Episode 38: How Private Practices Can Tackle Public Health

The medically underserved have been disproportionately impacted during the COVID-19 pandemic. It’s easy to feel helpless, but there are more opportunities than ever to step in and make a difference, according to John Gorman, chairman of Nightingale Partners, an advisory firm connecting capital to payers and providers of care to the medically underserved. Learn how independent providers can reduce the impact of social determinants of health during and after the quarantine, and other opportunities that come to light from a fragmented healthcare industry.

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Full Transcript

Announcer: It’s time to think differently about healthcare. But how do we keep up? The days of yesterday’s medicine are long gone. And we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans. And many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together. And here are some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare.” And thank you for listening. I’m Michael Roberts here today with my co-host, Scott Zeitzer. On today’s episode, we’re speaking with John Gorman. He’s a chairman of Nightingale Partners, an advisory firm connecting capital to payers and providers of care to the medically underserved. John, thank you so much for coming on the show today.

John: Hey, guys. Thanks so much for having me. And happy pandemic Thursday.

Michael: Absolutely. You gotta find the rays of light in the midst of all this stuff.

John: Yeah, absolutely.

Michael: So let’s dive right into this because we’ve already started talking about this a little bit before we hit the Record button so to speak. One of the things that I saw about your profile and the things that you do with the various audiences that you work with leads me right into this first question. So we’re talking about public health issues that have, you know, really just blown up during this pandemic.

You know, here in Louisiana, we’re dealing with a lot of the realities of social determinants of health in terms of who gets affected the most, who dies the most in our state. And this isn’t just happening in Louisiana, it’s happening in a lot of different places all around the country and even around the world. But for this conversation, we’ll just focus here. But it’s definitely happening in very disproportionate ways. And there’s a lot of factors to go into that. But, you know, one of the first things I’d like to start on is just, like, how big a role are we seeing poverty play on these health outcomes?

John: Specific to coronavirus?

Michael: I mean, all of it. But yes, definitely the coronavirus.

John: Coronavirus is really sort of the microscope that really shows us, you know, how inequality and even systemic racism has really impacted our healthcare system. I mean, you need only look at the death rates of African Americans from COVID to really see that people of color, especially low-income people of color with other chronic conditions that typically plague those populations like cardiovascular disease, obesity, diabetes, are all the folks at greatest risk of contracting COVID and dying from it.

In fact, in Louisiana, Michigan, Illinois, many other states, we’re seeing African Americans die from coronavirus at a rate of two to four times what they are represented in the population. So, you know, I posted recently on LinkedIn that coronavirus is racist as hell. And its lethal comorbidity is poverty. And when you have these two things together, it’s an excessively lethal combination especially for people of color.

Michael: Absolutely. And you do a lot of work you said like with government groups. But what does somebody outside of the government do in this kind of scenario? Is there any groups that can really help change this dynamic in any way?

John: Well, absolutely. I mean, certainly, health systems, health payers, you know, other stakeholders in our industry have an enormous amount to do in terms of addressing this particular concern about poverty and race really playing such a huge role in the death toll. First is, you know, we just have to do a better job of economic security for these populations because these are the folks that literally cannot afford to shelter in place. They can’t stay at home and keep themselves out of circulation from this virus.

Most of these folks, the nature of poverty is you’ve gotta work. And so these are the folks that are working at food service or other industries that are population…you know, they’re public-facing positions. And so you get African Americans and other low-income people of color that are disproportionately exposed to this virus just by virtue of their economic circumstances. They just don’t have the money or the luxury to be able to stay at home to stay out of work. They have to go to work. And so they are really exposing themselves to this at a much higher rate. You know, it’s just making these populations more economically resilient.

And the best way that we get there is by this universal public income or basic income that Andrew Yang made popular during his campaign, and now that is in the CARES Act, and these, you know, $1,200 checks people are gonna be getting, that really needs to continue indefinitely for as long as a lockdown is called for. Otherwise, you are literally forcing disproportionate numbers of African Americans into the streets, into the public, to go to work which they have to do. I mean, this thing has really kinda laid bare the fact that the vast majority of Americans don’t even have $400 in liquidity to help pay for emergency expenses as we’ve seen in countless Federal Reserve studies.

So, you know, the first vulnerability for this community is always gonna be economic. And then secondarily, it’s about their access to healthcare, their ability to pay for healthcare. Certainly in Louisiana, the historical racism and other access issues that have plagued African Americans access to healthcare. And then just making these communities in which they live more resilient. We are working on a big one right now in Baton Rouge that we’re getting very excited about where LSU has basically donated its old Memorial Stadium to us and a team of developers that we’re working with led by Roy Austin, that we are going to build Memorial Stadium into a ginormous healthcare campus for underserved populations in West Baton Rouge.

And it’s gonna have a core set of services that we know lower-income communities are in desperate need of like a walk-in clinic and access to primary care. We’re gonna have a community pharmacy there. We’re going to have an adult and child daycare center that’ll be multigenerational. We’re going to have a hub there for community health workers and community pharmacists to train and do their residency through LSU’s College of Pharmacy. And we’re basically going to begin a campaign with Roy and his team to convert these types of public spaces or work public spaces into healthcare hubs that better address the needs of medically underserved populations as we see in western Baton Rouge.

Scott: Yes, fantastic. I heard a little bit about that, read quite a bit about it as well. And it’s just wonderful what you’re doing. And it obviously needs to be happening throughout the country. I kinda wanted to focus on private practices, independent providers. What can they do to help, you know, regarding some of these public health issues? Can they get involved with this particular project you’re doing, you’re rolling out in West Baton Rouge?

John: The big drive in the West Baton Rouge project is to increase primary care. I mean, it is one of the worst urban underserved areas in the state. And so just expanding the primary care capacity is going to be huge for this facility. I mean, if you wanna think of this undertaking, it’s sort of like we’re building a shopping mall. Then primary care always has to be, you know, the Neiman Marcus or the Macy’s, the anchor store, the tent pole capability that you put in there and you build everything else around.

So, you know, if there are private practice primary care docs out there or even specialists who are wondering “What’s gonna happen to my specialty post-pandemic? Is it even relevant anymore?” You know, those are great questions. And I think what’s going to happen and one of the big effects of this pandemic is gonna be that smaller physician practices are just gonna end up going the way of Marcus Welby. I mean, you just cannot sustainably keep your doors open for an extended period when the best thing that you can do is telehealth visits that gets very hard to maintain a brick-and-mortar presence of a small practice.

And so I think the best advice that you can give to private practice docs in this environment is if you’re having a revenue concern about the viability of your own practice, you know, the imperative is just to get bigger, you know, to either try to bring in more docs to your practice or join another practice that’s bigger and with established relationships ideally with a local health system. Because post-pandemic, I mean, even pre-pandemic, guys, it was impossible for small physician practices to be able to keep up with the administrative cost of electronic medical records and everything else that the docs are forced to do these days.

And, you know, what this pandemic has started is a complete revenue disruption of a multi-month lockdown. There are very few physician practices which are, at their essence, a small business, you know, are gonna be able to sustain. So, you know, I’ve got docs that I’ve talked to that are considering specialty changes. My brother-in-law was a very accomplished surgeon, but he’s now completely reinvented himself as an urgent care doc. And he’s loving it. And he feels more relevant than ever. And he’s staying busy. And he feels like he’s contributing. So I think you’re gonna see some of that.

But I think the biggest trend that you’re gonna see is just a lot of consolidation of small physician practices, especially in states as hard hit as Louisiana. And those that survive and remain are just their imperative is gonna be to get bigger, and to offer a wider array of these kinds of social determinants of health kinds of services that enable you to take risk from insurers. That’s, you know, the indelible trend that you see happening here is that payers want docs to take more and more risks for the patients that they’re serving. And that entails having to offer a much broader panel of services in order to meet that need. Does that make sense, Michael?

Scott: Yeah, you know, it does in some ways. I really do think that prior to COVID, we had spoken to a lot of primary care physicians, whether that was pediatrician, or just a general internist, primary care provider, etc. And they were all coming up with different models, whether that was, to your point, joining a larger group, coming up with subscription offerings, which seemed very interesting as well. And I don’t even call it post-pandemic, I call it post-quarantine, the pandemic is not gonna go away in the next few months.

John: Right, right. We’ll still be here.

Scott: And how you operate? Do you combine with other forces? Sure, that certainly could be a very intelligent way to help share costs. I was talking to an orthopedic surgeon who said to me, “You know, the smaller practices may actually do better than some of the practices that are in the middle, you know, the people with, like, 10 people,” whereas the larger practices, yes, just to your point, it’s a little bit easier that, “Hey, you’ve got a chief operating officer. There’s financial people. They’re making decisions basically.” Like, “Hey, you, orthopedic surgeons, you’re not gonna take a salary for the next couple of months, but we’ll be able to keep everybody on. And then we’ll take it from there.” You get two or three people in a practice, they can have a conversation and have less of an ego conversation about what do we need to do for the next few months while we figure things out?

You get a group of 10 or 12 surgeons and I say this with love, I have lots of friends who are surgeons, they have large egos. You need to have one to be a good surgeon, there’s no doubt. And they’re all fighting, you know, about what to do. And they all know “what to do.” And they’re gonna have more difficulty. That was what he was saying. And we’ve been having a lot of conversations with a lot of different docs on this podcast offline as well about what to do next. But I’m kinda focused on these poor people who are, to your point, people of color, people of poverty who either don’t have access to good health care, don’t have the ability to simply “shelter in place.” It’s one thing to shelter in place and have income. To your point, I couldn’t agree with you more. Thank you for the $1,200 dollar check. But what’s next month because I didn’t pay my rent?

John: Didn’t pay my utilities.

Scott: Exactly, all of those things. And yeah, it’s great that you can’t evict me. But wow, what’s that gonna do for me next month? And so I am hoping that we come up with some solutions that makes sense. And we tend to stay away from the politics of things on this podcast. So I’ll just leave it there so that we don’t get into a long drawn-out conversation about universal income and etc. But from my perspective, as I’m listening to you, a lot of us feel helpless. What can we as citizens do to try to help? Is it about volunteerism? Is it about donating? Is that what it is for right now?

John: I mean, the best thing to do is stay home. That’s it, so simple. Just do that. If you’re really feeling a need to be out there among humanity and doing something directly, go work at a food bank. I mean, every shot that you’re seeing on the news is 10,000 people showing up at these food banks. Go help the folks who are at greatest risk and with the fewest options. Go help get homeless people to shelters that they get care. Go work at a food bank. Go do light tasks for healthcare workers just to help out.

I mean, you can do so much just for these frontline personnel just by dropping them off a meal at night, or by walking their dog three times a day when they’re stuck on a 48-hour shift at the ER. Really, the best thing you can do is stay home. If you can write a check, write a check to Meals on Wheels because they are desperate right now as are most other social service organizations helping seniors and the poor. And then think about how do we help our frontline personnel be more resilient and, you know, able to survive an extended deployment against this virus over the coming months.

I mean, this is just not going to be something that goes away four weeks from now. We are still going to be, as you mentioned earlier, Scott, we’re gonna be dealing with this for years to come and we have to help our frontline personnel be more resilient. So again, if that’s just as simple as dropping them awesome food, or walking their dog, or however else you can help them continue doing what they’re doing, that’s where the need and help will be greatest.

Scott: Yeah. I think donating money to food banks, services that help out healthcare workers all are just essential at this point right now. Here in New Orleans, I think there’s something called Red Beans Krewe, they’re trying to knock off two birds with one stone. You donate money, the money goes to restaurants to feed people who are not working in the restaurant business, which is part of our New Orleans business.

John: Yeah. Oh, yeah.

Scott: And they do that by not only feeding those employees, but they also then pick a hospital a day. And they just feed, you know, the ICU unit, you know, think of a local hospital. I loved your idea about, like, if you got neighbors, etc., that need a little extra help and you need to go outside. First of all, wear a mask.

John: Yeah, absolutely.

Scott: Wash your hands before you walk out. Wash your hands when you come back in. All those small little things that didn’t mean that much before the pandemic hit really mean a lot later.

John: Oh, yeah.

Scott: And I do agree with you. Those lines for food are very, very long. And there are a lot of people out there who used to work multiple jobs and thought they were fantastic having few hundred dollars saved, who are right now seeing that quickly go away. And they are not, like, unlucky enough to “complain” about sitting at home and having to figure out what to watch on Netflix.

John: Right.

Scott: “Oh, woe is me”–that’s not a big deal. But there are people right now trying to figure out like, “How do I feed my family right now?” And you’re right.

John: Where’s the next meal coming from?

Scott: Where is my next meal coming from? And I do think anybody listening to this, most of the people we’ve talked to, that’s not really a major concern. I get it. There are some people listening to this where that is a major concern and to all of them, I’m donating what I can, time and money-wise, and I hope everybody else listening is who can afford to do it. Please…

John: Exactly.

Scott: …take the extra step. Take the extra step.

John: I mean, if you’re really feeling compelled to help, help those who are most vulnerable and help the helpers. Then do what you can and make our healthcare personnel and other frontline folks. I mean, even just, you know, the guys who are emptying your garbage bins, all these guys are absolutely, we’re seeing now, essential personnel. We pay them peanuts in exchange for this essential work. So, I mean, anything that we can do to make these frontline personnel more resilient, and then just appreciated and feel a little more secure about where they are in the world is really gonna just be good for not just our local communities, but for society.

I mean, this thing has really shown how pathetic the social safety net is in the United States. I mean, we spend less than 1% of our gross domestic product on our social safety net. And now is when we see the effect of that. What’s fascinating is watching in situations like this, healthcare payers and healthcare providers basically look to as almost like a public utility that’s responsible for everybody’s health. The system really doesn’t work well, obviously, as we said for lower-income and minority folks.

You know, in situations like this is when you see the fact that because health insurance companies are 100% at risk for all of the healthcare costs of their enrollees that now is when you really see the huge effect of poverty and a completely insufficient social safety net. And it all falls to insurers to make up the gap. So now, for the first time, BlueCross BlueShield of Louisiana is really seeing the kinds of investments it needs to make in places like West Baton Rouge in order to better manage the costs of these populations. I mean, this is what brought our company, Nightingale, forward a few months ago, was just knowing that investing in our social safety net is probably the single best thing that you can do to support the health system right now.

So our mission and the kinds of stuff that we do are to invest in big social determinant interventions like food security, or housing security, or adult and child daycare, or transportation to doctors’ appointments because these things reliably save 3x to 8x ROI of what you invested in the intervention. And sometimes, it’s even a lot more than that. I mean, two years ago Geisinger did an incredible study where they found they were spending $300,000 per patients per year on their uncontrolled diabetics. So they started a medically appropriate meal delivery program for them. And within 14 months, they had knocked down the average cost of their uncontrolled diabetics to $48,000. So net of the cost of the meal preparation and the delivery, they saved almost $200,000 per patient per year just by feeding people, okay?

And so that, to a guy like me, is an investable event that allows us to really look at a broad food security initiative in a place like Louisiana, which is, you know, just absolutely riddled with diabetes and other food-related maladies. That really shows us this is a replicable program that saves a staggering amount of money. And that that money can then be…the savings can then be reinvested back into that system to make it even more efficient and higher-quality just by meeting basic human needs. And this is where, to our estimation, the system really has to go especially in the middle of this pandemic.

Michael: This is really interesting, John. Like, this actually kinda reminds me of an episode that we recorded a while back with a guy named Dan Dunlop. And he brought up the group Build Health. And going after some of the same kinds of issues that you’re pointing out here, trying to come up with new ways to get transportation to doctors’ appointments, trying to come up with new ways to really pull organizations together that aren’t used to working together. And, you know, hospitals working with the nonprofits in the area, working with the churches in the area, working with whichever groups have the most impact and the ability to connect. And 100% agree, like, we have to think differently. Like, we cannot keep doing what we’re doing and expect things to get any better in that way.

John, thank you so much for coming on the show. There’s a ton that you’ve given me to think about for sure and I’m sure our audience as well. I’m very excited to hear about the project that you guys are doing in our area for sure. That’s very encouraging for the state. And I’m sure the other projects that you’re working on as well. So, John, thanks so much. And we really appreciate it. And, guys, thank you so much for listening to the show today.

Announcer: Thanks again for tuning in to the “Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neural practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.