Support independent journalism on Substack and beyond! If you can’t subscribe, consider donating just $2—or whatever feels comfortable—to https://venmo.com/Richard-CBridge; every bit helps keep stories like this alive.
Nate Kaufman
This is Nate Kaufman with the Healthcare Bridge, part of The Common Bridge family of podcasts. Our goal is to have an unscripted, brutally honest conversation with thought leaders in the healthcare industry today. I’m excited to chat with Scott Becker, Esquire. Scott is a lawyer, entrepreneur, one of the first podcasters in healthcare, and an author of a new book. He has been at the forefront of healthcare for decades. I can remember this little memory of actually working with you, Scott, on one of the first ambulatory surgery center deals - so welcome.
Scott Becker
Nate, it’s great to be with you. You know, one of my favorite, favorite people in healthcare and best commentators is Nate Kaufman. I’ve had a chance to watch your work, be surrounded by your work, the impact you’ve had some health systems with physicians, with others, remarkable leadership and thought leader. And you are more opinionated than me, but I’ll try and be interesting today too. I’m going to try, so thank you.
Nate Kaufman
Well, let’s start with something interesting, your origin story. Can you give a little background for people who don’t know you, like who you are, how you got here, and there’s this big Beckers thing that goes on in healthcare. Maybe you can fit that in as well?
Scott Becker
Sure. I’m the founder, publisher, of Becker’s Healthcare, and again, and we spend a lot of time in, obviously, the healthcare world. Becker’s Healthcare is a media company, digital events, conferences in healthcare. The core offerings revolve around hospital health systems, but lots of other areas too. Started it 30 years ago, as Nate rightly reflects on the surgery center world where I started to work. Becker’s Healthcare really grew out of something totally different. You mentioned earlier, Scott Becker Esquire, I’m a lawyer by background. A long time ago, when I was, I would say, a younger lawyer, I was starting to build a healthcare practice. And really the origins of Becker’s Healthcare was not to be a media company, it was really just trying to be involved in the healthcare world and build a brand, what you would call thought leadership today. I don’t know that they wrote a term for it back then, but it was trying to be in the center of healthcare, and particularly in an earlier iteration in the surgery center niche. Started with a Becker Surgery Center brand and offering a newsletter and conference. Then about 25 years ago, we branched out into hospitals and health systems in orthopedic and spine. Hospitals and health systems became the overwhelming majority of what we do in terms of Becker’s Healthcare. Then we’ve got separate events, health IT, and other areas related to healthcare. But really that’s the origin story. It started something very different, then about 25 years ago I got more serious about it as its own thing and started to hire people. Hired a great team, sorted out a great team, have great leadership on the editorial side, on the commercial side, Jessica Cole, she’s been with us for 20 plus years as a CEO, and has just been a fantastic leader and driver. We’ve got 30 something full time journalists that cover the healthcare field constantly. And it’s been a great ride. It’s been great, great fun, and it allows me to talk to people like you so it’s a great thing. It’s really been a chance to learn and to be in the middle a lot of things, and create chances for others to amplify themselves. We have really loved it, and I love the team that we have that really drives it today.
Nate Kaufman
And you still practice law.
Scott Becker
I practice law - kind of. I would say, I advise clients. I’m related to some clients. I still have a great relationship with some clients. I’m very close to the team that we built in the law firm in healthcare. But when somebody says to me today, and says Scott, can you handle our deal? I would say, well, I would, but you’re far better off having this person or that person handle it, who does that full time, who really does that and does that well. You can’t do these things unless you’re doing them full time. You can’t do them at the level of really doing the deals, really doing the transactions, really negotiating the documents, unless you do them all the time. I’d say I’m much more closely aligned with clients on thought and strategy and business and who’s the right person for what they have to do than doing it myself versus directly practicing law.
Nate Kaufman
That brings us to your new book, “Building Great Businesses.” I know it’s on Amazon. I don’t know if it’s pre-order or published or what. Where are we on that?
Scott Becker
Yes, that book is essentially an iteration of something I had done earlier. It’s available for pre-order on Amazon. We’re trying to get people to buy books. Nate, I’ll beg you, after the call, after the podcast, to buy a book. I’ll probably even send you a gift card to do so, we appreciate it. It’s “Building Great Businesses: Create Momentum, Overcome Setbacks and Scale with Confidence.” It’s not a didactic exercise. It’s about 200 plus pages. It’s intended to be an easy read. We hope that people come away from it a little bit inspired, a little bit motivated. Most people that are really evolving in business, it’s not so much that I could teach them something, they could teach me something, but hopefully, a lot of the thoughts resonate with them, and they’re useful for categorizing their thoughts and becoming a little bit more motivated whatever they’re doing: whether building a business, whether in a business, as an entrepreneur, an intrapreneur, or somebody building a great career, because a lot of the thoughts resonate. We just hope it’s helpful and that people enjoy it. I’ve asked a lot of people to buy it, so I’m hoping that when they get it, they’re not like, oh my god, this is awful. I think it’s solid. It’s an improvement over something I’d done years ago and we’ll see how it goes. It’s allowed me to do one of the things I love doing, which is connect with a lot of people over this six month period. It’s coming out in June. It’s for pre-order on Amazon. I won’t go through the whole spiel. I’m pushing people to pre-order right now, and I will bother you when we’re done to pre-order it, but I’ll send you a gift card to do it.
Nate
You’ve already bothered me once and I plan to pre-order it. So you wrote a book on building great businesses and scaling and all that stuff, and you are exceptionally knowledgeable about healthcare systems. Are our healthcare systems great businesses at this point?
Scott Becker
I don’t know that you would call the health systems great businesses. The health systems that we have in our country do something that’s very necessary in taking care of our people. They’re a challenging business. If you were building something just to be a business, you wouldn’t build it around all the bricks and mortar and all the labor that health systems have to have. But they’re very different things. Our health systems fulfill an absolute critical need for our country, for our people. We’re at a spot where we’ve got 350 million people. We are woefully short and getting shorter of the amount of doctors and nurses we need in this country, particularly doctors, and it’s unpopular to say, but particularly specialists, primary care. We’ve lost the battle, and I don’t mean that in a bad way. I love my primary care physician, but the next generation is not going to have their own primary care physician. The numbers just don’t work. We don’t have enough of them for 350 million people. We’re the third largest country in the world after China and India. Are health systems great businesses? Some are, some aren’t, but that’s not really what they’re there for. I mean, HCA is there to be a great business, and they are a great business. Most of our not-for-profit health systems run at 1-2% margins, 40% of hospitals run below margin. But that’s not their mission. COVID, if it proved nothing else, [showed] the hospitals are still the safety net for our country. They’re just absolutely critical. You could like them and could hate them, you could criticize them, you could criticize the level of administrative cost, all those kinds of things and I get all that, but they are labor intensive businesses. They’re bricks and mortar intensive businesses, and they’re full, so we need them, we’ve got a growing aging population. Judging them, I can’t judge them against the NASDAQ company. If you’re a NASDAQ company, you want to be short on labor, high in technology, and very short on bricks and mortar. Well, that’s not the mission that hospitals have. It’s just not. That’s not the mission. So it’s like, are they great businesses? They are needed and fantastic. They’re needed - not all of them - they’re overall needed and fantastic. In the overall, people don’t give the health system enough credit. There are so many challenges with the health system. It’s great and it’s challenged. We are the third largest country in the world after China and India. We take care of 350 million people. We’re short on resources. The health systems, are they great businesses for investing? No, but for what they do for us, yes. I mean, different judgment.
Nate Kaufman
I agree. I know you’re very active in private equity (PE). You do tons of podcasts, I think one podcast dedicated to PE. One of the issues about hospitals, as you mentioned, is they’re anchored in these bricks and mortar, which are essential. But anything that’s not tied down, it looks like somebody’s going to try to create a business out of it, whether it’s surgery centers or imaging centers or just personnel, like anesthesia. I mean, how do you feel about the fact that there are all of these peripheral companies that are taking the best business out of the hospitals?
Scott Becker
Yeah, I don’t know that I have an absolute judgment on it. You’ve got 7-8% of physicians employed at the end of the day by private equity sponsored companies, 7-8%, and we have one insurance company that employs 8-9%, so I don’t know that I have an absolute moral compass on that. The insurance companies are for profit too. The private equity companies are for profit. Hospitals manage themselves good, they manage themselves bad. You’ve got about - I forget the latest number - 8% of hospitals that are private equity funded or sponsored one way or another. And within that there are some really well run ones and there are some really poorly run ones. But there are some really well run not-for-profits, and some really poorly run not-for-profits. I don’t have any absolute like it’s this capital structure or it’s that capital structure. Private equity is a bad partner when you’re in a low margin business and you add debt to it. So for example, people criticize private equity around the Steward Health Care situation, and rightfully so, because low margin business loaded up with debt doesn’t work. But you have to remember, of the 34 hospitals that became part of Steward, there were probably ten of those that were failing before they were acquired by private equity. Private equity exasperated some of the problems for some of those, but there were some deep problems. A lot of the private equity ends up acquiring hospitals that need a purchaser, they’re not acquiring the best but the ones which are really in trouble, not well run houses. And so you can’t blame ten of the 34 hospitals that Steward acquired on private equity if ten of those were broke when Steward acquired them. Private equity is not the answer. The capital is not the answer. All these things are great distractions for politicians, from my perspective. The politicians on the left; we need coverage for all. The politicians on the right; we need a free market. The reality is we have a real supply and demand problem. We don’t have enough doctors to take care of our people. You and I are the age that we know so many people that have died of cancer, we know so many people have died of sub-specialty cancers. And you get into these sub-specialties, there are two people in the country that know that area or there are three, and if that person’s on a vacation, you can’t get that person, your friend dies, literally, not an exaggeration, literally. The bench in specialties is so short, and our politicians spend so much time on platitudes: coverage for all or free market. What’s happened? Coverage for all, great. I think we should have coverage for everybody. I agree with that, but coverage for all without fixing the supply problem is like writing a check you can’t cash. It’s an enormous slogan. I agree with it. I want coverage for all, but don’t talk about coverage for all without figuring how we’re going to fix the supply problem, which is horrible. It’s just getting worse. You and I have better access than most people, because we’re connected, we know people, stuff like that. But even with people like you and I, it’s hard to get the right specialist for the right problem with the right time for the right person. So think about that for the 90% of the population that’s not connected, this supply and demand thing. You want to talk about fixing health equity, you can’t fix health equity with a lot of slogans on the left and right. You can’t fix it without fixing supply. Supply is everything, and if you don’t run up doctors, people who get hurt the most are people in the health equity care that can’t afford stuff. It’s a debacle. But our politicians spend no time on what counts - supply and demand - they spend all their time on platitudes around free market or... Free market has led us to turn over a huge amount of the federal fiscal to big managed care companies, and that just has ended up being a cluster. When I see them in Washington yelling at the managed care companies, they’re yelling at a problem that Washington created, together with the insurance side. But it’s a problem Washington created. We turned over the federal fiscal to the big, big insurance companies, both for Medicare and Medicaid, it led to the situation of what we call other people’s money. People are all spending other people’s money. It’s led to huge inflation in healthcare cost. It’s not led to fixing the supply/demand problem. It’s been just a disaster, and it’s getting worse, not better. It’s political theater to see those in Washington yelling at the insurance companies when it’s those in Washington that fund the insurance companies.
Support independent journalism on Substack and beyond! If you can’t subscribe, consider donating just $2—or whatever feels comfortable at by sending via Zelle®—to rich@richardhelppie.com
Every bit helps keep stories like this alive.
Nate Kaufman
What I say is that the biggest health care benefit organization on the planet is the federal government, and every four to eight years that company - all the executives - are replaced by somebody who won a popularity contest and may or may not have any competency in healthcare. As a result of that, what would you expect of any company? You sure can’t build a great business if every four to eight years you’re replacing people based on popularity contests. I want to go back to your issue about supply, because I think people don’t understand that when physicians and nurses are in short supply, costs are going to go up because they’re going to demand higher payments. That’s where I live all day, is negotiating those kinds of agreements. And so the issue of affordability and price caps, I mean, these are really dangerous, because what they could create, in my opinion, is less supply for the people that need it most. So access becomes the bigger problem in the end. Your thoughts?
Scott Becker
That’s one hundred percent right. When you look at supply and demand, if you don’t have enough doctors... you talked about private equity, you talked about health insurance companies; there are not enough doctors. Those that could afford to buy up the doctors, buy up the doctors, then there are less doctors for everybody else. And so you talk about that, then you talk about tiers of health care. You used to have commercial versus governmental versus indigent. Now you’ve got another whole tier that’s come into play for the top 10% of wealthy people in the country, which is this concierge world. In the concierge world - I don’t blame the doctors one bit, there’s a shortage of doctors, a lot of them are getting crushed - if they could do concierge and see 300 patients a year, 2000 a piece, and have a base, and then they bill insurance - God bless them. But when you move people towards concierge, there are plenty of states in the country where you can’t get a primary care doctor without paying concierge, and this is a disaster from a health equity perspective. I don’t blame the doctors one bit. I applaud them. In my area, you’ve got increasing concierge for internal medicine. You’ve now got it for cardiology practices. You now have a dermatology practice in the area that charges an an administration fee which is concierge. And so it’s a supply and demand issue you have. Doctors are overwhelmed. They don’t have time, and if they can find a little bit easier way to make a living, God bless them. But from a health equity perspective, as you break this down further, concierge versus commercial, it used to be commercial you had the access you wanted. More and more challenging, Medicare, Medicaid, depends what state you’re in, how those look. And then the indigent, we were on the phone the other day with health system leaders from Banner Health and Honest Health, and they’ve got another 700,000 people with no insurance this year. That becomes real value-based care, there’s still some private care to them, so how do they take care of them at a reasonably low cost because they’re going to eat the cost of that. And so you have more and more of that as people end up off of insurance rolls. I’m not saying we created this horrendous problem. We need subsidies for people to get insurance, because insurance costs now $35,000 a year for a family of four. People need subsidies for it. But whenever we have subsidies, we increase the cost of everything, because people are paying for something with other people’s money. You end up in a situation where you’ve got these subsidies, you sort of need them, because the average families in our country make $70-80,000 a year. Insurance is now $30-35,000 a year. The numbers just don’t work at all. They just don’t work and so you’ve got to have subsidies. But at the same time, anytime you subsidize things... I mean, you and I went to college a long time ago before it was expensive like it is today, but the education industrial complex has made college unaffordable, and a big part of it is we’re lending a lot of people a ton of money go to college. The people aren’t spending their own money, at least in the first instance. So colleges can then raise and build their own industrial complex. Now, the cost to go to some of these colleges is $50-100,000 a year, and that just doesn’t make any sense. The cost benefit analysis, what you get out of that college, what your jobs are afterwards, the numbers don’t make sense, but it’s all built on other people’s money system that somebody else is paying for. You go to college, even though you don’t realize you’ve got to pay that loan back at some point. It all feels okay until you’ve got to pay it back, but it’s a disastrous system. We’ve got a similar thing in healthcare. It’s not that we move towards price transparency, fixing everything, but this concept of flooding all the money through the insurance companies and them flooding it down, we’ve sort of gotten what we’ve designed and it’s a debacle.
Nate Kaufman
You live in Chicago, and the University of Chicago has these behavioral economists, and I was listening to one of them the other day. What they talk about is, does the industry need just a light nudge or does it need a shove? Now, from my perspective, value-based care is a nudge. Accountable Care Organizations (ACOs) are a nudge, the American Society of Anesthesiologists (ASA) is a nudge. Our industry is... and as you said, supply is going to become an issue, and actually - excuse the expression - trump affordability. That’s the primary concern. What do we need to do as an industry? Do we need a shove of some sort? And if so... for example, my belief is Medicare and Medicaid somehow or another have to start paying the cost of care, at the same time the commercial rates need to come down. I’m thinking about some form of neutralizing the effects of Medicare and Medicaid, because I think that causes our problem. Do you have any thoughts about shoves?
Scott Becker
I think at the end of the day, what I worry about in our country is you could talk about all the payment policies you want. If you’re on the fee for service side, there’s X percent abuse fee for service. We used to joke, if a person had 12 toes, a podiatrist would bill for 12 toes. But there’s some abuse on that side. On the managed care side, what people call value-based care, it’s an unfair narrative that one “kind of” cares. Value-based care is not [that] because if you go to a surgeon and he or she does a great job for you, they think they’re providing good value for care, whether it’s the fee for service or value-based care. Value-based care has been a term stolen by the managed care industry. Is it more effective? Who knows? At the end of the day, value-based care - with all the value-based care providers - cleaned up during COVID for the absolute wrong reason. They are doing exactly what we pay them to do. During COVID they did great because procedures and screenings weren’t being done, so medical cost ratios went down to 78-80% - everybody cleaned up. It was fantastic, but that’s just as bad as the abuse on the fee for service side. That’s worse, actually, that’s denying care. When Washington complains about the insurance companies denying care using pre-authorizations, well that’s exactly what we’ve turned up with the federal money for them to do, which is to try and control the cost of care. We’re used to having access at a rational cost, now the rational cost has gone way out of control. I think at the end of the day we’re going to end up with the situation... I already saw it. I had a friend who had a melanoma of the eye, died of it. There are two specialists in the country that deal with that. When one specialist is on vacation, you couldn’t get the help you need. You see this a lot. You and I are at of age where you know enough people who died of cancer - and even young people know enough people who have died of cancer - to know it. But what they don’t understand is how short the supply is in different places. Until finally, these Washington people, the congressman, say I couldn’t get access to my doctor, well, that’s not because of the insurance company, that’s because we don’t have residency spots. We’ve got the situation in our country where [doctors] are not practicing until they are 31. In other countries - and we’re the huge beneficiary of this - they’re done by age 27-28. In our country, they’re part time by 40-45, fine, God bless, but we need enough doctors to fill those gaps. We’re trying to do so many of the wrong things versus the right things. If you want to take care of deep sub-specialties, we need the best and brightest in medicine, and we need them out somehow another by age 30. If you made med school three years versus four years, it probably wouldn’t make a difference. If we made residencies three years or four years, we’d lose a little bit, but wouldn’t make a difference. At the end of the day, you do so much in the long run, learning and practicing. Medical education - our country was built before the internet, literally - so it’s still based on a ton of rote memorization. And the proof is we have so many important immigrant doctors from other countries that are educated in a shorter period of time. It’s not like we have to say, oh my god, it’s a big risk. We can’t do that. They’re doing it in other places, and we’re the beneficiaries of it here. We could talk all we want about payment systems; do it this way, do it that way. I would say, like, James Carville, it’s not the payment system, the problem is supply and demand. If we don’t fix that, we’re going to get to the spot... by the time you fix, like you talked about, the four, eight year problem, by the time you really make a plan and long term fixing the supply problem with specialists, it takes several years to develop those specialists. So by the time we actually decide to take it seriously, we’re going to lose 10-20 years of healthcare that we desperately need for an aging population. You know this because we go to places in Texas where there’s one neurologist for 500,000 people. In Minnesota, there’s one dermatologist for every 500,000 people. It’s just the numbers just don’t work. Washington has been immune to a lot of it. The rest of us see it. You and I have access. But even now, you and I can only bother our friends so much to get access without driving them crazy. I have to be very careful when I ask this person or that person for access for family members, it’s like there’s only so much they can give.
Announcer
Before we dive back into today’s enlightening discussion, we have a quick message for all you Common Bridge enthusiasts out there. Did you know that you can find this episode and over 300 more on Substack as part of the Common Bridge series. You can also find written columns and opinions as well. Subscribe at TheCommonBridge.substack.com for a full Common Bridge experience. There you can comment and express your opinion on all the topics we cover on this and the past seven seasons of our podcasts. If you’d rather support the show without subscribing, you can do so with Zelle at Rich@RichardHelppie.com or use Venmo at Richard-CBridge. Thanks for listening. Now back to the episode.
Nate Kaufman
The other issue is that Medicare has made many practices unaffordable to be independent. For those who don’t know, over two decades, Medicare has increased their payments to physicians by maybe 10%. They’re now cutting payments to specialists. I apologize when I go to see a specialist for being on Medicare. I seriously do. They have to find some place for income security, and they end up going to the hospitals or health systems who end up employing them. Now what’s happening is the policymakers - a lot of them who are paying academics for research and stuff like that - are saying, well, we’ve got to cut the commercial reimbursement to hospitals. But ultimately, what that’s going to do is cascade down, and they’re not going to be able to afford the physicians to practice in the market and you’re going to have a big access crisis.
Scott Becker
You have a generation of policymakers that resented what specialists made, and so they ended up constantly cutting specialists, it’s a horrendous, horrendous policy. It’s a horrendous thing. There’s some kind of craziness in it that people hate the fact that that doctor makes $500,000, that one makes $700,000. I’m not talking about the doctors like the skin doctor who does thousands of mostly clean-up procedures. I’m not talking about that. I’m talking about your average specialist who makes a lot of money, but went to school till they’re 32. Whatever they make within reason is fantastic, and they need it, and we need the best and brightest. A generation ago, our parents would have said, be a doctor, lawyer, an accountant, whatever we’re going to be. You’ve got another whole generation now that said, I’m not going to be a doctor, that’s ten years, I’d rather be in computer science, investment banking, whatever it is - good people just assigning to a different career path because you made it too hard. You’ve got a whole Washington establishment that look down on those people for being in a high income specialty. The amount they work, the amount they do, God bless them, we need them. Everybody hates them until you need one. In Chicago, we’re down to a handful of brain surgeons and we’re in a major city. Imagine, in the rural area and you need brain surgery, you’re obviously not going to the rural [hospital] you’re coming to a hub. But even in the major metropolitan area, you get past a few of the people, and you’re out of the top brain surgeons. That’s it. It’s a disaster. It’s horrendous. Policy gone wrong by a lot of bureaucrats on the right and the left that resent people that make money. Specialists do great work, and they ought to get paid for it.
Nate Kaufman
I got criticized the other day on the internet a little bit by some academic who got up and said, here’s the answer: site neutrality. Reduce payments for this, reduce payments for that. And I said, overly simplistic solutions to complex problems usually end up with some unintended consequences. Someone criticized me for that. But that’s exactly what’s going on in healthcare.
Scott Becker
People can criticize in a vacuum. Hospitals get reimbursed like this: they got the 340B thing, they’ve got this thing, they’ve got that thing. What they don’t understand is we’ve developed this ridiculous quilt work of how hospitals get paid. Taking aside the for profit hospitals, most hospitals are running at a very small margin, 40% of margins of hospitals are running below margin. To your point, a huge amount of physicians are employed by systems, and the more that hospitals can’t make it go, the less that they get paid, the less people that want to go into medicine. It’s a ridiculous system, and when people criticize, they can always criticize the one piece about how health systems get paid. Many health systems have to be the right size, the right amount of people. Some have built crazy bureaucracies, but by and large, they are doing what we need them to do, and they are the safety net for our country. So killing hospital reimbursement or going after one piece of it without recognizing it’s a quilt work, how we got there. It’s to your point of a nudge versus a real solution. You can’t take away one part of it without recognizing this is how they make it work. It’s not right, but somehow or another, we’ve got to fix it. The AHA (American Hospital Association) has been pretty powerful. They’ve always done a pretty good job. If they get killed in reimbursement here, they make it up there. In the old days I did a lot of work in the surgery center environment, and people would ask, why won’t the payer just use that surgery center company versus the hospital? And here was the issue; that outpatient surgery center was 3% of the payer’s budget. The hospital costs were 30%, so even if they took the surgery out of the hospital to the surgery center - and a lot did it - somehow or another, that hospital was their biggest supplier in town, so they still had to work in the hospital, and they had to find other ways to get the hospital the money. It made more sense to me to understand why the payers and hospitals had to try and figure this out together, versus just go to the lower costing service. You mentioned earlier, there are lots of different pieces being spun out and that’s been going on for a long time now - good or bad - but holistically, we do need some concept of enough doctors. We need enough hospitals. We’ve got to take care of people. Unfortunately, it can’t be a total free market, because already 50% of it’s paid for by government.
Nate Kaufman
A lot of health systems actually, I hope, will listen to this podcast. What’s your advice? We’ll ask about health systems, and then we’ll ask about patients. What is your advice about health systems?
Scott Becker
Well, for health systems, I do go back to a couple of concepts we talk about a lot, which is, most health systems have to figure out what are they going to be great at, where are they going to be great. Working with the health system here, they’ve got to be deep in a few areas and be really good in the place to go to, and also to take care of the community which are very challenging, competing goals. I was at an airport kiosk in one of both of our favorite systems city, the Hartford Health system. Hartford Healthcare, which has done this tremendous job of filling a need in the state of Connecticut, over the years. The improvement they made over the last 20 years is amazing. They’ve made this real effort to be technology first, to be very close to people, to take care of people, and have clarity about their mission. So I say it about systems. They have to be great at something. They have to have great clarity about their mission, what they’re trying to do. Hartford did a really good job early on of building alliances with lots of physicians and really doing a nice job of growing a system between the leadership of Jeff Flaks and Elliot Joseph. They just did a great job of it, and with a lot of your consulting, quite frankly. But they’re one of the real success stories over the last 20 years. They’re coming from like a nothing system into a great, great system. We have one here; Endeavor Health system, has become a great system. But even these systems that have become great have to constantly focus on what are they going to be great at. What’s the clarity of what they’re doing? There’s a great system in Florida - I mean, there are a lot of great systems in Florida, and I’m not talking about AdventHealth, which is fantastic, and some other systems are great - but NCH, Naples Community, has tried to build into a much larger, better system. You need people that have a vision, that really want to be great at things. You need to look at systems, you can’t be a commodity. You have to take care of everybody, but you can’t be a commodity. You’ve got to figure out what are you going to be great at. We think about that for systems often and it’s very easy as a system to slowly lose your edge, to slowly not be great, to where your veneer looks good, but you’re not really great. One of the things about healthcare that I love is every one of us is a consumer. You can hear all the PR about a health system, but when you’re in a hospital bed at night and there’s one person on the floor, you feel like you’re in a desert. It’s a very scary place to be. You know what it’s like. You know when you’re having good care. You know when you’re well taken care of and you know when you’re not. Health systems have to figure out what are they going to be great at. I love the fact that we’re all consumers, because all of us see this one way or another. Ten years ago, they were advertising 30 minute wait times in ERs, now it’s three hours. And that’s not the fault of the health system. That’s where we’re at as a system, we’re overloaded in so many places. We’re in short supply in so many places. People default to going back to the ER. Never in our lifetime, did you and I think that would become a thing again, where the default was to go back to the ER. Again, there are so many other good solutions, but it’s a real challenge. And people do it not because they’re uninformed consumers, people are very smart. They know where they have to go to get taken care of. We’re not geniuses, but we all sort of know, like, I don’t take my grandma or my mom to the ER - my grandma passed away 30 years ago, so if I take her to the ER, I’m in trouble - I don’t take my mom to the ER because I have a ton of choices. I take her there because I need to take her there. There’s not a good answer at that point, and you’ve got all these things that are overloaded because there’s not enough access points, there’s not enough doctors, and not enough nurses and so forth. We’re doing better on nurses than we’ve done in a long time in producing nurses, graduating nurses, but doctors we’re so woefully short. It’s so bad and we need to get better at it.
Nate Kaufman
You mentioned concierge docs, I will confess that my psychiatrist, who I desperately need, and my primary care doctor are both concierge physicians who’ve opted out of Medicare, who don’t take any insurance. By the way, there’s nothing in the world that’s better than a good doctor. (Scott Becker: 100%.) The point is that I’ve got great doctors. It’s not cheap, but you are absolutely right, in this direct primary care, they limit their practices to 600. The average primary care doctor, I think they burn out after seven years. Everyone talks about, oh, the answer is primary care. Well, it takes 31 years to bake one of those muffins.
Scott Becker
Well, we’re never getting there. And the thing is, a great doctor - I’ve had the same primary care doctor forever, I love him - the next generation is not going to have that. When my doctor retires, I’ll either have to go without it. In Illinois, I could do that. Where we’re at in other towns I can’t do that. You end up with this very transactional health system where you go to the urgent care for this, go for that, and it’s not a good way to do it. We’re never getting back to all of us having primary care, it’s just not going to happen. Psychiatrists, another area where we are woefully short. In our country, psychiatrists, we’re just totally short in behavioral health resources. It’s a booming disaster, and until enough people feel it, it’s no good. But to go back to this point, I hate politicians on every side of the table. I hate them all. I think they’re all almost worthless at solving problems. You have Gavin Newsom this week, bragging about, I’m a 950 SAT guy, I should be governor or president, and it’s not about any of that, but I want my doctors to be 950 SAT guys. I want the best and brightest attracted to medicine. I want the best and brightest of every color, every gender, attracted to medicine. There’s nothing better. Obviously, every doctor today is going to be supplemented by AI, they’re going to need it; if you’re an oncologist, you are overwhelmed. You’re going to need technology next to you to tell do the best you can. It’s brutal, but you need bright people doing stuff. We have great PAs, we have great nurse practitioners, great nurses, everything, like doctors. It’s a continuum of very good to very bad and all over the board, and you have to navigate that as a patient, but we want the best and brightest. In a perfect society, the best and brightest wouldn’t all be doing law, they’d be doing medicine. I mean, pretty clearly, you’d prefer it - research, science, medicine.
Nate Kaufman
What advice do you have for patients to deal with this crazy health business?
Scott Becker
Patients, at the end of the day, like my mother and sister are great examples to me of patients. They both suffered from different cancers, different challenges, and they are complete and constant advocates for their own health. They’re constantly trying to make sure they’re on top of their health, you have to. You and I are old enough to know you have to make physical and mental health a priority, and you’re in charge of it. Your doctor is going to make mistakes. They’re imperfect and you can’t be too mad at them, they’re going to make mistakes. They’re not going to be perfect, but you have to be the advocate of your health. My sister and my mother do a tremendous job of constantly making sure they’re on top of stuff. They’re dealing with stuff, constantly policing their own health and it’s a full time job, literally. I mean, it’s not good or bad. They’ve done a tremendous job of it. They’re examples to me. But as a patient, you have to take care of your physical, mental health on the front end, and then you’ve got to be constantly taking care of it. It’s baseline for everything else that we do, and you have to navigate the system, it’s not easy. I don’t know if there are easy ways to develop relationships, stuff like that, but you have to take care of your own care and figure out the best way you’re going to take care of your care and know where you’re going when you get a more serious problem. In our area, there’s a system we go to for certain things. There’s another system we go to for certain other things. And the one system that does the highest acuity, most complex surgeries, is not as good at just general day to day care, coordination and all the other things we need. But you have to take care of yourself, know your systems, and you’ve got to go to the right place for the right things and it’s not easy.
Nate Kaufman
How often do you get calls from people saying, where should I go for this? I would say I get at least a couple calls a month.
Scott Becker
One hundred percent, I’d say it’s around there. And then you try and advise them, and you can’t. Like, every time that that happens, I can’t text my local doctor leader or local CEO or local this guy, because those people would stop taking my texts. So it depends on the situation, it depends how serious a problem it is. When my mother had a serious problem, then we call the hospital president and say, Oh, my God, I need help. Can you help us, can we get the right person? If somebody else has a problem, it depends on what it is and how serious a problem it is. If I have a problem, until it’s really a problem I don’t call anybody I know to ask for help. I take care of it because I don’t want to bother them until I have to.
Nate Kaufman
The point is that, unfortunately, you know an insider. It’s always good to consult an insider when you have a problem in healthcare today.
Scott Becker
One hundred percent agreed. The insiders that I know are trying to be, and are, very, very helpful. The flip side is their bandwidth is also limited, because if you went back X years, it was easy for them. Now they’re trying to deal with their own staffing shortages and problems. I agree with you, knowing an insider, there’s nothing better. I mean, we’ll have an offline discussion; you do the concierge thing, we do something else, but there are different ways to deal with that and it’s really challenging. And you think about that, you and I have access and means to do those things; 90% of the country does not. That’s a disaster. If you think of how hard it is for people that know some people and have connections, if it’s that hard for us, other people don’t even know what they’re not having, I think, because they’re so removed from having insider connections. It’s not good. But it comes back to what we talk about all the time, which is supply and demand. There are not enough doctors, then when there are shortages, equity gets crushed. You could talk all you want about health equity, about all these things, they always get crushed in every society - communist, capitalist - every society, it gets crushed when there’s not enough supply. If you’re in a communist country, it goes to all the dictators and the elites. If you’re in a capitalist country, it’s not too different, I mean, it goes to the people that are wealthy and can afford it. But the real answer is DC, when they talk about coverage for all, I’m on board. I want coverage for all, but don’t give me coverage for all without fixing the supply problem. On the right, they talk about free market healthcare. Government’s already paying 50% healthcare. We don’t have a free market in healthcare. We need to fill the gaps and figure out how to fix the supply issue. This concept, years ago - obviously multiple different iterations of all of our thinking - when Hillary Clinton said, we’re not going to need so many doctors, because managed care is going to handle it all, that was obviously just wrong. When managed care said, well, we’re going to get killed by this, that was wrong too, because managed care is sort of the house; they always seem to win. They always seem to make money. But both were very wrong. And at the end of the day, when you have problem solvers in Washington... you see some governors in the country, they’re truly problem solvers, there are not that many, most of them are politically all over the place, you’ve got a few. The guy in Ohio seems to me to be generally a problem solver. There are different governors, problem solvers versus politicians constantly. And in Washington, we have too many politicians. There’s so little actual solving problems. I hear these people say platitudes, coverage for all platitudes, free market. Oh my god. What’s the problem we have? The problem is we’re 10,000 specialists short. Let’s get 10,000 more resident spots tomorrow, so that in ten years, we won’t have this problem, that we’re creating enough specialists in enough different areas. People say, well, AI and preventive health is going to take care of all of it. I’m a trust but verify person. I’m a trust but verify person: technology plus people. That’s my perspective on it, Nate.
Nate Kaufman
All right, well, is there anything else? We’re getting close on time. Is there anything else that you want to mention or talk about that we haven’t covered?
Scott Becker
No, I don’t have anything to mention. To me, it’s like one of the great pleasures in my professional career is getting to deal and talk to you, Nate, so this is fantastic. I mean, it just is fantastic. I love your thinking. I love your posts. You’ve got a position, a point of view on things, and I just love it. I agree with you a lot of time. I don’t always agree on everything, but overall, I’m huge fan of your thinking and what you do and how you approach things. I think you’ve done a wonderful job, like, I see the work you did with Hartford Healthcare, some other places - remarkable. So to me, it’s a great pleasure to be here with you.
Nate Kaufman
It’s definitely a pleasure meeting with you. You are one of the definitive healthcare leaders, and you’ve always been on the forefront. It’s been a lot of fun talking to you. Anything else, Scott, before we go?
Scott Becker
I got nothing, Nate, you’ve talked me out. It’s been great.
Nate Kaufman
Coming to you with the Healthcare Bridge, thanking Scott Becker for his time, and we’ll call it a podcast. Thanks, Scott.
Scott Becker
Thank you so much.
Editor’s Note: We hope you enjoy the content you have just seen. If you’d rather just listen to the podcast, click the button above to Apple Podcasts: The Common Bridge. It is also available on all other podcast platforms. We offer this program in it’s entirety to our paid subscribers, and welcome all to subscribe below.
You can also help the show by contributing in any of these methods:
• Venmo. https://venmo.com/Richard-CBridge
• Via Zelle. rich@richardhelppie.com
• Buy Me a Coffee. buymeacoffee.com/RichHelppie
You can also send an email to Editor@TheCommonBridge.com
Thanks!
