Health system executives continue to tell us that the top issue now keeping them up at night is workforce engagement.
Exhausted from the COVID experience, facing renewed cost pressures, and in the midst of a once-in-a-generation rethink of work-life balance among employees, health systems are having increasing difficulty filling vacant positions, and holding on to key staff—particularly clinical talent. One flashpoint that has emerged recently, according to leaders we work with, is the growing divide between those working a “hybrid” schedule—part at home, part in the office—and those who must show up in person for work because of their roles. Largely this split has administrative staff on one side and clinical workers on the other, leading doctors, nurses, and other clinicians to complain that they have to come into work (and have throughout the pandemic), while their administrative colleagues can continue to “Zoom in”. There’s growing resentment among those who don’t have the flexibility to take a kid to baseball practice at 3 o’clock, or let the cable guy in at noon without scheduling time off, making the sense of burnout and malaise even more intense. Add to that the resurgence in COVID admissions in some markets, and the “help wanted” situation in the broader economy, and the health system workforce crisis looks worse and worse. Beyond raising wages, which is likely inevitable for most organizations, there is a need to rethink job design and work patterns, to allow a tired, frustrated, and—thanks to the in-person/WFH divide—envious workforce the chance to recover from an incredibly difficult year.
In theory, the idea of salaried compensation for employed physicians makes a lot of sense. For one thing, it’s blessedly simple, with the potential to remove the tensions that arise in shifting to value-based payment or implementing lower-cost (but lower-reimbursement) care models like telemedicine.
However, medical group leaders have long feared that productivity would tank if doctors were put on salary. (As a consulting colleague said recently, the switch to salary would cause a 20+ percent drop in productivity in the medical group, creating a challenge akin to keeping an airline profitable after removing a quarter of the seats on its planes). We’ve been expecting that more doctors might seek stable compensation models in the wake of the pandemic, and so weren’t entirely surprised when the question of moving to straight salary came up in three conversations over the past two weeks.
In all three cases, leaders are hoping to create more predictability, and to decrease the resources and effort needed to execute against a menu of complex plans. They believe that a move to salary is inevitable, and their questions have more to do with timing.
Gauging when to make the move should be determined not by external market shifts, but by internal cultural and operational readiness. Are the systems in place to enable doctors to work at a high level of efficiency? And do we have the group collaboration needed to maintain high performance without paying doctors as if they are salesmen on commission?
Another wrinkle has popped up for groups who might be ready now: the past year has upended the benchmarks that groups might otherwise use to inform decisions on where to set salaries. Nevertheless, over time we expect more groups to move in this direction, with the hope of getting off the “hamster wheel” of compensation committee meetings and ever more exotic permutations of bonus plans, in search of a more stable model.
As we reported recently, healthcare M&A hit record highs in the first quarter of 2021—with deal activity in the physician practice space surging 87 percent. The graphic above highlights private equity firms’ increasing investment in the sector over the last five years. Both the number and size of PE-backed healthcare deals have increased substantially from 2015 to 2020, up 39 and 45 percent respectively.
In 2020, physician practices and services comprised nearly a fifth of all transactions, with PE firms driving the majority. One in five physician transactions involvedprimary care practices—a signal that investors are banking on profits to be made in the shift to value-based care models.
Meanwhile, PE firms are still rolling up high-margin specialty practices, with ophthalmology, orthopedics, dermatology, and anesthesiology groups all receiving significant funding in 2020. PE investment in physician practices will likely continue to accelerate, as investors view healthcare as a promising place to deploy readily available capital.
But we remain convinced that private equity investors have little interest in being long-term owners of practices,and will ultimately look for an exit by selling “rolled-up” physician entities to health systems or insurers.
Exactly 300 years ago, in 1721, Benjamin Franklin and his fellow American colonists faced a deadly smallpox outbreak. Their varying responses constitute an eerily prescient object lesson for today’s world, similarly devastated by a virus and divided over vaccination three centuries later.
As a microbiologist and a Franklin scholar, we see some parallels between then and now that could help governments, journalists and the rest of us cope with the coronavirus pandemic and future threats.
Smallpox strikes Boston
Smallpox was nothing new in 1721. Known to have affected people for at least 3,000 years, it ran rampant in Boston, eventually striking more than half the city’s population. The virus killed about 1 in 13 residents – but the death toll was probably more, since the lack of sophisticated epidemiology made it impossible to identify the cause of all deaths.
What was new, at least to Boston, was a simple procedure that could protect people from the disease. It was known as “variolation” or “inoculation,” and involved deliberately exposing someone to the smallpox “matter” from a victim’s scabs or pus, injecting the material into the skin using a needle. This approach typically caused a mild disease and induced a state of “immunity” against smallpox.
Even today, the exact mechanism is poorly understood and not muchresearch on variolation has been done. Inoculation through the skin seems to activate an immune response that leads to milder symptoms and less transmission, possibly because of the route of infection and the lower dose. Since it relies on activating the immune response with live smallpox variola virus, inoculation is different from the modern vaccination that eradicated smallpox using the much less harmful but related vaccinia virus.
The inoculation treatment, which originated in Asia and Africa, came to be known in Boston thanks to a man named Onesimus. By 1721, Onesimus was enslaved, owned by the most influential man in all of Boston, the Rev. Cotton Mather.
Cotton Mather heard about variolation from an enslaved West African man in his household named Onesimus. Bettman via Getty Images
Known primarily as a Congregational minister, Mather was also a scientist with a special interest in biology. He paid attention when Onesimus told him “he had undergone an operation, which had given him something of the smallpox and would forever preserve him from it; adding that it was often used” in West Africa, where he was from.
Inspired by this information from Onesimus, Mather teamed up with a Boston physician, Zabdiel Boylston, to conduct a scientific study of inoculation’s effectiveness worthy of 21st-century praise. They found that of the approximately 300 people Boylston had inoculated, 2% had died, compared with almost 15% of those who contracted smallpox from nature.
The findings seemed clear: Inoculation could help in the fight against smallpox. Science won out in this clergyman’s mind. But others were not convinced.
Stirring up controversy
A local newspaper editor named James Franklin had his own affliction – namely an insatiable hunger for controversy. Franklin, who was no fan of Mather, set about attacking inoculation in his newspaper, The New-England Courant.
From its first edition, The New-England Courant covered inoculation. Wikimedia Commons
One article from August 1721 tried to guilt readers into resisting inoculation. If someone gets inoculated and then spreads the disease to someone else, who in turn dies of it, the article asked, “at whose hands shall their Blood be required?” The same article went on to say that “Epidemeal Distempers” such as smallpox come “as Judgments from an angry and displeased God.”
In contrast to Mather and Boylston’s research, the Courant’s articles were designed not to discover, but to sow doubt and distrust. The argument that inoculation might help to spread the disease posits something that was theoretically possible – at least if simple precautions were not taken – but it seems beside the point. If inoculation worked, wouldn’t it be worth this small risk, especially since widespread inoculations would dramatically decrease the likelihood that one person would infect another?
Franklin, the Courant’s editor, had a kid brother apprenticed to him at the time – a teenager by the name of Benjamin.
Historians don’t know which side the younger Franklin took in 1721 – or whether he took a side at all – but his subsequent approach to inoculation years later has lessons for the world’s current encounter with a deadly virus and a divided response to a vaccine.
That he was capable of overcoming this inclination shows Benjamin Franklin’s capacity for independent thought, an asset that would serve him well throughout his life as a writer, scientist and statesman. While sticking with social expectations confers certain advantages in certain settings, being able to shake off these norms when they are dangerous is also valuable. We believe the most successful people are the ones who, like Franklin, have the intellectual flexibility to choose between adherence and independence.
Perhaps the inoculation controversy of 1721 had helped him to understand an unfortunate phenomenon that continues to plague the U.S. in 2021: When people take sides, progress suffers. Tribes, whether long-standing or newly formed around an issue, can devote their energies to demonizing the other side and rallying their own. Instead of attacking the problem, they attack each other.
Franklin, in fact, became convinced that inoculation was a sound approach to preventing smallpox. Years later he intended to have his son Francis inoculated after recovering from a case of diarrhea. But before inoculation took place, the 4-year-old boy contracted smallpox and died in 1736. Citing a rumor that Francis had died because of inoculation and noting that such a rumor might deter parents from exposing their children to this procedure, Franklin made a point of setting the record straight, explaining that the child had “receiv’d the Distemper in the common Way of Infection.”
Writing his autobiography in 1771, Franklin reflected on the tragedy and used it to advocate for inoculation. He explained that he “regretted bitterly and still regret” not inoculating the boy, adding, “This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”
A scientific perspective
A final lesson from 1721 has to do with the importance of a truly scientific perspective, one that embraces science, facts and objectivity.
Smallpox was characterized by fever and aches and pustules all over the body. Before eradication, the virus killed about 30% of those it infected, according to the U.S. Centers for Disease Control and Prevention. Sepia Times/Universal Images Group via Getty Images
Inoculation was a relatively new procedure for Bostonians in 1721, and this lifesaving method was not without deadly risks. To address this paradox, several physicians meticulously collected data and compared the number of those who died because of natural smallpox with deaths after smallpox inoculation. Boylston essentially carried out what today’s researchers would call a clinical study on the efficacy of inoculation. Knowing he needed to demonstrate the usefulness of inoculation in a diverse population, he reported in a short book how he inoculated nearly 300 individuals and carefully noted their symptoms and conditions over days and weeks.
The recent emergency-use authorization of mRNA-based and viral-vector vaccines for COVID-19 has produced a vast array of hoaxes, false claims and conspiracy theories, especially in various social media. Like 18th-century inoculations, these vaccines represent new scientific approaches to vaccination, but ones that are based on decades of scientific research and clinical studies.
We suspect that if he were alive today, Benjamin Franklin would want his example to guide modern scientists, politicians, journalists and everyone else making personal health decisions.Like Mather and Boylston, Franklin was a scientist with a respect for evidence and ultimately for truth.
When it comes to a deadly virus and a divided response to a preventive treatment, Franklin was clear what he would do. It doesn’t take a visionary like Franklin to accept the evidence of medical science today.
On Thursday, the Biden administration issued the first of what is expected to be a series of new regulations aimed at implementing the No Surprises Act, passed by Congress last year and signed into law by President Trump, which bans so-called “surprise billing” by out-of-network providers involved in a patient’s in-network hospital visit.
The interim final rule, which takes effect in 2022, prohibits surprise billing of patients covered by employer-sponsored and individual marketplace plans, requiring providers to give advance warning if out-of-network physicians will be part of a patient’s care, limiting the amount of patient cost-sharing for bills issued by those providers, and prohibiting balance billing of patients for fees in excess of in-network reimbursement amounts.
The rule also establishes a process for determining allowable rates for out-of-network care, involving comparison to prevailing statewide rates or the involvement of a neutral arbitrator, but falls short of specifying a baseline price for arbitrators to use in determining allowable charges. That methodology, along with other details, will be part of future rulemaking, which will be issued later this year.
Of note, the rule does not include a ban on surprise billing forground ambulance services, which were excluded by Congress in the law’s final passage—even though more than half of all ambulance trips result in an out-of-network bill. Expect intense lobbying by industry interests to continue as the details of future rulemaking are worked out, as has been the case since before the law was passed.
While burdensome for patients,surprise billing has become a lucrative business model for some large, investor-owned specialist groups, who will surely look to minimize the law’s impact on their profits.
This week, the Supreme Court declined to hear an appeal challenging Medicare’s 2019 regulation calling for “site-neutral payment” for services provided by hospitals in outpatient settings, clearing the way for the rule’s implementation. The appeal was filed by the American Hospital Association (AHA), along with numerous hospitals and health systems, after a lower court ruling last year upheld the change to Medicare’s reimbursement policies.
The rule aims to level the playing field betweenindependent providers and hospital-owned clinics by curtailing hospitals’ ability to charge higher “facility fees” for services provided in locations they own. Site-neutral payment has been a longstanding target of criticism by health economists and policymakers, who cite the pricing advantage as a driver of consolidation in the industry, which has tended to push the cost of care upward.
The AHA expressed disappointment in the Court’s decision not to hear the appeal,saying that the changes to payment policy “directly undercut the clear intent of Congress to protect them because of the many real and crucial differences between them and other sites of care.” The primary difference, of course, is hospitals’ need to fully allocate their costs across all the services they bill for, making care in lower-acuity settings more expensive than similar care delivered by practices that don’t have to subsidize inpatient hospitals and other costly assets.
Over the years that legitimate business need has turned into adeliberate business model—purchasing independent practices in order to take advantage of higher hospital pricing. As Medicare looks to manage Baby Boomer-driven cost growth, and employers and consumers grapple with rising health spending, expect increasingly rigorous efforts to push back against these kinds of pricing strategies.
Warren Buffett is no doubt one of the few business icons who can deliver the gift of wisdom and truth when we need it most. And those truths, when you really stop and consider them, are always spot-on.
When you’re nearing your end of life, your only measure of success should be the number of “people you want to have love you actually do love you,” he answered.
“I know people who have a lot of money, and they get testimonial dinners and they get hospital wings named after them. But the truth is that nobody in the world loves them,” said Buffett. “If you get to my age in life and nobody thinks well of you, I don’t care how big your bank account is, your life is a disaster.”
That’s right, a self-made billionaire says that the amount you are loved — not your wealth or accomplishments — is the ultimate measure of success in life.
To give and receive
Love is one of the most powerful emotions a human being can feel, and yet, we still live in an individualistic society of keeping up with the Joneses: We forge ahead with our business ventures and strategically plan our career paths in hopes of finding fame and fortune. We feel we’ve finally arrived at the top when we’re able to vacation twice a year to exotic islands and drop a European luxury car (or two) in the garage. We dream about having all of these things, love be damned.
“The problem with love is that it’s not for sale,” Buffett told the students. “The only way to get love is to be lovable. It’s very irritating if you have a lot of money. You’d like to think you could write a check: I’ll buy a million dollars’ worth of love. But it doesn’t work that way. The more you give love away, the more you get.”
So how can we follow Buffett’s principle of success in a way where we can truly leave behind a legacy? The path of putting love into motion is a daring and courageous one, but here are a few ways to do it:
1. Be selfless and don’t expect anything in return
The laws of love are reciprocal. When we choose to love someone unconditionally by encouraging and believing in them, love comes back in full force through respect, admiration, trust and loyalty.If you get to my age in life and nobody thinks well of you, I don’t care how big your bank account is, your life is a disaster.Warren BuffettCHAIRMAN AND CEO, BERKSHIRE HATHAWAY
What’s more, when we receive those things, we become more self-compassionate. A 2011 study conducted by the University of California found that self-compassion can increase motivation, willpower and the ability to recover from failure. Another study, published in 2007 in the Journal of Research in Personality, concluded that people who have self-compassion are more likely to be happy, optimistic and show personal initiative.
2. Be empathetic
Empathy is one of most common traits of likable (or, as Buffett prefers to say, “lovable”) people. True empathy occurs when you’re able to step into someone else’s shoes and see their perspective.
Empathy also plays a major role in a person’s potential to influence others. In a DDI study of more than 15,000 leaders across 20 industries, researchers found that the ability to listen and respond with empathy was the most critical driver of a team’s overall performance.
3. Make work enjoyable and fun
When you enjoy work, you enjoy life. In Carol J. Loomis’ biography of Buffett, “Tap Dancing to Work: Warren Buffett on Practically Everything,” she mentions a quote from Buffett: “I love every day. I mean, I tap dance in here and work with nothing but people I like. There is no job in the world that is more fun than running Berkshire, and I count myself lucky to be where I am.”
The evidence here is clear: In positive and uplifting cultures where people share the same values, beliefs and norms, you’ll find a high-performing group of people who attract folks of the same kind.
4. Treat others the way they want to be treated
As children, we’re often taught the Golden Rule: “Treat others as you want to be treated.” But the Platinum Rule takes it to a whole new level: “Treat others the way they want to be treated.”
When we follow the Platinum Rule, we can be more certain that we’re respecting what they want, instead of projecting our own values and preferences. That doesn’t mean we should ignore the Golden Rule altogether, but we should realize its limitations given that every person and every situation is so different.
5. Follow your passion
If you want to have your dream career, you must follow your passion. It’s that simple. Many of us take our cushy paychecks and job security for granted, even though we might hate our jobs and would rather be doing something else — something we actually love.
As humans, doing what we love is a major contributor to true happiness in life. So if you don’t know what your passion is, it’s time to figure that out.
What makes someone extraordinary? As a retired FBI agent with more than 40 years of studying human behavior and performance, no question has captivated me more.
Extraordinary people have a wisdom and way of being that inspires and commands respect. They energize you with their wisdom and empathy. You want them to be your friend, neighbor, co-worker, manager, mentor or community leader.
The 5 traits of extraordinary people
Surprisingly, the qualities that make these people stand out aren’t related to their level of education, income or talents (say, in athletics or art or business).
As it turns out, based on thousands of observations, there are five traits that set exceptional individuals apart from everyone else — but you must have the entire set, and not just one or a few.
Self-mastery brings out your best in whatever you do through dedication, curiosity and adaptability.
Usain Bolt, the fastest human to ever live, didn’t achieve that status merely through athletic ability. He achieved it through self-mastery: He learned, sacrificed, worked hard and remained diligently focused. Michael Jordan, the greatest basketball player of all time, did the same.
But another side to self-mastery is knowing our emotions, strengths and, more importantly, our weaknesses. By understanding ourselves, we know things like when others should take the lead, when today is not our day or when we need to confront our demons.
Start attaining self-mastery by asking:
What areas need attention?
What knowledge, training or skills will help me pursue my goals?
What can I do now to initiate change?
How can I better myself through books, mentors, organizations, video tutorials or online classes?
2. Observation
We’re taught to look, but not to observe. We look to see if we can cross the street safely or what supermarket line is moving the fastest. It’s a passive experience that’s useful, but may not provide complete information.
Observing, on the other hand, is active; it requires effort, but the results are more enlightening. It’s about using all our senses to decode the world in real time for a more informed understanding of our environment and of others.
By working as an FBI agent and as an ethologist, I’ve developed my sensitivity for reading the needs, wants, desires, concerns and preferences of others — all crucial information for understanding and communicating with people.
The most observational people have a skill set that many lack. They instantly know:
What they are seeking and whether there may be multiple explanations.
How context and/or culture factors in.
How they can validate their observations and conclusions.
How to prioritize, separating the inconsequential from the essential.
3. Communication
We communicate constantly. Do it right and people will adore you. Do it wrong and you create doubt, indifference, even anger.
Exceptional communication skills elevate the quality of your relationships. It’s not about communicating perfectly, but rather effectively — and that builds trust. Here’s how:
Address emotions first. We cannot think or communicate clearly until emotions are dealt with. This is where reading body language is helpful.
Build rapport through caring and kindness. It can be verbal or nonverbal: a wave or an outstretched hand to acknowledge or welcome. Mirroring your companion’s gestures goes far.
Be prompt. Answering emails and calls promptly shows that you value others. Bad news shouldn’t be delayed, nor should gratitude and affirmation.
Listen to validate. Listen not only for what is said, but also in what order and how often certain words are mentioned. Repetition of a topic, for example, can shed light on unresolved or underlying problems.
4. Action
Our actions are the nonverbals that show who we are, what’s important to us and how we feel about others.
You can’t fully master this trait without the previous three: Self-mastery prepares us for possible actions to take based on what’s happening; observation allows us to understand the situation in context so we can act appropriately; communication allows us to give and receive the information and support to act.
Exceptional individuals weigh four major factors when making decisions:
Do my actions build trust?
Do my actions add value?
Do my actions positively influence or inspire?
Do my actions benefit others?
5. Psychological Comfort
Psychological comfort is a state where our biological and emotional needs and preferences are met.
It forms the bedrock of our mental and physical health, driving everything from our relationship choices to the brands we buy. We thrive when we have psychological comfort, and it’s especially essential in difficult times.
Since we’re primed to receive psychological comfort, it doesn’t take a grand gesture — it just takes the right one. It could be a calm voice, a kind word, an acknowledgment, a thank you note, a welcoming smile or suggesting a break.
Psychological comfort is where self-mastery, observation, communication and action join forces, helping you recognize and provide what best reduces unwanted emotions like stress, fear or apprehension.
It’s simple: In the 21st century, whoever provides the most psychological comfort wins.
HENRY KOTULA 
