April 14, 2025 • 36 mins
Episode Overview:
In this episode, MGMA consultant Adrienne Lloyd sits down with Jill Arena, a nationally recognized expert in medical practice operations, to discuss the growing need for financial fluency among physicians. Jill shares insights from her work with the Physician Leadership Project and offers practical strategies for improving financial transparency, navigating payer mix, and creating a safe learning environment for clinical leaders.
Key Topics Covered:
- 02:19 – Jill explains the financial literacy gap for physicians and how the Physician Leadership Project helps close it.
05:44 – Medical training’s “knowledge shame” culture and why physicians struggle to ask financial questions.
07:23 – Embezzlement is widespread: 83% of practices are affected. Jill discusses the urgent need for transparency and oversight.
10:09 – Reframing capital requests: Jill shares how she guides physicians through financial trade-offs instead of just saying “no.”
14:20 – “All patients are created equal, but all payers are not”: A clear framework for understanding RVUs, payer mix, and financial viability.
20:43 – Creating safe spaces for financial education: brown bags, pre-meeting Q&A, and planting “starter questions.”
26:49 – Using benchmarking data to drive productivity and encourage top-of-license work for both physicians and staff.
28:03 – Harnessing physician competitiveness with transparent performance data and peer-led learning.
Resources:
To see other episodes of the Women in Healthcare Podcast, watch the video versions on YouTube, or apply to be on an upcoming episode, please visit:
Additional MGMA Resources
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Adrienne Lloyd (00:04):
Everyone, and welcome to the latest edition of
Women in Healthcare podcasthosted with MGMA. I am Adrienne
Lloyd, and I'm excited to behere today with Jill Arena and
really just excited to share.Jill is the CEO of Healthy
Practices and leads itsoperations. She's a nationally
recognized expert in medicalpractice, finance and
(00:25):
operations, as well as revenuecycle management and leadership
development. She's a serialentrepreneur, which I love, and
has co founded several differententities and as a frequent
speaker and convener in themedical community.
And if you've been to a, MGMAconference in the last few
years, you've probably seen heron the stage or seen her at, in
(00:45):
one of the exhibitor booths, butjust has a wealth of knowledge.
She has, is also the author ofPhysician Heal Thy Financial
Cell, which was written forphysicians who want to master
the finances of their practices.And she produces a weekly
podcast for physicians andadministrators called Medical
Money Matters, which is just soimportant. And she also given
(01:05):
her passion for the leadershipdevelopment, also co founded the
Physician Leadership Project in2020, which is a year long
program for high potentialphysician leaders and really
helping just continue to helpthem develop into those formal
leadership roles. And Jill,we're just so excited to have
you and I love so much of whatyou're doing and having worked
with so many physicians over theyears and leadership roles are
(01:28):
just regular roles.
As we all know, there's such agap between what people are
taught in medical school andwhat they actually need to know
in order to be successfulparticipants and then
potentially leaders or owners intheir practices. And I just love
that you're helping helpingthem. So thank you so much for
taking time to be here with ustoday.
Jill Arena (01:46):
Thank you. Thanks for inviting me. I'm excited
about the conversation.
Adrienne Lloyd (01:50):
Me too. Me too. And tell us too. I think you're
tell us where you're based, andwhat's one thing that you love
to do for fun?
Jill Arena (01:57):
Oh, well
Adrienne Lloyd (01:58):
Not doing all of these entrepreneurial adventure.
Jill Arena (02:01):
Based in the beautiful Portland, Oregon. And,
one thing I love to do for fun,I love to visit the Oregon
Coast. And so now I'm gonna outthe Oregon Coast. It's
beautiful. It's a little colderthan the California coast, but,
equally beautiful.
And my daughter and her crazylabradoodle like to go and run
on the beach.
Adrienne Lloyd (02:19):
Oh, I love that. I love that. So kind of diving
in first question, manyphysicians do lack the formal
financial training. How have youfound or created effective ways
to communicate the complexfinancial concepts to leaders
and practice owners? And I knowfor many of us who've been on
the administrator side, reallybeing able to speak the language
(02:40):
in a way that connects with themand, how have you found the
ability to do that?
And what are some suggestionsyou might have for either side
as they're trying to have thoseconversations?
Jill Arena (02:50):
Well, I trained in accounting and finance. So
before I came into healthcarethirty three years ago, I
actually worked as an auditorfor one of the large public
accounting firms. So finance andnumbers is sort of my comfort
zone, right? That's where I goback to. When I have any kind of
question or I wanna analyze apurchase or a strategic
(03:11):
decision, I go to the numbers.
I have found literally in aboutthe last four or five years in
getting started with thephysician leadership project,
where as you mentioned in theintroduction, we get these high
potential physician leaders in.We spend a year with them really
honing those skills. And as youcan imagine, out of 11 sessions
(03:32):
across the year, two of those wededicate to finance. At the
beginning of the first one, weclose the door and we say, okay,
it's Vegas in here. So what'ssaid it here stays here.
And let's now make a list of allthe finance topics that you've
heard and that you'd like tofind. Like, you don't understand
what they need. And then my jobis to hold a straight face while
(03:54):
they make a really big list, ofthings. So that's really been my
learning in the last five yearsis, for the prior, you know,
whatever that is, twenty eightyears of my career, I was
wandering around as a financeand and operations professional,
spouting off all kinds of thingsin board meetings about return
on investment calculations andbudget to actual variances. Just
assuming that all theseintelligent, well educated
(04:16):
people sitting with meunderstood everything I was
saying.
And there was a lot of noddingand smiling. And I imagine our
listeners probably get a lot ofthat in their board meetings.
And what I've learned comingthrough the physician leadership
project work is that we don'tteach accounting and finance in
medical school. That is not athe medical school curriculum
(04:37):
today. That's probably a projectfor my retirement, right, is to
go and infiltrate the medicaleducation system.
Adrienne Lloyd (04:43):
Let me know if I can help. That sounds
Jill Arena (04:45):
great. Absolutely. I'd I'd have a lot of
competitors I think. Really do adisservice to our physicians,
right? We put them through allthis amazing clinical training
and we give them all these greattools for diagnostics and
pharmaceuticals.
And we teach them nothing aboutloss statements or analyzing any
kind of big strategic purchaseor any of that. So understanding
(05:10):
that now this, you know, sort ofat this stage in my career, it's
one of these moments. Oh, I'vebeen running around and spouting
up all kinds of things thathasn't really been helpful. The
other piece of that to sharewith your audience is what I've
learned in having deeperconversations with physicians
about this is that the medicalschools by and large have what I
(05:36):
call a knowledge shame culture.And that means, you know, as the
physician or the physician intraining, you're expected to
have the knowledge.
And you if you don't, you justkeep your head down and you
pretend, or you just hope thatthey don't call on you, because
the attending is gonna, youknow, be all over you if you
don't have the answers. So thatcoming through that and learning
how to function in that kind ofan environment, doesn't lend
(06:00):
itself really well to having theconfidence to stop and say, hey,
can you explain what you mean bybudget variance? Right? Just it
they they don't come out ofmedical school with that
knowledge or the skill setreally Right. To communicate.
And it requires some courage.Right? Put your hand up in the
air and say, I don't know.
Adrienne Lloyd (06:17):
Well, and it's a lot of I mean, I know I've
interviewed and hired a lot ofphysicians over the years and
then talking to them, especiallyif they're new out of fellowship
or residency and, you know,they're trying to compare an
offer maybe that they alreadyhave with one that we're giving
them. And they're giving me I'mlike, well, you know, tell me
about tell me as much as you'rewilling to share. And they're
saying like, well, I'm gonna getx percent after overhead. And
I'm like, well, did they talkabout what's in the overhead?
(06:37):
And it's like, no.
And I'm like, I can hide a lotin overhead. You know? Sure can.
So just, you know, here's somequestions whether you choose a
job with, you know, us or youchoose a job with someone else.
Like, you might wanna ask, like,to really kind of dive into what
does that look like and whatwould you have the ability to
influence and, you know, controlat an individual provider level.
(06:58):
And then obviously, you know, Iwork with a lot of physician
owners of smaller big groupstoo, it's similar, you know, and
they hire managers andadministrators. And I truly
believe, you know, eighty,ninety, 90 five, 90 nine percent
of us are in it for the rightreasons, trying to do the right
thing. But if you don't have theanswers to these questions, you
can end up in situations thatnone of us want to be in. I'm
(07:21):
sure you've had that experiencetoo. The
Jill Arena (07:23):
embezzlement statistics are staggering in
those practices. And I thinkthat MDMA's current statistic is
eighty three percent of medicalgroups. So I like to say, you
know, if you're a physician andyou're out to you know, for
drinks with four friends, know,only one of you has not been
invested at some point. Youknow? It's just crazy.
And those are, you know, 83%,those are the ones we know
about. The really talented onesdo it and move on and you never
(07:46):
know. And I
Adrienne Lloyd (07:47):
think there's the culture, which is so
shocking. And then there'sthere's a culture, and and I
completely understand this. Whenyou're building your practice
and you're starting small, youknow, you wanna hire people that
you you feel like you can trust.You can kinda build this, you
know, family for better or forworse environment, but, at least
you become close to them andthen you wanna trust them. And
if you don't have the answers tothose questions or know what to
(08:08):
look at or trends to dive into,it can be a slippery slope.
One of the things you mentionedtoo, led me one of the things
that came to mind is having beenin leadership roles and having
to say no to provider requestson something like extra staff or
new capital equipment or thosekinds of things can always, you
know, be tricky. And so, youknow, talk a little bit about
(08:31):
the importance of financialtransparency within healthcare
organizations and some specificexamples that you've, how you've
implemented this and the impactof TAG. Cause I know that's
something that, yeah, I've kindof wrestled with how much and do
you share and when and all ofthose things?
Jill Arena (08:44):
Absolutely. Well, I tend to be a fan of a %
transparency amongst the ownersat a minimum. Right? So the
partners in the practice. Andanytime we go into a practice
and there's not thattransparency, at least with the
owners, I start having lots ofquestions and sort of hearkening
back to our, you know, ourentitlement conversation.
(09:05):
Like, is there something oddgoing on here? You know, why why
aren't you willing as thefinance person or the managing
partner? You know, why aren'tyou willing to share? So I much
prefer those environments whereit's open. I've even been a
proponent of sharing thefinancials at a high level with
everyone in the practice.
And that's spending some timeeducating everybody about, you
(09:28):
know, how this looks. If youlook at any practice, mostly,
you know, private practicespecifically and primary care
specifically, the margins are sothin in those practices, meaning
there's so little money leftover Yeah. That that really can
help you as a leader from myperspective when everyone
understands, you know, howlittle money is left over at the
(09:51):
end of the month or the end ofthe year. Yeah. Puts us where I
like to be with financialdiscussions, especially when
there's, you know, there's notgoing to be enough for all of
the assets perhaps that thephysicians wanna purchase.
You know, somebody wants asparkling new C arm or
something, and these are Yeah.
Adrienne Lloyd (10:08):
The toys. And I,
Jill Arena (10:09):
I try hard I try hard not to say no because, you
know, that's uncomfortable. Butit really kinda helped just lead
them to the answer. Like, youknow and it with anything, when
you have a fixed pie, right,there's just just a choice. It's
like, well, you can have thehundred and $20,000 c arm, and
that means all 10 partners needto take a $12,000 pay cut. Are
you ready?
Right. And that's you know, andmaybe not quite that bluntly,
(10:32):
but you can help them get there.And then they're in a space of
choice rather than you as thefinance or administrator having
to say no. Yeah. And I like toremember with, you know, private
practices, it's their money.
They can spend it however theylike. And I really try to, you
know, provide guidance andwithout a lot of judgment. Mhmm.
(10:53):
And that's that's a that's aleadership skill. Right?
That's a ghost. Right. Let melet me show you what this means
financially. And if you ask mefor my opinion, I'm happy to
give it to you. And at the endof the day, it's it's your
decision.
Adrienne Lloyd (11:05):
Yeah. Yeah. And I found those conversations.
And, obviously, you know,sometimes there are incremental
items that are to enhance thepractice or perhaps one provider
is interested in this newdevice, and it seems more like a
nice to have versus a have tohave. And sometimes there's real
decisions around we havecritical items that are breaking
and there's just not enough togo around what we're gonna do.
But one of the things I foundhelpful with those kind of nice
(11:27):
to haves or expansions ofpractice and service lines is to
have those conversations, as yousaid, with here's what it costs,
here's what it would take for usto break even. Do you feel like
you can see that many patients?Do you feel like that's
reasonable? How quickly do youthink you could get there? I
need your commitment to helpingwork to that.
Obviously, you can't alwaysbuild that into any kind of
contract per se or anything.But, you know, really just
(11:49):
having that transparentconversation I think is really,
really helpful for theconversation. I
Jill Arena (11:55):
love that. Yeah. We like to give scenarios too. So
we'll we'll run the good, thebad, and the ugly. Right?
It's like, let's you know, if ifwe really do hit it out of the
park, here's what this newservice line or this new piece
of equipment may generate forthe practice. And if growth is a
little slower than expected,then here's, you know, here's
the cost that we're gonna haveto bear. And if you really
don't, have the volume that youexpect, then here's the expense
(12:19):
you're gonna have.
Adrienne Lloyd (12:20):
Looking upstream and downstream of, you know, x
number x percentage of patientstend to have this procedure,
but, you know, new patientsversus returns. Are you gonna
add new patients to yourpractice to actually bring those
those volumes in or, you know,those kinds of things I think
are really, really helpful too.
Jill Arena (12:35):
You see physicians sometimes wanting to look at
things that are a little bitmore, you know, they may or may
not have a positive return oninvestment, which is fine. But I
always want physicians armedwith that information. Like if
you go ahead and provide thisservice, it really just amounts
to convenience for yourpatients. And that might be
(12:57):
enough for you to say yes. We'llincur the expense.
So I love having thoseconversations and try to really
get everybody as muchinformation as possible so that
they can make a really informedchoice.
Adrienne Lloyd (13:11):
Right. And I think too anchoring into the why
and translating it both from theadministrator side, the finance
side to the physicians of howthis is going to help benefit
the patients, the practice, theteam, whatever the case may be
is really, really key.
Jill Arena (13:25):
I love seeing like a prioritized asset purchase list,
capital asset list that thewhole ownership group gets to
weigh in on. And however theygovern themselves, you know, if
it's a simple democracy,everybody gets to vote on, you
know, where does this live onthe list? And then we can look
and see with, you know, fundsthat are remaining for
investment. How you know, how dowe
Adrienne Lloyd (13:47):
Yeah. Which those can be tricky discussions,
especially if you have multispecialty groups that are
fighting for cardiology or GIthis and so forth. But, yes,
very important. One of thethings I know that you've talked
about in some of your moneymatters, as I've watched on
LinkedIn and other places, ifyou're looking for Jill, is the
concept of all patients arecreated equal, but all payers
(14:09):
are not. And how can healthcareleaders really take this to help
improve the financialunderstanding and management of
their practices and kind oftheir physician partners?
Jill Arena (14:20):
The, I I probably need to get that statement
printed on a T shirt, don't I?And it actually resonates with
the physicians when I say thatout loud. And then it opens us
up to having a conversationabout payer mix. What I'll say
to physicians and what Igenerally coach administrators
to say to physicians very simplyis, again, patients are all
(14:45):
equal, payers are not. And whenwe talk about your saleable
unit, that relative value unit,when we get the physicians clear
that that really is their unitof value.
And when we say very simply,that unit of value with a
Medicare patient is worth $33and some change this year.
(15:09):
Medicaid, depending on the stateis probably paying you somewhere
in the mid to high twenties forthat same unit of And your
commercial payers is where youbalance it out. So you're maybe
depending on your market $50 to$60 depending on the size of
your group, it might be a littlehigher. And I usually just
really break it down to thosebasic levels. And then we have
an important part of theconversation, which is your cost
(15:32):
to generate an RVU in thepractice.
Most practices probablysomewhere in the forties. So as
soon as we say those things,then you can kinda see the light
bulb coming on and physiciansget like, oh, why not? Oh, no.
And so then you can have acogent conversation about why we
need to manage payer mix in aprivate practice. And, that, you
(15:55):
know, you if you're if you'relosing money on every sale, you
can't make that up in volume.
You know? Just take it that way.The physics don't work. So we
have to have, you know, theright amount. And it sort of
puts each individual clinic ormedical group in the space of
having to kind of balance theirown portfolio, if you will.
Yeah. Yeah. That usually helps.Just laying out those very
(16:18):
simple facts usually helps drivea discussion about why we need
systems up front, why we needscheduling templates, why we
need to be certain that we have,you know, the right number of
commercial patients comingthrough the door to be able to
afford the things that we want.And I've had to have that
conversation with full staffbecause sometimes well, sure you
(16:39):
see it with your practice too.
You get a lot of pushback fromfolks at the front desk. You
know, why would I give you know,they they get can get very
indignant and very righteous.You know? Why would I give
priority to a commerciallyinsured patient over a Medicaid
patient? You know?
Why should I pay it differently?And it's like, you're not
treating the human differently.You're treating the payer
differently. Right. They treatthe practice very differently
Okay.
Monetarily. So yeah. That's athat's a really interesting
(17:03):
conversation. I recall havingthat with a group of
orthopedists about twelve yearsago
Adrienne Lloyd (17:08):
and Yeah.
Jill Arena (17:08):
At a 7AM meeting. And with the I could just sort
of see their eyes getting biggerand bigger. And they had asked
me why their revenue, had beenfalling over the last eighteen
months. And when I went andlooked at their, financial
reports, it was a ten year trendon an eighteen month trend. And
it was really their zip code.
Their zip code was becoming farheavier Medicaid. And so when I
(17:31):
explained that, I said, well,you you have a real increase in
Medicaid in the ZIP code, andthey kind of looked at me
blankly. So I did the basicbuilding blocks, and then I see
the eyes get really big. And sothis is a 7AM meeting, and at
about ten, one of them poppedinto the office that I was
sitting in, and he looked alittle pale and drawn. And I
said, what's up, Jeff?
And he says, I've just seenthree Medicare patients in a
(17:52):
row. And he was all He's like,oh, no. I said, okay. Good.
Let's get back out there and seesome commercial ones.
Quite sure what to tell you. But
Adrienne Lloyd (18:02):
Well, I think it's I think it's very key, I,
you know, I do a lot of processimprovement change management,
both, you know, coaching and,you know, operational
consulting. And I think that'susually one of the first, you
know, kind of where are we andpart of where are we today and
where we versus where do we needto go is that financial
component, both as anorganization, what we're doing.
And I know one of the groups, asI was working with,
(18:23):
gastroenterology back in theday, you know, we were having
for our Medicare patients, weactually had a significant loss
in our commercial patients.There was margin there, but not
as much as we needed, but it wasactually just really a stimulant
to the conversation of like, whydo we need to shift? Why do we
need to be more efficient?
Why do we need to look at theprocess? And having that
conversation with the frontlinestaff and the providers was very
(18:47):
important and eye opening Ithink for them too. Because I
was in a system at the time thatpresumably had all the resources
in all the world, why do we needto worry about it? But being
able to say like, actually forevery patient we take care of,
here's what it's costing. Here'swhat we're getting reimbursed.
This is why we need to make ourprocesses as streamlined and
sufficient for every patients,but also to really appeal to
(19:08):
those commercial contractpatients. We get great reviews
and they continue to come andsee us and support what we're
doing. So
Jill Arena (19:14):
yeah. Commercially insured patients, think, are
probably the first ones toconsider health care a bit more
of a commodity. And they reallyare looking, I know I behave
this way as a patient, I'mlooking for the practices that
make it easy for me to interactwith And scheduling is easy,
paying my bill is easy. I wanteverything on my You know, I
(19:36):
don't I don't wanna have to dealwith a piece of paper that comes
in the mail. I'd love to give acredit card on file and just
leave it there.
Please use that for me whenwe're done. Let me know how much
it was, but so yeah. And I Irealized I'm not every consumer.
I'm not always the typicalconsumer, but I really feel like
practices today using technologyand really looking at it from
(19:57):
the patient experience on arethe ones where, to your point,
you're streamlining all theoperations.
Adrienne Lloyd (20:03):
Agree.
Jill Arena (20:04):
Making it attractive for those kind of actions that
we all need.
Adrienne Lloyd (20:08):
Well, to that, like, the overall education of
physicians, what strategies youknow, again, I think we've all
heard the fake it till you makeit and all of those things. But
what strategies have you which Ihave mixed perceptions on. I
think, you know, that sometimesmakes us feel way more stressed
than we need to versus feelinglike we can ask questions. But
what strategies have you foundsuccessful to help physicians
recognize when they maybe arefaking their understanding of
(20:31):
the financial concepts? And howdo you approach those
conversations either throughyour programs or otherwise?
What would you advise kind offor the administrators to help
them maybe feel more comfortablein opening up with positions?
Jill Arena (20:43):
Yeah. Our physician leadership project, program,
which is a Pacific Northwestthing, is a year long program
for high potential physicianleaders, and we have two out of
11 sessions devoted to finance.That's the level of import that
we assign And we routinely, youknow, we'll ask the physicians a
(21:05):
lot of questions, about whatthey do and don't understand.
And, I I find there is a lot ofvariation in understanding of
finances. So when I'm presentingfinancials at a physician board
meeting, I usually aim reallylow in terms of just
understanding and I start withbasics.
(21:25):
And I'll never forget one I wassitting in where they really
hadn't had financials presentedto them for several years in
their trading, which I was kindof trying to, you know, close my
mouth when they said that's me.Really? Okay. Let's do it. And
so I brought them, and I recallhaving a two page profit and
loss, and I handed those out atthe board meetings.
And, I said, okay. When I read aprofit and loss, I usually start
(21:49):
with the bottom line, and I flipover the page. And I could see
every other person in the roomflipped over their page, and I
and I look all the way down tothe bottom line. If there's a
positive or negative variance.So just literally talking
through at that level.
And I will sometimes just open aconversation by saying my
experience with physician groupsis there's always a variety of
levels of understanding. I'mgoing to start with the basics.
(22:13):
And if this is too basic for allof you, please let me know that
and I'll step it up. We'll gofrom 25 miles an hour to 60
miles an hour and see how thatpace works for you. And I have
not yet had a group ofphysicians say to me, yeah,
yeah, we got this go higher.
It's always when we start atthat basic level of
understanding, we're reallyexplaining the mechanics of you
(22:37):
know, your profit and loss. Andthis is a month's worth of
information about what came inand what went out and literally
talking about it at that level,is, generally welcomed by
groups. Occasionally, I run intoa group where there's been a,
you know, administrative leaderor a finance leader who has done
the basics. That's alwaysrefreshing. Yeah.
(22:57):
Well, I was keynoting aconference about a year ago that
was really around physician realestate purchases. And one of the
speakers prior to me said thatyou know, he said one or two of
the physicians in your groupactually understand the real
estate component. The rest arejust faking it. And I I followed
(23:18):
on his statement beautifully. Isaid, I think he nailed it.
And I would double down on thatstatement and say one or two of
your physicians reallyunderstand the finance. Rest are
probably faking it. That's, Ithink really for just
administrators and finance folksto have that understanding that
Yeah. Probably you've been likeme. You've been talking at a
(23:39):
level for a lot of years thatthey really don't like.
Adrienne Lloyd (23:42):
Yeah. And I think it could be a great
opportunity for administrators,especially if you're new kind of
to the practice or maybe you'regoing through some change or
finances aren't looking asbeautiful, positive as you would
like them as to I don't know.You can what are some
suggestions that you might have?I could think off the hand maybe
doing, like, a brown bagsession, like ask me anything,
you know, kind of open book.
Jill Arena (24:03):
We love those. And with this technology because, I
mean, Zoom is great. Yeah. Andso we'll offer a brown bag. We
will record it on Zoom, and thenwe post that in wherever's the,
you know, the SharePoint for theclinic so that physicians can go
and watch it anonymously if theywant to.
And I find that one's superhelpful. So a lot of people
don't wanna cop to the fact thatthey've been faking it in the
(24:25):
board meeting, you know, sixyears. But, that one's good.
Sometimes we will, aside, youknow, we'll add like a half hour
to the front of the boardmeeting and we'll just say, this
is gonna be open forum on thefinances. So if you have
questions,
Adrienne Lloyd (24:39):
if I'm really
Jill Arena (24:40):
Hopefully, leaders are handing out their financial
statements a few days in advanceof the board. Yeah. I do find
there are some physicians thatreally need that processing
time. So getting outinformation, especially if
there's detailed financialinformation you're gonna be
reviewing, sharing it ahead oftime really helps. And that also
follows by subspecialty too.
(25:00):
There's some that are veryinformation hungry and they take
it all in and process it. So atleast a couple two, three days
in advance. And then yeah,offering thirty minutes ahead of
time that you're just there forQ and A. It's also nice if you
can you know, enroll some ofyour more senior physicians who
do understand a bit more aboutthe finance, to either act as
(25:24):
financial mentors or theiryounger colleagues or to be a
plant for you in the brown bagor in the half hour before the
board meeting. So if you sit andask what sort of appears as a
dumb question.
Right? So they'll Mhmm. But youcan say, hey. If nobody asks
this, would you please ask itfor me? And any other topics,
you know, you can kinda line upwhat you wanna cover if there
(25:45):
aren't any questions.
Adrienne Lloyd (25:46):
Yeah. Yeah. One of the, having worked, like,
consulting now, I do all workwith all kinds of practices, but
the, kinda most of my career wasmore in the academic large
health system. I mean, we wouldhave some slides from time to
time that was like, where doesthe money come from? Where does
it go?
And so anything from a mix of,like, what types of services are
we offering? What are those kindof trailing and leading into the
(26:07):
revenue, to the payerdiscussions, to the revenue
cycle? And then, you know, wheredoes it go? That always, I
think, as administrators can bea little nerve racking when you
start getting the pointedquestions of like, well, how
many staff do we need all thestaff that we have? Or maybe we
need more staff or why can't wepay the staff more?
You know, whatever those expensecategories are, I think being
able to share like here's whathere's what's paying for what at
(26:29):
a high level and thenaccompanying that with and I'm
you know, don't know if you dosome of this too, but like the
benchmark of you know, we dobenchmark with whatever
association makes the most sensefor you, on staff, on
productivity, and those thingsso that you have those can help
you navigate some of those morepointed questions with
physicians if you
Jill Arena (26:49):
The great things. I love the highly performing
practices dataset. That one isfun to point to and to talk a
little bit about, you know, whenwe talk about staffing ratios
where I, you know, traditionallywe've sort of been in this three
to one world and then we look atthe highly performing practices
and they're more like five toone or six to one. Right? And
(27:09):
having the conversation with thephysicians about the why that
and really talking aboutworking, practicing at the top
of your license and reallydelegating and pushing down all
of the work that doesn't makeyou a physician.
And as I like to say to them,you should spend it, Same is
true for executives too. Right?As you move through your career,
you should spend most of yourday talking and signing your
(27:31):
name. And that's pretty much allyou should do. You know?
And, obviously, if you're seeingpatients, you might be doing,
you know, of the number ofprocedures, but always, always
being at the top of yourlicensure.
Adrienne Lloyd (27:42):
Yeah. Agreed. Agreed. If you've looked across
physician groups, obviously,there's variation in every every
area of practice as there is inall of health care and is there
isn't all of business, really.There's but how have you found
ways to kinda use the data andto drive the, you know,
productive discussions withproviders or just practices at
the high level?
Jill Arena (28:03):
I one of the things I learned early in my career is
physicians, by and large, are acompetitive bunch. And so that
is beautiful
Adrienne Lloyd (28:13):
over Yeah. That
Jill Arena (28:17):
is beautiful fuel for your leadership when we're
you're wanting to change in agroup, if you can just harness
the the competitive nature ofthe physicians, that is that is
gold right there.
Adrienne Lloyd (28:30):
Vidyapist's leader is probably the same, I
guess, we That
Jill Arena (28:32):
know your friend about you. Same is true. Same is
true for, yeah, high performingexecutives too. But you wanna
win. Yeah.
I have many times, and and thisis a bit of, you know, culture
development within the group.But I many times, I have just
posted or shared amongst all thephysicians, performance on any
metric, you know, by physician.And in in those who are not
(28:57):
accustomed to that kind of datasharing, we might start by
blinding them, you know, doctora, doctor b, doctor c, and just
letting them know which one theyare. That will spark, you know,
the the competitive nature. Imuch prefer, you know, moving
groups through that part oftheir cultural development into
a space where there's a %transparency, and it is doctor
(29:17):
Smith performed this way.
Doctor Jones performed this way.And, really, that makes your job
as a leader so much easierbecause you don't have to talk
much. You just share the data,and you wait.
Adrienne Lloyd (29:27):
And then you can ask questions like, how do we
make this better? Why do wethink there's differences? But
yeah.
Jill Arena (29:32):
And if we look at one you know, first, just to get
clarity on what the data means.And if it is giving a clear
message that one physician isperforming more optimally than
another or than group, what canwe learn from that individual?
And maybe allowing them toprovide some training. I've seen
this work really powerfully withcoding training, having
(29:53):
physicians teach otherphysicians, Here is how I do
this. Here's how I set up myvisits.
We had a rear foot and anklesurgery group years ago. And one
of the physicians, his per visitvalue was one and a half times
his colleagues. And so we wouldliterally just put him on stage
(30:15):
for most of the meetings wherewe're talking about coding. Talk
about it. He was great ataccessorizing his visits.
That's what I called it. It was,you know, if and and again,
thinking about are you acommercially insured patient?
Alright. Here we go. And, Iactually went to see him as a
patient, and, it was great.
He was kinda like, we shouldprobably talk about some
orthotics for you. And I kindanodded. He said, would you like
(30:36):
to get casted for those today?And I kinda nodded. And It was
wonderful because it was likethis intersection of appropriate
clinical, but also conveniencefor me as the patients.
So I love sparking those kindsof conversations within the
physicians so that they asthey're understanding more about
how the business actually works,they also can get that their own
(30:58):
personal habits of how theyconduct visits and how they code
have a huge impact as well.
Adrienne Lloyd (31:04):
Well, and I love the intersection of that. I
think that's where, there havebeen many jobs where the
finances really need neededimprovement. And it's like you
can't fix finances if operationseither aren't or, you know, are
broken or just truly aren't, youknow, to the level they need to
be. And that's a niceintersection of saying, like,
sometimes it's a if we canconclude, maybe not completely
conclude, but really serve thethe patient and getting as much
(31:27):
of the visit done and gettingthose extra procedures ordered
or even having testing prior tothe visit so you can actually
give them an answer and atreatment plan, You know,
thinking through those piecesversus I think depending on the
specialty sometimes or maybedepending on the practice,
there's that tendency to like,oh, we're just gonna do the and
there's some coding, you know,and regulatory issues we have to
navigate through, obviously.But, you know, we're just gonna
(31:49):
do this piece and then we'llhave them come back and we'll
have them come back.
And ultimately, there's a lot ofsituations where that's not
serving the patients. Again, wemay have to from a billing
perspective depending on what itis. But, you know, having those
discussions, I think really canbe helpful. And I love the
blinded approach. I've seen thatwork very well, both at provider
staff level on time starts tolength of stays, to quality
(32:12):
results for procedures, youknow, those kinds of things too.
I think that's a great place tostart if you're not ready to go
to the full transparency, level.But I I see it move pretty
quickly from the blinded to thefull transparency. It usually
doesn't take as long as youthink it might. So
Jill Arena (32:27):
Oh, no.
Adrienne Lloyd (32:28):
That is great.
Jill Arena (32:28):
We've it drive groups where you think about,
you know, the the distribution,and I'm not a statistical
expert, but when you can, youknow, graph the distribution of
the group and, if you can helpthe group both, you know, sort
of narrow the bell curve andmake it taller. Yeah. Part of
this, you know, can we reducevariation and can we improve
performance? So we're shiftingperformance to the right if
(32:49):
that's the way we want it to go,and we're making that bell curve
tighter and taller. That thatfor me is the fun, right, of
leadership.
Having those conversations tosay, can we learn from the folks
that we can identify areperforming really optimally?
Yeah. But what can the rest ofus learn from them? Hey. That's
beautiful.
And it it really does make theleadership job a lot easier in
(33:11):
this book. Lot less. It does.You sort of put the data up
there, you sit back and wait.Yeah.
Adrienne Lloyd (33:16):
I think data in anything. Anything you're trying
to do in change management, justgaining momentum, engagement,
the more that you can break itdown. So, like, again, this is
where we are. Here's where we'dlike to be. Help me understand
how to get there and kind ofshowing them information along
the way, the easier it's gonnabe for whether you're a
physician leader, administrativeleader, clinical leader, any of
those
Jill Arena (33:35):
those things. You have when you have alignment and
you show up as a leader with theintention of having the medical
group and the individual ownersand physicians really thrive.
Right. When you always come fromthat place, I think the
physicians get it, and they getthat you're motivated to be
there. A lot a lot lessresistance and a lot more trust.
Adrienne Lloyd (33:56):
Well, Joe, we could talk all day, but, last
question. What advice would yougive to health care leaders,
whether physicians oradministrators, to really
improve the financial IQ oftheir teams and organizations? I
know many of them listeningtoday may have been like, oh,
I'd love to go through theprograms, but obviously, they're
not all gonna be able to dothat. What do you feel like
would be kind of the best placefor as a phys individual
physician or overall as leadersthat they could do to help their
(34:20):
teams kinda raise that financialbar?
Jill Arena (34:23):
I would just encourage, openness and
curiosity. And I love that.Probably also trying to come at
it if you're a leader, trying tocome at it with zero assumptions
about what the physicians do anddon't know. And even saying to
them, well, I heard a podcast orI read a book and it seems like
(34:47):
perhaps, sometimes we talk aboutthese things at a level that
physicians don't get. What I'dlove to say is it's akin to you
as a physician handing me an EKGand asking me to read it.
I've gotten that. Yes. And hereI am handing you a profit and
loss and asking you to readthat, and you've had no training
how to do that. So, I think thatkind of, you know, reciprocation
(35:12):
and also listening for them andcreating an environment where it
is safe for them to say, don'tknow or I don't understand what
you're talking about. Thatrequires some leadership in
terms of creating that space,and that requires some courage
on their part to be vulnerablewith you because that is not how
they've been trained.
(35:33):
Now they've been trained toknow. And, when they don't know
that those behaviors come out inall kinds of sort of odd ways.
So Right. Reducing the pressureand really making it an open
space to ask questions as wesaid earlier with those kind of
brown bags or open forums orsetting up a senior leader to
really, you know, start askingquestions and model that
behavior so they know it's okayto ask questions. Yeah.
(35:57):
That it's, you know, this is aspace of curiosity.
Adrienne Lloyd (36:00):
No, I love that. I think it's such a The
finances, such a core part ofvision alignment so that you can
move the needle in whatever wayyou need, whatever the
individual physician oradministrator role is really
it's so important. So again,thank you for all the work that
you're doing, and thank you fortaking your time to be here with
us today. And we will have theinformation, below with the
(36:22):
podcast for you to find Jill,but you can also look for
Medical Money Matters, podcastthat Jill does. And she kinda
gives, you know, again, smallfocus tidbits around, different
areas or questions that havecome forward from physicians and
practice leaders.
So, Jill, thank you so much forbeing with us today, and,
hopefully, we may see you again.Who knows?
Jill Arena (36:41):
For having me.
Adrienne Lloyd (36:42):
Absolutely. Thank you.
Everyone, and welcome to the latest edition of
Women in Healthcare podcasthosted with MGMA. I am Adrienne
Lloyd, and I'm excited to behere today with Jill Arena and
really just excited to share.Jill is the CEO of Healthy
Practices and leads itsoperations. She's a nationally
recognized expert in medicalpractice, finance and
(00:25):
operations, as well as revenuecycle management and leadership
development. She's a serialentrepreneur, which I love, and
has co founded several differententities and as a frequent
speaker and convener in themedical community.
And if you've been to a, MGMAconference in the last few
years, you've probably seen heron the stage or seen her at, in
(00:45):
one of the exhibitor booths, butjust has a wealth of knowledge.
She has, is also the author ofPhysician Heal Thy Financial
Cell, which was written forphysicians who want to master
the finances of their practices.And she produces a weekly
podcast for physicians andadministrators called Medical
Money Matters, which is just soimportant. And she also given
(01:05):
her passion for the leadershipdevelopment, also co founded the
Physician Leadership Project in2020, which is a year long
program for high potentialphysician leaders and really
helping just continue to helpthem develop into those formal
leadership roles. And Jill,we're just so excited to have
you and I love so much of whatyou're doing and having worked
with so many physicians over theyears and leadership roles are
(01:28):
just regular roles.
As we all know, there's such agap between what people are
taught in medical school andwhat they actually need to know
in order to be successfulparticipants and then
potentially leaders or owners intheir practices. And I just love
that you're helping helpingthem. So thank you so much for
taking time to be here with ustoday.
Jill Arena (01:46):
Thank you. Thanks for inviting me. I'm excited
about the conversation.
Adrienne Lloyd (01:50):
Me too. Me too. And tell us too. I think you're
tell us where you're based, andwhat's one thing that you love
to do for fun?
Jill Arena (01:57):
Oh, well
Adrienne Lloyd (01:58):
Not doing all of these entrepreneurial adventure.
Jill Arena (02:01):
Based in the beautiful Portland, Oregon. And,
one thing I love to do for fun,I love to visit the Oregon
Coast. And so now I'm gonna outthe Oregon Coast. It's
beautiful. It's a little colderthan the California coast, but,
equally beautiful.
And my daughter and her crazylabradoodle like to go and run
on the beach.
Adrienne Lloyd (02:19):
Oh, I love that. I love that. So kind of diving
in first question, manyphysicians do lack the formal
financial training. How have youfound or created effective ways
to communicate the complexfinancial concepts to leaders
and practice owners? And I knowfor many of us who've been on
the administrator side, reallybeing able to speak the language
(02:40):
in a way that connects with themand, how have you found the
ability to do that?
And what are some suggestionsyou might have for either side
as they're trying to have thoseconversations?
Jill Arena (02:50):
Well, I trained in accounting and finance. So
before I came into healthcarethirty three years ago, I
actually worked as an auditorfor one of the large public
accounting firms. So finance andnumbers is sort of my comfort
zone, right? That's where I goback to. When I have any kind of
question or I wanna analyze apurchase or a strategic
(03:11):
decision, I go to the numbers.
I have found literally in aboutthe last four or five years in
getting started with thephysician leadership project,
where as you mentioned in theintroduction, we get these high
potential physician leaders in.We spend a year with them really
honing those skills. And as youcan imagine, out of 11 sessions
(03:32):
across the year, two of those wededicate to finance. At the
beginning of the first one, weclose the door and we say, okay,
it's Vegas in here. So what'ssaid it here stays here.
And let's now make a list of allthe finance topics that you've
heard and that you'd like tofind. Like, you don't understand
what they need. And then my jobis to hold a straight face while
(03:54):
they make a really big list, ofthings. So that's really been my
learning in the last five yearsis, for the prior, you know,
whatever that is, twenty eightyears of my career, I was
wandering around as a financeand and operations professional,
spouting off all kinds of thingsin board meetings about return
on investment calculations andbudget to actual variances. Just
assuming that all theseintelligent, well educated
(04:16):
people sitting with meunderstood everything I was
saying.
And there was a lot of noddingand smiling. And I imagine our
listeners probably get a lot ofthat in their board meetings.
And what I've learned comingthrough the physician leadership
project work is that we don'tteach accounting and finance in
medical school. That is not athe medical school curriculum
(04:37):
today. That's probably a projectfor my retirement, right, is to
go and infiltrate the medicaleducation system.
Adrienne Lloyd (04:43):
Let me know if I can help. That sounds
Jill Arena (04:45):
great. Absolutely. I'd I'd have a lot of
competitors I think. Really do adisservice to our physicians,
right? We put them through allthis amazing clinical training
and we give them all these greattools for diagnostics and
pharmaceuticals.
And we teach them nothing aboutloss statements or analyzing any
kind of big strategic purchaseor any of that. So understanding
(05:10):
that now this, you know, sort ofat this stage in my career, it's
one of these moments. Oh, I'vebeen running around and spouting
up all kinds of things thathasn't really been helpful. The
other piece of that to sharewith your audience is what I've
learned in having deeperconversations with physicians
about this is that the medicalschools by and large have what I
(05:36):
call a knowledge shame culture.And that means, you know, as the
physician or the physician intraining, you're expected to
have the knowledge.
And you if you don't, you justkeep your head down and you
pretend, or you just hope thatthey don't call on you, because
the attending is gonna, youknow, be all over you if you
don't have the answers. So thatcoming through that and learning
how to function in that kind ofan environment, doesn't lend
(06:00):
itself really well to having theconfidence to stop and say, hey,
can you explain what you mean bybudget variance? Right? Just it
they they don't come out ofmedical school with that
knowledge or the skill setreally Right. To communicate.
And it requires some courage.Right? Put your hand up in the
air and say, I don't know.
Adrienne Lloyd (06:17):
Well, and it's a lot of I mean, I know I've
interviewed and hired a lot ofphysicians over the years and
then talking to them, especiallyif they're new out of fellowship
or residency and, you know,they're trying to compare an
offer maybe that they alreadyhave with one that we're giving
them. And they're giving me I'mlike, well, you know, tell me
about tell me as much as you'rewilling to share. And they're
saying like, well, I'm gonna getx percent after overhead. And
I'm like, well, did they talkabout what's in the overhead?
(06:37):
And it's like, no.
And I'm like, I can hide a lotin overhead. You know? Sure can.
So just, you know, here's somequestions whether you choose a
job with, you know, us or youchoose a job with someone else.
Like, you might wanna ask, like,to really kind of dive into what
does that look like and whatwould you have the ability to
influence and, you know, controlat an individual provider level.
(06:58):
And then obviously, you know, Iwork with a lot of physician
owners of smaller big groupstoo, it's similar, you know, and
they hire managers andadministrators. And I truly
believe, you know, eighty,ninety, 90 five, 90 nine percent
of us are in it for the rightreasons, trying to do the right
thing. But if you don't have theanswers to these questions, you
can end up in situations thatnone of us want to be in. I'm
(07:21):
sure you've had that experiencetoo. The
Jill Arena (07:23):
embezzlement statistics are staggering in
those practices. And I thinkthat MDMA's current statistic is
eighty three percent of medicalgroups. So I like to say, you
know, if you're a physician andyou're out to you know, for
drinks with four friends, know,only one of you has not been
invested at some point. Youknow? It's just crazy.
And those are, you know, 83%,those are the ones we know
about. The really talented onesdo it and move on and you never
(07:46):
know. And I
Adrienne Lloyd (07:47):
think there's the culture, which is so
shocking. And then there'sthere's a culture, and and I
completely understand this. Whenyou're building your practice
and you're starting small, youknow, you wanna hire people that
you you feel like you can trust.You can kinda build this, you
know, family for better or forworse environment, but, at least
you become close to them andthen you wanna trust them. And
if you don't have the answers tothose questions or know what to
(08:08):
look at or trends to dive into,it can be a slippery slope.
One of the things you mentionedtoo, led me one of the things
that came to mind is having beenin leadership roles and having
to say no to provider requestson something like extra staff or
new capital equipment or thosekinds of things can always, you
know, be tricky. And so, youknow, talk a little bit about
(08:31):
the importance of financialtransparency within healthcare
organizations and some specificexamples that you've, how you've
implemented this and the impactof TAG. Cause I know that's
something that, yeah, I've kindof wrestled with how much and do
you share and when and all ofthose things?
Jill Arena (08:44):
Absolutely. Well, I tend to be a fan of a %
transparency amongst the ownersat a minimum. Right? So the
partners in the practice. Andanytime we go into a practice
and there's not thattransparency, at least with the
owners, I start having lots ofquestions and sort of hearkening
back to our, you know, ourentitlement conversation.
(09:05):
Like, is there something oddgoing on here? You know, why why
aren't you willing as thefinance person or the managing
partner? You know, why aren'tyou willing to share? So I much
prefer those environments whereit's open. I've even been a
proponent of sharing thefinancials at a high level with
everyone in the practice.
And that's spending some timeeducating everybody about, you
(09:28):
know, how this looks. If youlook at any practice, mostly,
you know, private practicespecifically and primary care
specifically, the margins are sothin in those practices, meaning
there's so little money leftover Yeah. That that really can
help you as a leader from myperspective when everyone
understands, you know, howlittle money is left over at the
(09:51):
end of the month or the end ofthe year. Yeah. Puts us where I
like to be with financialdiscussions, especially when
there's, you know, there's notgoing to be enough for all of
the assets perhaps that thephysicians wanna purchase.
You know, somebody wants asparkling new C arm or
something, and these are Yeah.
Adrienne Lloyd (10:08):
The toys. And I,
Jill Arena (10:09):
I try hard I try hard not to say no because, you
know, that's uncomfortable. Butit really kinda helped just lead
them to the answer. Like, youknow and it with anything, when
you have a fixed pie, right,there's just just a choice. It's
like, well, you can have thehundred and $20,000 c arm, and
that means all 10 partners needto take a $12,000 pay cut. Are
you ready?
Right. And that's you know, andmaybe not quite that bluntly,
(10:32):
but you can help them get there.And then they're in a space of
choice rather than you as thefinance or administrator having
to say no. Yeah. And I like toremember with, you know, private
practices, it's their money.
They can spend it however theylike. And I really try to, you
know, provide guidance andwithout a lot of judgment. Mhmm.
(10:53):
And that's that's a that's aleadership skill. Right?
That's a ghost. Right. Let melet me show you what this means
financially. And if you ask mefor my opinion, I'm happy to
give it to you. And at the endof the day, it's it's your
decision.
Adrienne Lloyd (11:05):
Yeah. Yeah. And I found those conversations.
And, obviously, you know,sometimes there are incremental
items that are to enhance thepractice or perhaps one provider
is interested in this newdevice, and it seems more like a
nice to have versus a have tohave. And sometimes there's real
decisions around we havecritical items that are breaking
and there's just not enough togo around what we're gonna do.
But one of the things I foundhelpful with those kind of nice
(11:27):
to haves or expansions ofpractice and service lines is to
have those conversations, as yousaid, with here's what it costs,
here's what it would take for usto break even. Do you feel like
you can see that many patients?Do you feel like that's
reasonable? How quickly do youthink you could get there? I
need your commitment to helpingwork to that.
Obviously, you can't alwaysbuild that into any kind of
contract per se or anything.But, you know, really just
(11:49):
having that transparentconversation I think is really,
really helpful for theconversation. I
Jill Arena (11:55):
love that. Yeah. We like to give scenarios too. So
we'll we'll run the good, thebad, and the ugly. Right?
It's like, let's you know, if ifwe really do hit it out of the
park, here's what this newservice line or this new piece
of equipment may generate forthe practice. And if growth is a
little slower than expected,then here's, you know, here's
the cost that we're gonna haveto bear. And if you really
don't, have the volume that youexpect, then here's the expense
(12:19):
you're gonna have.
Adrienne Lloyd (12:20):
Looking upstream and downstream of, you know, x
number x percentage of patientstend to have this procedure,
but, you know, new patientsversus returns. Are you gonna
add new patients to yourpractice to actually bring those
those volumes in or, you know,those kinds of things I think
are really, really helpful too.
Jill Arena (12:35):
You see physicians sometimes wanting to look at
things that are a little bitmore, you know, they may or may
not have a positive return oninvestment, which is fine. But I
always want physicians armedwith that information. Like if
you go ahead and provide thisservice, it really just amounts
to convenience for yourpatients. And that might be
(12:57):
enough for you to say yes. We'llincur the expense.
So I love having thoseconversations and try to really
get everybody as muchinformation as possible so that
they can make a really informedchoice.
Adrienne Lloyd (13:11):
Right. And I think too anchoring into the why
and translating it both from theadministrator side, the finance
side to the physicians of howthis is going to help benefit
the patients, the practice, theteam, whatever the case may be
is really, really key.
Jill Arena (13:25):
I love seeing like a prioritized asset purchase list,
capital asset list that thewhole ownership group gets to
weigh in on. And however theygovern themselves, you know, if
it's a simple democracy,everybody gets to vote on, you
know, where does this live onthe list? And then we can look
and see with, you know, fundsthat are remaining for
investment. How you know, how dowe
Adrienne Lloyd (13:47):
Yeah. Which those can be tricky discussions,
especially if you have multispecialty groups that are
fighting for cardiology or GIthis and so forth. But, yes,
very important. One of thethings I know that you've talked
about in some of your moneymatters, as I've watched on
LinkedIn and other places, ifyou're looking for Jill, is the
concept of all patients arecreated equal, but all payers
(14:09):
are not. And how can healthcareleaders really take this to help
improve the financialunderstanding and management of
their practices and kind oftheir physician partners?
Jill Arena (14:20):
The, I I probably need to get that statement
printed on a T shirt, don't I?And it actually resonates with
the physicians when I say thatout loud. And then it opens us
up to having a conversationabout payer mix. What I'll say
to physicians and what Igenerally coach administrators
to say to physicians very simplyis, again, patients are all
(14:45):
equal, payers are not. And whenwe talk about your saleable
unit, that relative value unit,when we get the physicians clear
that that really is their unitof value.
And when we say very simply,that unit of value with a
Medicare patient is worth $33and some change this year.
(15:09):
Medicaid, depending on the stateis probably paying you somewhere
in the mid to high twenties forthat same unit of And your
commercial payers is where youbalance it out. So you're maybe
depending on your market $50 to$60 depending on the size of
your group, it might be a littlehigher. And I usually just
really break it down to thosebasic levels. And then we have
an important part of theconversation, which is your cost
(15:32):
to generate an RVU in thepractice.
Most practices probablysomewhere in the forties. So as
soon as we say those things,then you can kinda see the light
bulb coming on and physiciansget like, oh, why not? Oh, no.
And so then you can have acogent conversation about why we
need to manage payer mix in aprivate practice. And, that, you
(15:55):
know, you if you're if you'relosing money on every sale, you
can't make that up in volume.
You know? Just take it that way.The physics don't work. So we
have to have, you know, theright amount. And it sort of
puts each individual clinic ormedical group in the space of
having to kind of balance theirown portfolio, if you will.
Yeah. Yeah. That usually helps.Just laying out those very
(16:18):
simple facts usually helps drivea discussion about why we need
systems up front, why we needscheduling templates, why we
need to be certain that we have,you know, the right number of
commercial patients comingthrough the door to be able to
afford the things that we want.And I've had to have that
conversation with full staffbecause sometimes well, sure you
(16:39):
see it with your practice too.
You get a lot of pushback fromfolks at the front desk. You
know, why would I give you know,they they get can get very
indignant and very righteous.You know? Why would I give
priority to a commerciallyinsured patient over a Medicaid
patient? You know?
Why should I pay it differently?And it's like, you're not
treating the human differently.You're treating the payer
differently. Right. They treatthe practice very differently
Okay.
Monetarily. So yeah. That's athat's a really interesting
(17:03):
conversation. I recall havingthat with a group of
orthopedists about twelve yearsago
Adrienne Lloyd (17:08):
and Yeah.
Jill Arena (17:08):
At a 7AM meeting. And with the I could just sort
of see their eyes getting biggerand bigger. And they had asked
me why their revenue, had beenfalling over the last eighteen
months. And when I went andlooked at their, financial
reports, it was a ten year trendon an eighteen month trend. And
it was really their zip code.
Their zip code was becoming farheavier Medicaid. And so when I
(17:31):
explained that, I said, well,you you have a real increase in
Medicaid in the ZIP code, andthey kind of looked at me
blankly. So I did the basicbuilding blocks, and then I see
the eyes get really big. And sothis is a 7AM meeting, and at
about ten, one of them poppedinto the office that I was
sitting in, and he looked alittle pale and drawn. And I
said, what's up, Jeff?
And he says, I've just seenthree Medicare patients in a
(17:52):
row. And he was all He's like,oh, no. I said, okay. Good.
Let's get back out there and seesome commercial ones.
Quite sure what to tell you. But
Adrienne Lloyd (18:02):
Well, I think it's I think it's very key, I,
you know, I do a lot of processimprovement change management,
both, you know, coaching and,you know, operational
consulting. And I think that'susually one of the first, you
know, kind of where are we andpart of where are we today and
where we versus where do we needto go is that financial
component, both as anorganization, what we're doing.
And I know one of the groups, asI was working with,
(18:23):
gastroenterology back in theday, you know, we were having
for our Medicare patients, weactually had a significant loss
in our commercial patients.There was margin there, but not
as much as we needed, but it wasactually just really a stimulant
to the conversation of like, whydo we need to shift? Why do we
need to be more efficient?
Why do we need to look at theprocess? And having that
conversation with the frontlinestaff and the providers was very
(18:47):
important and eye opening Ithink for them too. Because I
was in a system at the time thatpresumably had all the resources
in all the world, why do we needto worry about it? But being
able to say like, actually forevery patient we take care of,
here's what it's costing. Here'swhat we're getting reimbursed.
This is why we need to make ourprocesses as streamlined and
sufficient for every patients,but also to really appeal to
(19:08):
those commercial contractpatients. We get great reviews
and they continue to come andsee us and support what we're
doing. So
Jill Arena (19:14):
yeah. Commercially insured patients, think, are
probably the first ones toconsider health care a bit more
of a commodity. And they reallyare looking, I know I behave
this way as a patient, I'mlooking for the practices that
make it easy for me to interactwith And scheduling is easy,
paying my bill is easy. I wanteverything on my You know, I
(19:36):
don't I don't wanna have to dealwith a piece of paper that comes
in the mail. I'd love to give acredit card on file and just
leave it there.
Please use that for me whenwe're done. Let me know how much
it was, but so yeah. And I Irealized I'm not every consumer.
I'm not always the typicalconsumer, but I really feel like
practices today using technologyand really looking at it from
(19:57):
the patient experience on arethe ones where, to your point,
you're streamlining all theoperations.
Adrienne Lloyd (20:03):
Agree.
Jill Arena (20:04):
Making it attractive for those kind of actions that
we all need.
Adrienne Lloyd (20:08):
Well, to that, like, the overall education of
physicians, what strategies youknow, again, I think we've all
heard the fake it till you makeit and all of those things. But
what strategies have you which Ihave mixed perceptions on. I
think, you know, that sometimesmakes us feel way more stressed
than we need to versus feelinglike we can ask questions. But
what strategies have you foundsuccessful to help physicians
recognize when they maybe arefaking their understanding of
(20:31):
the financial concepts? And howdo you approach those
conversations either throughyour programs or otherwise?
What would you advise kind offor the administrators to help
them maybe feel more comfortablein opening up with positions?
Jill Arena (20:43):
Yeah. Our physician leadership project, program,
which is a Pacific Northwestthing, is a year long program
for high potential physicianleaders, and we have two out of
11 sessions devoted to finance.That's the level of import that
we assign And we routinely, youknow, we'll ask the physicians a
(21:05):
lot of questions, about whatthey do and don't understand.
And, I I find there is a lot ofvariation in understanding of
finances. So when I'm presentingfinancials at a physician board
meeting, I usually aim reallylow in terms of just
understanding and I start withbasics.
(21:25):
And I'll never forget one I wassitting in where they really
hadn't had financials presentedto them for several years in
their trading, which I was kindof trying to, you know, close my
mouth when they said that's me.Really? Okay. Let's do it. And
so I brought them, and I recallhaving a two page profit and
loss, and I handed those out atthe board meetings.
And, I said, okay. When I read aprofit and loss, I usually start
(21:49):
with the bottom line, and I flipover the page. And I could see
every other person in the roomflipped over their page, and I
and I look all the way down tothe bottom line. If there's a
positive or negative variance.So just literally talking
through at that level.
And I will sometimes just open aconversation by saying my
experience with physician groupsis there's always a variety of
levels of understanding. I'mgoing to start with the basics.
(22:13):
And if this is too basic for allof you, please let me know that
and I'll step it up. We'll gofrom 25 miles an hour to 60
miles an hour and see how thatpace works for you. And I have
not yet had a group ofphysicians say to me, yeah,
yeah, we got this go higher.
It's always when we start atthat basic level of
understanding, we're reallyexplaining the mechanics of you
(22:37):
know, your profit and loss. Andthis is a month's worth of
information about what came inand what went out and literally
talking about it at that level,is, generally welcomed by
groups. Occasionally, I run intoa group where there's been a,
you know, administrative leaderor a finance leader who has done
the basics. That's alwaysrefreshing. Yeah.
(22:57):
Well, I was keynoting aconference about a year ago that
was really around physician realestate purchases. And one of the
speakers prior to me said thatyou know, he said one or two of
the physicians in your groupactually understand the real
estate component. The rest arejust faking it. And I I followed
(23:18):
on his statement beautifully. Isaid, I think he nailed it.
And I would double down on thatstatement and say one or two of
your physicians reallyunderstand the finance. Rest are
probably faking it. That's, Ithink really for just
administrators and finance folksto have that understanding that
Yeah. Probably you've been likeme. You've been talking at a
(23:39):
level for a lot of years thatthey really don't like.
Adrienne Lloyd (23:42):
Yeah. And I think it could be a great
opportunity for administrators,especially if you're new kind of
to the practice or maybe you'regoing through some change or
finances aren't looking asbeautiful, positive as you would
like them as to I don't know.You can what are some
suggestions that you might have?I could think off the hand maybe
doing, like, a brown bagsession, like ask me anything,
you know, kind of open book.
Jill Arena (24:03):
We love those. And with this technology because, I
mean, Zoom is great. Yeah. Andso we'll offer a brown bag. We
will record it on Zoom, and thenwe post that in wherever's the,
you know, the SharePoint for theclinic so that physicians can go
and watch it anonymously if theywant to.
And I find that one's superhelpful. So a lot of people
don't wanna cop to the fact thatthey've been faking it in the
(24:25):
board meeting, you know, sixyears. But, that one's good.
Sometimes we will, aside, youknow, we'll add like a half hour
to the front of the boardmeeting and we'll just say, this
is gonna be open forum on thefinances. So if you have
questions,
Adrienne Lloyd (24:39):
if I'm really
Jill Arena (24:40):
Hopefully, leaders are handing out their financial
statements a few days in advanceof the board. Yeah. I do find
there are some physicians thatreally need that processing
time. So getting outinformation, especially if
there's detailed financialinformation you're gonna be
reviewing, sharing it ahead oftime really helps. And that also
follows by subspecialty too.
(25:00):
There's some that are veryinformation hungry and they take
it all in and process it. So atleast a couple two, three days
in advance. And then yeah,offering thirty minutes ahead of
time that you're just there forQ and A. It's also nice if you
can you know, enroll some ofyour more senior physicians who
do understand a bit more aboutthe finance, to either act as
(25:24):
financial mentors or theiryounger colleagues or to be a
plant for you in the brown bagor in the half hour before the
board meeting. So if you sit andask what sort of appears as a
dumb question.
Right? So they'll Mhmm. But youcan say, hey. If nobody asks
this, would you please ask itfor me? And any other topics,
you know, you can kinda line upwhat you wanna cover if there
(25:45):
aren't any questions.
Adrienne Lloyd (25:46):
Yeah. Yeah. One of the, having worked, like,
consulting now, I do all workwith all kinds of practices, but
the, kinda most of my career wasmore in the academic large
health system. I mean, we wouldhave some slides from time to
time that was like, where doesthe money come from? Where does
it go?
And so anything from a mix of,like, what types of services are
we offering? What are those kindof trailing and leading into the
(26:07):
revenue, to the payerdiscussions, to the revenue
cycle? And then, you know, wheredoes it go? That always, I
think, as administrators can bea little nerve racking when you
start getting the pointedquestions of like, well, how
many staff do we need all thestaff that we have? Or maybe we
need more staff or why can't wepay the staff more?
You know, whatever those expensecategories are, I think being
able to share like here's whathere's what's paying for what at
(26:29):
a high level and thenaccompanying that with and I'm
you know, don't know if you dosome of this too, but like the
benchmark of you know, we dobenchmark with whatever
association makes the most sensefor you, on staff, on
productivity, and those thingsso that you have those can help
you navigate some of those morepointed questions with
physicians if you
Jill Arena (26:49):
The great things. I love the highly performing
practices dataset. That one isfun to point to and to talk a
little bit about, you know, whenwe talk about staffing ratios
where I, you know, traditionallywe've sort of been in this three
to one world and then we look atthe highly performing practices
and they're more like five toone or six to one. Right? And
(27:09):
having the conversation with thephysicians about the why that
and really talking aboutworking, practicing at the top
of your license and reallydelegating and pushing down all
of the work that doesn't makeyou a physician.
And as I like to say to them,you should spend it, Same is
true for executives too. Right?As you move through your career,
you should spend most of yourday talking and signing your
(27:31):
name. And that's pretty much allyou should do. You know?
And, obviously, if you're seeingpatients, you might be doing,
you know, of the number ofprocedures, but always, always
being at the top of yourlicensure.
Adrienne Lloyd (27:42):
Yeah. Agreed. Agreed. If you've looked across
physician groups, obviously,there's variation in every every
area of practice as there is inall of health care and is there
isn't all of business, really.There's but how have you found
ways to kinda use the data andto drive the, you know,
productive discussions withproviders or just practices at
the high level?
Jill Arena (28:03):
I one of the things I learned early in my career is
physicians, by and large, are acompetitive bunch. And so that
is beautiful
Adrienne Lloyd (28:13):
over Yeah. That
Jill Arena (28:17):
is beautiful fuel for your leadership when we're
you're wanting to change in agroup, if you can just harness
the the competitive nature ofthe physicians, that is that is
gold right there.
Adrienne Lloyd (28:30):
Vidyapist's leader is probably the same, I
guess, we That
Jill Arena (28:32):
know your friend about you. Same is true. Same is
true for, yeah, high performingexecutives too. But you wanna
win. Yeah.
I have many times, and and thisis a bit of, you know, culture
development within the group.But I many times, I have just
posted or shared amongst all thephysicians, performance on any
metric, you know, by physician.And in in those who are not
(28:57):
accustomed to that kind of datasharing, we might start by
blinding them, you know, doctora, doctor b, doctor c, and just
letting them know which one theyare. That will spark, you know,
the the competitive nature. Imuch prefer, you know, moving
groups through that part oftheir cultural development into
a space where there's a %transparency, and it is doctor
(29:17):
Smith performed this way.
Doctor Jones performed this way.And, really, that makes your job
as a leader so much easierbecause you don't have to talk
much. You just share the data,and you wait.
Adrienne Lloyd (29:27):
And then you can ask questions like, how do we
make this better? Why do wethink there's differences? But
yeah.
Jill Arena (29:32):
And if we look at one you know, first, just to get
clarity on what the data means.And if it is giving a clear
message that one physician isperforming more optimally than
another or than group, what canwe learn from that individual?
And maybe allowing them toprovide some training. I've seen
this work really powerfully withcoding training, having
(29:53):
physicians teach otherphysicians, Here is how I do
this. Here's how I set up myvisits.
We had a rear foot and anklesurgery group years ago. And one
of the physicians, his per visitvalue was one and a half times
his colleagues. And so we wouldliterally just put him on stage
(30:15):
for most of the meetings wherewe're talking about coding. Talk
about it. He was great ataccessorizing his visits.
That's what I called it. It was,you know, if and and again,
thinking about are you acommercially insured patient?
Alright. Here we go. And, Iactually went to see him as a
patient, and, it was great.
He was kinda like, we shouldprobably talk about some
orthotics for you. And I kindanodded. He said, would you like
(30:36):
to get casted for those today?And I kinda nodded. And It was
wonderful because it was likethis intersection of appropriate
clinical, but also conveniencefor me as the patients.
So I love sparking those kindsof conversations within the
physicians so that they asthey're understanding more about
how the business actually works,they also can get that their own
(30:58):
personal habits of how theyconduct visits and how they code
have a huge impact as well.
Adrienne Lloyd (31:04):
Well, and I love the intersection of that. I
think that's where, there havebeen many jobs where the
finances really need neededimprovement. And it's like you
can't fix finances if operationseither aren't or, you know, are
broken or just truly aren't, youknow, to the level they need to
be. And that's a niceintersection of saying, like,
sometimes it's a if we canconclude, maybe not completely
conclude, but really serve thethe patient and getting as much
(31:27):
of the visit done and gettingthose extra procedures ordered
or even having testing prior tothe visit so you can actually
give them an answer and atreatment plan, You know,
thinking through those piecesversus I think depending on the
specialty sometimes or maybedepending on the practice,
there's that tendency to like,oh, we're just gonna do the and
there's some coding, you know,and regulatory issues we have to
navigate through, obviously.But, you know, we're just gonna
(31:49):
do this piece and then we'llhave them come back and we'll
have them come back.
And ultimately, there's a lot ofsituations where that's not
serving the patients. Again, wemay have to from a billing
perspective depending on what itis. But, you know, having those
discussions, I think really canbe helpful. And I love the
blinded approach. I've seen thatwork very well, both at provider
staff level on time starts tolength of stays, to quality
(32:12):
results for procedures, youknow, those kinds of things too.
I think that's a great place tostart if you're not ready to go
to the full transparency, level.But I I see it move pretty
quickly from the blinded to thefull transparency. It usually
doesn't take as long as youthink it might. So
Jill Arena (32:27):
Oh, no.
Adrienne Lloyd (32:28):
That is great.
Jill Arena (32:28):
We've it drive groups where you think about,
you know, the the distribution,and I'm not a statistical
expert, but when you can, youknow, graph the distribution of
the group and, if you can helpthe group both, you know, sort
of narrow the bell curve andmake it taller. Yeah. Part of
this, you know, can we reducevariation and can we improve
performance? So we're shiftingperformance to the right if
(32:49):
that's the way we want it to go,and we're making that bell curve
tighter and taller. That thatfor me is the fun, right, of
leadership.
Having those conversations tosay, can we learn from the folks
that we can identify areperforming really optimally?
Yeah. But what can the rest ofus learn from them? Hey. That's
beautiful.
And it it really does make theleadership job a lot easier in
(33:11):
this book. Lot less. It does.You sort of put the data up
there, you sit back and wait.Yeah.
Adrienne Lloyd (33:16):
I think data in anything. Anything you're trying
to do in change management, justgaining momentum, engagement,
the more that you can break itdown. So, like, again, this is
where we are. Here's where we'dlike to be. Help me understand
how to get there and kind ofshowing them information along
the way, the easier it's gonnabe for whether you're a
physician leader, administrativeleader, clinical leader, any of
those
Jill Arena (33:35):
those things. You have when you have alignment and
you show up as a leader with theintention of having the medical
group and the individual ownersand physicians really thrive.
Right. When you always come fromthat place, I think the
physicians get it, and they getthat you're motivated to be
there. A lot a lot lessresistance and a lot more trust.
Adrienne Lloyd (33:56):
Well, Joe, we could talk all day, but, last
question. What advice would yougive to health care leaders,
whether physicians oradministrators, to really
improve the financial IQ oftheir teams and organizations? I
know many of them listeningtoday may have been like, oh,
I'd love to go through theprograms, but obviously, they're
not all gonna be able to dothat. What do you feel like
would be kind of the best placefor as a phys individual
physician or overall as leadersthat they could do to help their
(34:20):
teams kinda raise that financialbar?
Jill Arena (34:23):
I would just encourage, openness and
curiosity. And I love that.Probably also trying to come at
it if you're a leader, trying tocome at it with zero assumptions
about what the physicians do anddon't know. And even saying to
them, well, I heard a podcast orI read a book and it seems like
(34:47):
perhaps, sometimes we talk aboutthese things at a level that
physicians don't get. What I'dlove to say is it's akin to you
as a physician handing me an EKGand asking me to read it.
I've gotten that. Yes. And hereI am handing you a profit and
loss and asking you to readthat, and you've had no training
how to do that. So, I think thatkind of, you know, reciprocation
(35:12):
and also listening for them andcreating an environment where it
is safe for them to say, don'tknow or I don't understand what
you're talking about. Thatrequires some leadership in
terms of creating that space,and that requires some courage
on their part to be vulnerablewith you because that is not how
they've been trained.
(35:33):
Now they've been trained toknow. And, when they don't know
that those behaviors come out inall kinds of sort of odd ways.
So Right. Reducing the pressureand really making it an open
space to ask questions as wesaid earlier with those kind of
brown bags or open forums orsetting up a senior leader to
really, you know, start askingquestions and model that
behavior so they know it's okayto ask questions. Yeah.
(35:57):
That it's, you know, this is aspace of curiosity.
Adrienne Lloyd (36:00):
No, I love that. I think it's such a The
finances, such a core part ofvision alignment so that you can
move the needle in whatever wayyou need, whatever the
individual physician oradministrator role is really
it's so important. So again,thank you for all the work that
you're doing, and thank you fortaking your time to be here with
us today. And we will have theinformation, below with the
(36:22):
podcast for you to find Jill,but you can also look for
Medical Money Matters, podcastthat Jill does. And she kinda
gives, you know, again, smallfocus tidbits around, different
areas or questions that havecome forward from physicians and
practice leaders.
So, Jill, thank you so much forbeing with us today, and,
hopefully, we may see you again.Who knows?
Jill Arena (36:41):
For having me.
Adrienne Lloyd (36:42):
Absolutely. Thank you.
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