source verification process.
Dr. Houston joins me on the podcast with Florida attorney Abbigail Webb. Ms. Webb raises an alarm about the loss of physician autonomy and points to the striking differences in professional autonomy between the medical profession and the legal profession. She raises questions about why non-physicians are in control of healthcare institutions and physician practices. She underscores how compromised physicians are in their ability to meet their fiduciary duty to patients because of the obvious conflicts of interest in healthcare systems run by non-physicians. In the U.S., only lawyers are allowed to own law firmsâin marked contrast to ACA language (link to glossary below) that prohibits physicians from owning hospitals.
She draws additional comparisons between medicine and law:
â˘Legal oversight bodies such as State Bars and State Supreme Courts are made up of attorneysâunlike medicine where regulatory bodies have a variety of competing agendas creating oversight policies for the medical profession.
â˘Law firms are not publicly traded because lawyers are not allowed to be governed by or beholden to the interests of non-lawyer shareholders. Contrast that with the behemoth Fortune 50 healthcare systems driven by a profit motive, not medical professional values.
â˘Lawyers are not subject to non-compete clauses because it is deemed unethical to restrict clientsâ ability to freely seek legal assistance from whomever they choose. The 70% of physicians who are employed are very often hamstrung in their career decision-making by non-compete clauses.
â˘The legal profession closely safeguards the practice of law, not allowing non-lawyers or paraprofessionals to hang out a legal shingle or use terms like lawyer, attorney, or Esq. Not so in medicine, where consumers and patients are unclear, sometimes misled, about who is a physician.
Ms. Webb believes quality of care for patients would be served by physician leadership of healthcare and she is an advocate for the digital solutions that Dr. Houston proposes.
What are those solutions?
Moving ownership of physician credentials to physicians themselves. This can be accomplished by storing credentials in an immutable, immediately accessible, blockchain wallet. A self-sovereign identity (SSI) means physicians themselves retain control and thus provide the primary source verification of their credentials and decide who has access and for how long. HPEC provides this capacity for physicians to have a wallet containing their credentials (and other digital assets). Dr. Houstonâs other company, EverCred, provides a mechanism and platform for certifying bodies to issue credentials directly into decentralized identity wallet systems (like HPEC, but others as wellâas long as they use rigorous established security standards). These systems are in development with pilot projects underway including a physician training program that is issuing credentials directly into HPEC.
The use of blockchain for establishing secure self-sovereign identities (SSI) for physicians opens the door to Dr. Houstonâs bigger vision of physician autonomy and leadership. This includes: physicians creating their own referral networks; establishing patient records that belong to the patient (and not a healthcare system that uses patient data for their own profit-motivated purposes); and physicians establishing specialty-specific or other groups that advance physiciansâ professional interests. She refers to the latter element as a âdigital physician guild.â
Click the link for a glossary of blockchain and episode #33 terms. https://us19.campaign-archive.com/?u=933cc24c82771ef6017b37225&id=83d997e6e9
Meet the Guests
Leah Houston, MD
Dr. Houston is an emergency medicine physician and entrepreneur who has been a part of the blockchain and distributed ledger technology community since 2012. She is the founder of HPEC, building a platform to revolutionize the way physicians interact with health systems, insurance companies, and most importantly patients. HPEC gives practicing physicians ownership of their professional brand in a digital space through blockchain enabled self-sovereign digital credentials and identities. This will create employment mobility for physicians which will provide a mechanism for them to restore their autonomy and control over the sacred doctor patient relationship.
Dr. Houston is active on social media and is an internationally requested speaker and author on the topic of self-sovereign identity in healthcare.
https://twitter.com/LeahHoustonMD
https://twitter.com/HPECid
HPEC-Humanitarian Physicians Empowerment Community https://www.hpec.io/
Abbigail Webb, JD
Ms. Webb is a Florida Licensed attorney and General Counsel for a multistate automotive organization, with a background in litigation and business, consumer finance, and banking law. She has expertise in dispute resolution and enterprise risk reduction. She is an economic empowerment and financial literacy teacher, as well as a Bitcoin technology advocate.
https://www.floridabar.org/
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My guest this week is national healthcare leader Dr. Jack Cochran. As CEO of the Permanente Federation, he was the top national leader for over 20,000 physicians who cared for more than 10 million people in their Kaiser Permanente medical practices. In this animated conversation, the inspiring and articulate Dr. Cochran describes his non-linear and unexpected path to executive leadership and international activism on behalf of excellent and accessible healthcare.
In his early days as a practicing plastic surgeon, Jack encountered the healthcare system in a different way when his parents became ill. As he says, âfour years of medical school, six years of surgery residency, five years of practicing surgery, did nothing to prepare me to be the son of dying parents.â This pivotal time changed him. Jackâs appreciation for all caregivers, especially nurses, led to the creation of nursing programs and a nursing scholarship that has endured for 33 years.
We worked together when he was selected for his first CEO role which prompts Jack to recall both his trepidation and his gratitude during this initiation into leadership. Encouragement from well-respected leaders who had âcourage, values and substanceâ inspired Jack to take on a role which he says he was not prepared for.
Quick to call himself naĂŻve at the time, Jack began his executive role with a listening tour, speaking personally with 500 physicians, 4-5 at a time throughout the region. What Jack heard, was shaped into the 3 constants:
â˘Preserve and enhance the physician career
â˘Streamline the care process
â˘Optimize the care experience
Determined to change a failing culture, Jack thoughtfully selected his executive team. This diverse group was made up of passionate, respected clinicians who were determined to keep the patient at the center of their decisions. The âColorado turnaroundâ resulted in transformation of the organizationâs reputation, finances, quality, serviceâand at the root of it allâremarkably ramped-up physician engagement.
When asked how important physician leadership in the C-Suite is he pauses before he responds:
âIâm trying to find a way to be thoughtfully objective and Iâm having trouble.
I think itâs essential. Essential.â
Quotable Jack:
â˘Physicians are not more important, but we are disproportionately impactful.
â˘Medical education and the resulting MD and DO degrees are a âpluripotent professional preparationâ for leadership.
â˘Difference has to be a differentiator.
â˘When you are offered a leadership role: Donât lean your ladder against the wrong wall.
â˘Complexity has made specialty care more primary and primary care more special.
â˘Be very, very careful when people tell you what cannot be done. Be very suspect of advice that tells you exactly why things can't get done or won't get done⌠or are impossible.
Meet Jack Cochran, MD
Dr. Jack Cochran is an innovative leader who has inspired countless physicians and healthcare workers, and driven health care transformation on a national level. He is a plastic surgeon, acclaimed leader, author, consultant, and international speaker.
He led the Permanente Federation which represents the national interests of the regional Permanente Medical Groups, which employ 20,000 physicians caring for more than 10 million Kaiser Permanente members. During his tenure as CEO, Kaiser Permanente was recognized as a national leader in clinical quality by the Medicare Star program and the National Committee for Quality Assurance (NCQA).
Prior to his national role, Dr. Cochran served as Executive Medical Director, President, and Chairman of the Board of the Colorado Permanente Medical Group (CPMG). He led physicians through the transformation of a culture faced with financial challenges as well as declining membership, and poor physician and patient satisfaction.
Philanthropy has long been a part of Dr. Cochranâs life. He has volunteered his reconstructive surgery and consulting services in Third World countries, aiding underserved populations in Nicaragua, the Philippines, Ecuador, Tanzania, and Nepal. He is also a past president of the Consortium for Community Centered Comprehensive Child Care (C6), a foundation that has built hospitals in East Africa. He is a vocal advocate for nurses and oversees the Lois and John Cochran Education Award, an annual scholarship given to oncology nurses at the Lutheran Medical Center in Denver, Colorado.
Dr. Cochran earned his medical degree from the University of Colorado and served residencies at Stanford University Medical Center and the University of Wisconsin Hospital. He is board certified in otolaryngology (head and neck surgery) and in plastic and reconstructive surgery.
Links:
Website: https://jackcochranmd.com/
Books: https://jackcochranmd.com/books/
LinkedIn: https://www.linkedin.com/in/jackcochranmd/
Twitter: https://twitter.com/JackHCochran
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Lisa Marchiano is a Jungian psychoanalyst and cohost of the marvelous âThis Jungian Lifeâ podcast. We discuss Swiss psychiatrist Carl Jungâs work and the implications for physicians and the ailing medical profession.
Lisa explains that Jung believed: âWe are all on a path toward wholeness. The goal of life is to become more wholeâand when that path is blocked in some way, we get symptoms.â
Unlike the so-called manualized therapies (following a manual with techniques outlined for various diagnoses) there are no prescribed âtechniquesâ in psychoanalysis. The conversation and the relationship that is created between the analyst and patient are the therapy. Lisa Marchiano says that the therapist doesnât have the solution but rather it arises from the wisdom of the patient. âI see my job as creating the space where the patient and I can listen for that solution to come forward.â
Lisa offers this WHIRLWIND TOUR OF THE PSYCHE ACCORDING TO JUNG:
Persona: The mask we adopt based on our role (e.g., CEO or professor or caregiver). It is useful and socially adaptive and allows us to meet the demands of our culture but becomes a problem if we over-identify with a persona.
Ego: This is the conscious personality, when I say âIââ thatâs the ego. Itâs the part of our personality that gets stuff done and also manages our inner world of emotions.
Personal Unconscious: Things weâve forgotten about or repressed but that still affect us and motivate us.
Collective Unconscious: A more mystical element of Jungâs framework which points to broad patterns of behavior and motifs (archetypes) that are not inherited from recent ancestors but are a priori and related to instincts.
The Self: A central non-verbal intelligence that is considered the unconscious guiding self or in Jungâs words: the God within.
The concept of the unconscious is central to Jungâs work. The process of becoming whole, or individuating, involves being open to the unconscious Self and bringing more of that content into consciousness. Because one access point to the unconscious is the content of dreams, most Jungian analysts pay close attention to patientsâ dreams.
In this episode:
¡Jung believed that most of his patients were suffering from a lack of meaning.
¡âIdeally, physicians are well-placed to have a sense of meaning in this world- but thatâs less and less true.â
¡Medicineâs plight of systemization, corporatization and the loss of autonomy threatens the sense of meaning in this noble profession.
¡There is protection in the transpersonal energy of the physician-patient relationship- but this ability to connect is disrupted in the dehumanizing setting of corporate medicine
¡âWhen you're just a cog and told exactly what to do and you don't have any autonomy - could you still feel like that was meaningful?
¡âDoctors should rise up- those with the heroic energy- and say we need to take this back.â
Meet Lisa Marchiano, LCSW, Certified Jungian Analyst:
Lisa Marchiano is a writer, Licensed Clinical Social Worker, and certified Jungian analyst in private practice in Philadelphia, Pennsylvania. She is the co-founder and co-host of the podcast This Jungian Life. She received her MSW from New York University and completed analytic training at the Inter-Regional Society of Jungian Analysts. Lisa is on the faculty of the Philadelphia Jung Institute. Her writings have appeared in Quillette, the journal Psychological Perspectives, and the Journal of Analytical Psychology. She has presented on Jungian topics across the US as well as in Europe. Lisaâs first book Motherhood: Facing and Finding Yourself explores motherhood as a catalyst for personal growth.
Lisa's webpage: https://lisamarchiano.com
To buy Lisa's book: https://www.amazon.com/Motherhood-Finding-Yourself-Lisa-Marchiano/dp/1683646665
Lisa's podcast with Deborah Stewart & Joseph Lee, This Jungian Life: https://thisjungianlife.com/podcast/
Facebook: https://www.facebook.com/LisaMarchiano/
Twitter: https://twitter.com/LisaMarchiano/
Instagram: https://www.instagram.com/lisamarchiano
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This episode is a continuation of my animated conversation with Professor J.-C. Spender, a nuclear engineer-turned-business school professor, author, expert on the history of business education, and former executive and business school dean.
At the onset of episode #30 I asked Dr. Spender if getting an MBA degree would provide whatâs needed if someone wanted to efficiently manage a healthcare organization.
His response was YES. But he added âthatâs a kind of modified and slightly tangled yes.â
What I heard was âNo.â Take a listen and see what you think.
Professor Spenderâs contrarian penchant is delightful and provocative. He offers no instant gratification: no conversational closure rewarding me with a satisfying hit of dopamine. No schmoozy cooperation providing a squirt of oxytocin. The effect of this professorâs conversational style is attentionâwhat IS he saying? How does this comment jive with that last one? Where are we headed?!
He paints a bleak picture when it comes to the management training or even the management potential of someone who has been awarded an MBA degree. Non-partisan in his criticism, he also deemed my assertion that physicians must lead healthcare as âa misdiagnosis.â And what did I hear with that? I heard that Dr. Spenderâs primary interest is spotlighting the âmultiplicity, the plurality of conversations, that is the fundamental challenge for leadership.â Agreed.
When it comes to leadership and management he would have us attend to:
â˘The history of business education--from whence the âbullshitâ came
â˘Practice (experience) vs. principles (rules)âand the true crucible of leadership when principles donât serve us
â˘Uncertainty as the state which drives the engine of business
â˘The fundamental ethical problem of business: monetizing someone elseâs imagination to serve oneself
â˘The lack of conversation in business school about human beingsâ capacity for imaginationâyet it is imagination which produces an organizationâs value
In this episode:
â˘The balanced scorecardâdeveloped as a remedy to the dominance of finance during board-level strategic conversations
â˘Business geniuses are those who flourish in business as an âartistic mediumâ
â˘The demise in popularity of managerial accounting and the ascendancy of financial accounting
â˘Clouding true intentions by invoking âtrustâ when monetization to satisfy shareholder demands is the business objective
â˘Economic discourse as an arena that is incapable of creating new economic value
â˘Tacit knowledge is knowledge derived more from practice than from principle
â˘Racism and oppression as actions to silence the language of entire communities
For more information including âA Glossary of Sortsâ (aka Spenderisms) see the 11/9/21 newsletter
https://us19.campaign-archive.com/?u=933cc24c82771ef6017b37225&id=91ffd12b00
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J.-C. Spender, PhD, is an engineer-turned-business school professor, an author, an expert on the history of business education, and heâs a former business executive and business school dean. These credentials equip him to have insight into the goings-on of business schools and real expertise in the practical challenges of graduate business education. Dr. Spender has a distinct philosophical bent which surfaces in this episode (and more so in Part 2 of this interviewâEpisode #30). He sports a professorial persona, likely honed with endless graduate students, which means a few pugilistic remarks punctuate our conversation even when we are in âviolent agreement.â
I asked him to come onto the LTL podcast to talk about Managerialism. He and Robert R. Locke co-wrote the book Confronting ManagerialismâHow the Business Elite and their Schools Threw our Lives out of Balance.
Dr. Spender makes it clear from the get-go that controversy related to managerialism must be seen in terms of conflicting values. By necessity, there are distinct values driving people who are involved in the financial or operational details of large organizations. He believes critics of managerialism might suffer from the delusion that itâs possible to run a complex organization without applying attention and resources to maintaining the multiplicity of needs of the enterprise itself. This âidiotic and fruitlessâ stance ignores the fact that friction between managers and professionals represents an inevitable clash of values.
In this episode Dr. Spender says âThe issues of managerialism in the healthcare sector are extraordinarily important--they are the cutting edge of getting a sense of how on earth do we manage these systems?â
In this episode:
-Principles and theoryâthe scaffolding for the actual practice of a profession
-Tacit knowledgeâyou wonât escape this podcast without a clear picture of the critical nature of experiential learning
-Principles and theory must step aside to allow tacit knowledge, practice, and the âreal youâ to assert agency in times of uncertainty
-The mystifying chasm between the business community and business school curriculum
-The âdeadly, fatalâ loss of critique in academic business literature
-Business school faculty priorities: getting published, tenured, and pensioned
-Being âpresentâ vs. sacrificing yourself to a principle
Meet J.-C. Spender, PhD
Dr. Spender is a Research Professor at Kozminski University, Warsaw; an Emeritus Research Fellow, Rutgers Institute for Ethical Leadership; and a Visiting Scholar with Fordham Center for Humanistic Management.
He served in Royal Navy submarines and he worked with Rolls-Royce on nuclear propulsion, IBM on financial computing, and as an investment banker before earning a PhD at the Manchester Business School (UK). He retired in 2003 as Dean of the School of Business & Technology at FIT/SUNY (New York).
He has published eight books, and over 100 journal articles and book chapters. His most recent book is Business Strategy: Managing Uncertainty, Opportunity, and Enterprise (Oxford UP 2014) which is his dissident view of strategy as a practice that includes the need to manage a business's creative responses to uncertainty. He also writes about the theory and ethics of the firm, business strategy, and the history of management education.
In 2014 he was awarded an honorary doctorate in economics by the Lund University School of Economics & Management. He is also Commissioning Editor for the Cambridge University Press Elements in Business Strategy.
For details of his current work, broader interests, and a detailed resume go to: https://jcspender.com/
For a Glossary of Sorts (aka Spenderisms) in this episode, read the 10/19/21 Licensed to Lead newsletter https://us19.campaign-archive.com/?u=933cc24c82771ef6017b37225&id=ef2f8c8df0
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What is the Corporate Practice of Medicine?
In this episode, Brad Adatto, a business law and healthcare attorney, takes us on a journey through the intent, implications, and risks associated with state laws that âbanâ the corporate practice of medicine. He describes how these state laws arise from a variety of legal and regulatory sources, and prohibit corporations (or any ânon-physiciansâ) from employing physicians or owning medical practices.
The Corporate Practice of Medicine Doctrine (CPMD) originated in the early 1900s and sought to prevent:
1. Commercialization of medicine or lay people profiting from physician practice
2. Business interests conflicting with the best interests of patients
3. Obligations of employment interfering with physician decision-making
How do the Corporate Practice of Medicine laws vary by state?
Widely! To further complicate the legal landscapeâthere are big variations in enforcement. Mr. Adatto divvies the states up into three categories:
1. Strict adherence: only physicians can own medical practices (example: New York)
2. Mixed: Physicians and non-physicians can co-own a medical practice as long as physicians own a majority (example: California)
3. Lenient: Anyone can own a medical practice (example: Florida)
How could a physician get in trouble with the Corporate Practice of Medicine?
Well, I have to admit, Mr. Adatto did not reassure me that Corporate Practice of Medicine Laws were the answer to my quest for bolstering physician leadership and physician autonomy. In his business law practice, he not only advises non-physician entities about how to avoid legal snarlsâhe also counsels physicians about how to stay out of trouble with the Corporate Practice of Medicine laws.
Here is some of his advice:
1. Do not assume âbecause everyone is doing itâ your practice structure is legal.
2. Hit âpauseâ and hire a healthcare attorney to make sure the contract you are about to sign protects your interests AND is legal.
3. Have you been asked to be a Medical Director to help out a non-physician entrepreneur and make a few bucks yourself? Donât be an âabsenteeâ medical director just so a non-physician can check the âphysician-runâ box. Itâs YOUR hard-earned license at risk if you are prosecuted for âaiding and abettingâ violations of these laws.
4. Believe it or not, if you submit to corporate practices that could harm patients then you are putting your medical license at risk. Regardless of corporate pressure, poor staffing, prior authorization mandates, or practice management chaosâYOUR obligation is to protect the patient. (THIS is the stuff of burnout and moral injury.)
Wait a minute Brad Adattoâdonât all healthcare systems violate Corporate Practice of Medicine laws? How is this legal?
Our new friend of the show, healthcare legal whiz, and business law podcaster walks us through how corporatized medicine is allowed to exist:
1. Some states allow ânot-for-profitâ systems to employ physicians.
2. Management Services Organizations (MSOs) established by non-physicians (or physicians) can contract with physician groups through a Management Services Agreement (MSA). This structure gives non-physicians an opportunity to profit from medical practices.
3. Even with various exceptions, there must be no interference with the physicianâs clinical decision-making. (After all, corporations are not allowed to practice medicine, right?)
Other questions that are answered in this podcast:
-How is a physicianâs medical license like a Ferrari?
-Why is filing a lawsuit like driving at high speed and throwing your steering wheel out the window?
-Who is always ultimately responsible for patient care?
Meet guest, Brad Adatto, JD
Bradford E. Adatto is an attorney in the business law firm ByrdAdatto. He specializes in regulatory, transactional, and securities law. Having worked in health care law his entire career, he has an in-depth knowledge of the âdoâs and donâtsâ of this heavily regulated industry. He enjoys helping physicians, physician groups and others build successful businesses by showing them how to avoid legal problems, create new opportunities, develop new partnerships, and form new entities. He and Michael Byrd, the co-founder of their law firm, host the Legal 123s podcast together and write extensively about business law on their website blog.
Legal 123s with ByrdAdatto Podcast is available on all podcast platforms. You can listen on Spotify here: https://open.spotify.com/show/2hRPYPo52ZBgbrt3bfVQHU?si=66Q-BYh-Tu2q_N2-0yLRqA&dl_branch=1
Facebook: https://www.facebook.com/ByrdAdatto/
Twitter: https://twitter.com/ByrdAdatto
Instagram: https://www.instagram.com/byrdadattolaw/
LinkedIn: https://www.linkedin.com/company/byrdadatto
YouTube: https://www.youtube.com/channel/UC6VSOw0W5lrrj4iIl1HxTbg
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Pharmacy benefit managers, or PBMs, are companies that manage prescription drug benefits for payers like insurance companies, government programs such as Medicare and Medicaid, and self-insured employers. They are the middlemen and money handlers who negotiate with pharmaceutical manufacturers to determine drug prices and drug placement on formularies. Considering the costly and far-reaching impact of their negotiations, they have been allowed an inexplicable level of unchallenged secrecy in all of their transactions. Their work determines the total cost the payer will spend on prescription medications, the patientsâ access to medications, and how much pharmacies are paid. While their role, ostensibly, is to help control waste and rein in spending on pharmaceuticals, it doesnât appear those goals made it onto most PBM to-do lists. Abject lack of oversight in a for-profit environment has turbocharged the opportunism among PBMs. The three largest PBMs control over 75% of the business, all three are ensconced in the Fortune 50, and all three are facing racketeering charges. There are a slew of investigations and state and federal legislation focused on curtailing predatory behavior by PBMs.
In this episode, I'm tapping the expertise of Dr. Barbara McAneny, an oncologist, CEO and founding partner of the New Mexico Cancer Center, and former AMA president. Dr. McAneny helps me walk through the myriad ways PBMs increase their own profits while causing harm to patients, pharmacists, and doctors.
In this podcast, you will find 13 problems with PBMs including these five moneymaking machinations:
--Discount and Rebate Strategiesâthat INCREASE drug prices
--Spread Pricing â a kissing cousin of skimming
--Administrative Feesâuntil the cows come home
--Mail Order Wasteâa money-making scheme
--Direct and Indirect Remunerationâsurprise billing PBM-style
Meet Barbara L. McAneny, MD:
Dr. Barbara McAneny is nationally recognized as an advocate, an innovator, a business leader, and a doctorâs doctor. She is a board-certified medical oncologist and hematologist from Albuquerque, New Mexico where she is the CEO and co-founder of the multi-specialty, multi-site New Mexico Cancer Center. She also founded the New Mexico Cancer Center Foundation, which provides grants to help patients with nonmedical expenses. In 2012 she received a $19.8 million grant to create an oncology medical home, demonstrating that triage pathways would improve outcomes and also lower costs. The Come Home medical home has been recognized and adopted as a recommended model by CMS. Her leadership roles reach well-beyond New Mexico, including nearly two decades with the American Medical Association leading up to her role as the president of the AMA in 2018.
Resources:
Barbaraâs Website: https://www.barbaramcaneny.com/
â¨AMA: https://www.ama-assn.org/â¨
Twitter: @BarbaraMcAnenyâ¨
LinkedIn: linkedin.com/in/barbara-mcaneny-88636ab
PBMs blamed for step therapy, nonmedical switching, other restrictions on patients by Jason Laday: https://www.healio.com/news/rheumatology/20190821/pbms-blamed-for-step-therapy-nonmedical-switching-other-restrictions-on-patients
The Sopranos of the Pharmaceutical Industry by Kevin Campbell, MD
https://www.washingtonexaminer.com/the-sopranos-of-the-pharmaceutical-industry
Examples of small, non-predatory pharmacy benefit managers:
--WithMe
--Capital Rx
--Navitus Health Solutions
--RxPreferred Benefits
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In todayâs encore episode, I am sharing an excerpt from an earlier episode discussing myths
about physician leadership and dispelling those myths with evidence.
MYTH: a widely held but false belief or idea
Time to bust some of the myths and stereotypes about physicians being arrogant, un-herdable
cats and lone wolves who don't understand teamwork, business or finances.
StereotypeâŚ
#1 Doctors are lone wolves or cowboys who canât get along on a team
#2 Physicians have a command and control decision-making style
#3 Physicians are lousy at managing their money
#4 Docs are greedy and are primarily motivated by money
#5 Physicians are not suited to lead and not capable of running the business
Find out why the stereotypes are not only wrong but are harmful to physicians, staff and
patients. Stereotypes make leadership roles look unappealing to physicians, allow
administrators to wave off concerns by physicians, permit apathy about the need for vigilant
recruiting and selection, and permit avoidance by administrators of tough behavioral issues.
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For todayâs episode, I asked Dr. Barbara McAneny about her upcoming talk: Stop Blaming the Doctors! My main intention in asking Barbara to come back on the podcast (she was a guest on Episode #13) was to have her guide me through the malodorous sewer where Pharmacy Benefits Managers live. But since I had her corralled on Zoom I suggested we both give a preview of our Global Summit presentations. As an oncologist, the founder and CEO of a large, multi-specialty practice, and former AMA president, Dr. McAneny knows her stuff. Enjoy this short Espresso Shot and donât miss the upcoming full-length episode where we wade into the mud and muck of the PBM abyss.
In this episode:
Employed is a big enough problemâREPLACED is bad news for everyone
Physicians can be haunted by the knowledge that there were better options for their patients
Thatâs offensive! There is no such thing as âOncology Liteâ or âNeurology Liteâ
No one is independent. Working interdependently is a hallmark of the medical profession
Tax exempt? Yes. Not-for-profit? Ha! No way.
Meet Barbara L. McAneny, MD:
Dr. Barbara McAneny is nationally recognized as an advocate, an innovator, a business leader, and a doctorâs doctor. She is a board-certified medical oncologist and hematologist from Albuquerque, New Mexico where she is the CEO and co-founder of the multi-specialty, multi-site New Mexico Cancer Center. She also founded the New Mexico Cancer Center Foundation, which provides grants to help patients with nonmedical expenses. In 2012 she received a $19.8 million grant to create an oncology medical home, demonstrating that triage pathways would improve outcomes and also lower costs. The Come Home medical home has been recognized and adopted as a recommended model by CMS. Her leadership roles reach well-beyond New Mexico, including nearly two decades with the American Medical Association leading up to her role as the president of the AMA in 2018.
For more about Dr. McAneny and access to resources including the âCome Homeâ model go to https://www.barbaramcaneny.com/
Resources:
Barbaraâs Website: https://www.barbaramcaneny.com/
Come Home Program: http://www.comehomeprogram.com/
AMA: https://www.ama-assn.org/
Twitter: @BarbaraMcAneny
LinkedIn: linkedin.com/in/barbara-mcaneny-88636ab
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In this encore episode, Iâm touching on some of the enormous quantity of research that has been directed at physician burnout. We have clear and convincing descriptions of the causes of physician burnout. What we donât have, is a lot of action directly tackling those causes.
How is it that healthcare leadership has had a lackluster response to the crumbling careers of those whose credentials are required to open a hospital? Whether itâs the head honchos of healthcare systems, advocacy organizations, or hospitals -- the response to physician disaffection has been anemic. In many cases, disingenuous.â¨â¨
A case in point is captured in this week's encore excerpt. Ten prominent healthcare system CEOs and the CEO of the AMA put their heads together and published Physician Burnout is a Public Health Crisis: a Message to our Fellow Healthcare CEOs. They presented this call to action by saying: âAddressing the issue of burnout is a matter of absolute urgency.â
â¨â¨I walk through their âCall to Actionâ and raise the question: whereâs the action? Where are the decisive moves and hard dollar commitments to knock down barriers and build up solid systems that work? Itâs a cringe-worthy list of waffle words like monitoring, tracking, and trying. In this podcast I offer up a few of my own suggestions that are better suited to be on a list regarded as a âmatter of absolute urgency.â
What will it take to get physicians from being commoditized assembly line workers who pose a flight riskâto well-supported professionals with the autonomy required to serve patients (not profits)? â¨
Hereâs what:
--Leadership courage to speak clearly about the issues, ditch the waffle words and B.S. â and to sponsor real bucks for real fixes.
--A professional leadership ideology that recognizes the following as critical foundational leader traits: superb technical expertise, profound respect among peers and staff, and deep tacit knowledge of the profession.
--New leaders â with MDs and DOs behind their names.
Resources:
Ending Physician Burnout Global Summit
Landon BE, Reschovsky J, Blumenthal D. Changes in Career Satisfaction Among Primary Care and Specialist Physicians, 1997-2001. JAMA. 2003;289(4):442â449. doi:10.1001/jama.289.4.442
Friedberg, Mark W., Peggy G. Chen, Kristin R. Van Busum, Frances Aunon, Chau Pham, John P. Caloyeras, Soeren Mattke, Emma Pitchforth, Denise D. Quigley, Robert H. Brook, F. Jay Crosson, and Michael Tutty, Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, 2013
Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians: A Pilot Randomized Clinical Trial. JAMA Intern Med. 2019;179(10):1406â1414. doi:10.1001/jamainternmed.2019.2425
Schrijver, Iris, Brady, Keri J.S., Trockel, Mickey An Exploration of Key Issues and Potential Solutions that Impact Physician Wellbeing and Professional Fulfillment at an Academic Center. PeerJ. 2016; 4: e1783. Published online 2016 Mar 10. doi: 10.7717/peerj.1783
Frederick Herzberg HBR One More TimeâHow Do You Motivate Employees?
Agarwal SD, Pabo E, Rozenblum R, Sherritt KM. Professional Dissonance and Burnout in Primary Care: A Qualitative Study. JAMA Intern Med. 2020;180(3):395â401. doi:10.1001/jamainternmed.2019.6326
Health Affairs Blog March 2017 Physician Burnout Is A Public Health Crisis: A Message To Our Fellow Health Care CEOs
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In this encore episode I highlight a portion of my conversation with Dr. Patty Gabow, former CEO at Denver Health. During this 15 minute segment, Patty reacts to my question about the value of physiciansâ tacit knowledge and the built-in leadership qualities physicians develop in their training. Listen in as Dr. Gabow weighs in on why physicians must lead, how values must drive healthcare strategy, and why her latest book Timeâs Now for Women Healthcare Leaders is focused on doing what it takes to get women into leadership positions.
And if you want to hear more about Pattyâs interesting life and career, listen to the full interview in episode #9.
Resources:
https://www.patriciagabowmd.com/
TIMEâS NOW for Women Healthcare Leaders: A Guide for the Journey by Patricia A. Gabow, MD
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