Financial Sustainability, Productivity, & Culture with Jeff Allen, FORVIS

Speaker A: Welcome to the CHC podcast. My name is Chase Marable, and we are so excited to have some very exciting topics to discuss today. Uh, really impacting the fairly qualified health centers that are listening in. Uh, what we're going to discuss today is everything from sustainability financially moving forward to provider productivity and management relations, all the way to ending today with culture and, and how the organizational values really align to meet that sustainability. And I am joined today with my co host.

Speaker B: Yeah, good morning everybody. Thank you for joining us. My name's Dawson Nemo, and as, uh, Chase alluded to, we've just got one incredible, one incredible guest, Mr. Jeff Allen from the Forbis team. Jeff, if you could just take a moment, introduce yourself and give just a brief background. Most people know who you are, but just in case, we've got some listeners that don't. Um, if you wouldn't mind, just take a moment.

Speaker C: Yeah, absolutely. Thanks for having me on. Uh, yeah, my name is Jeff Allen. I'm a partner in the CPA firm Forvis Mazars. I, uh, used to be BKD a few years ago. Been, uh, work. This has been doing this about 32 years and 25 plus of those years have been working just with community health centers. So, uh, I am the partner in charge of our community health center practice nationwide. Uh, Forest, Missouri, works with about 400 health centers across the country. And I'm the partner in charge of that practice. And I really just, you know, we enjoy the health centers. I love those. I love what they do, I love how they affect their communities. And so it's a really just a pleasure of mine to be able to work in this industry.

Speaker B: Well, Jeff, we are certainly honored to have you on today. And first topic, you know, we, and I'm sure you're getting the same questions we are, but it seems like everybody's talking about sustainability in the space and Chase alluded to that a little bit. And, um, you know, first question I've got for you, you know, what are you telling different health center teams around the country and their team members when they call you and say, hey, we would want to make sure that we can stay open in the future? What are you telling folks and how are you guiding them in that space?

Speaker C: Yeah, you know, it is a great question. I would imagine that probably over half. And, uh, I don't have anything to back this up. It's just purely from the gut, but I would say more than 50% of the calls coming into the office right now are about sustainability issues. And it's just a big Deal. And it's one that, you know, health centers are starting to struggle. The average margin in a community health center right now is hovering right around break even and that's average. So um, you know, we got a lot of health centers that are having operating losses and some that are doing okay, that are, that are still surviving. But, but really it's about how do we, what do we do to make sure that we are sustainable into the future? And, and it's about really making sure you're, you're, you're blocking and tackling, make sure you're running a clinic like you should, doing all the little things. Right. I, I was joking to a group the other day, I was giving a presentation on this and I asked the group if any of them read Don't Sweat the Small Stuff. And oh, I'd say two thirds, you know, the people probably raised their hands. Yeah, they've read that book, they were familiar with it. And I said, well forget what you learned in that book because in a community health center you got to sweat the small stuff. And there is a lot of health centers that do things fairly, fairly well, but they don't really mind their P's and q's on the little bit of the small things. Like they might have a Medicare Advantage as a, uh, as a significant payer in their clinic, but they don't realize they can get RAP rates to get up to the national rate if they, if they, if they just would set those RAP rates up with the Mac. They don't realize that maybe they could claim Medicare bad debts on their cost report. They don't realize that they could bill for chronic care management as a separate service outside the PPS rate. They don't realize that their commercial insurance rates maybe haven't been updated in five or six years and they probably could get paid 15, 20 bucks more an encounter if they just really made that investment and worked on that a little bit. But what happens is in a lot of community health centers, we're just focused on Medicaid and what we get paid for the grant through our self pay. So hey, we got sliding fee and Medicaid. That's what we're doing focused on. We're not worried about Medicare, we're not worried about Medicare Advantage, we're not worried about commercial. But in a lot of cases I've been able to show I was talking to a clinic at just a medium sized clinic, not a large community health center, just a medium sized clinic that I showed them that their commercial insurance rates were just at what normal prevailing rates are not asking for any favors, just getting kind of paid what everybody else is getting paid for the same type of work. It would be about quarter of a million dollars a year more to their margins, their bottom line. So you know, just minding those little things, you know, trying to make sure that your revenue cycle is working well, making sure that um, you know, that you're billing and collecting for the services that you provide. A write off is an everyday occurrence in a health center. And that does happen. But trying to minimize those to the extent possible. There are still a few clinics right now that are looking at staffing. You know, we kind of up staffed a little bit during the COVID years. We got a lot of grant money that encouraged us to hire staff and do that. There are some clinics, uh, that are overstaffed at this point that they probably need to look at that and consider whether their salary costs are really more than what they need. But I would say nine times out of 10, it's all the revenue cycles. Learning how do I maximize that revenue cycle, how do I make sure I get paid for everything that I do? That is still the blocking and tackling of running a community health center.

Speaker B: Yeah, that's just, that's just some incredible insight there. And, and you know, as you mentioned, you know, a lot of this is basic blocking and tackling that you know, can often be forgotten about. Um, but it's still unbelievably important to keep in mind. And then you know, you talked about some additional ways to pick up some, some extra revenue there. Just incredible stuff. And, and uh, we, we greatly appreciate that insight.

Speaker C: Yeah, absolutely no worries.

Speaker A: And having Richard Carlson with Don't sweat the small stuff, it's so important in the time of so much uncertainty from the state, uh, and federal legislation, a lot of health centers are taking a second look at these different items. Especially the revenue cycle that you mentioned, Jeff. We've talked about that in the last few episodes. Uh, and I think it's also very important to know is that revenue cycle is not just a function of accounting, it's not just a function of billing, it's a function of the whole organization. And I'm sure that's something that, that you visit with your health centers on.

Speaker C: Absolutely. You know, even. Excuse me, apologize. The revenue cycle, you're right, is so much more than just billing. Uh, and a lot of times, in fact I had a clinic that just in the last few months I had a clinic where I had mentioned that they needed to really kind of improve their Revenue cycle. And I really, I learned a lesson because they interpreted that is that, oh, they need to really watch their billing and collecting and they need to make sure they do that well. And that was all they, they did. But really what I was meaning is that their front desk was not doing what it needed to do to check to make sure insurance were current or maybe do their even customer service type stuff there. You know, even, you know, uh, scheduling. Do we have a call center to take appointments? Is that call center working correctly? Is it, Are we scheduling patients, uh, for that day when they call in, or do we have to wait several days? Because, well, we've got the schedule all mucked up with some things and things like that. So we've got to really put, pay attention to that. I mean, if I'm trying to grow a Medicare practice because I really want my payer mix to improve and I'm a Medicare patient and I call and I try to schedule an appointment and it's two weeks before I can get in. Every provider wants a Medicare patient. So I have all these choices in which to seek care that needs to be fixed. That's part of your revenue cycle too. Uh, all kinds of the patient flow through the clinic and making sure that's efficient and making sure that, you know, that when the patient presents there at the front desk to be seen by the provider, that it doesn't take 40, 45 minutes to finally get the provider in the room from that. And a lot of that's not the provider's fault. It's just because the process is broken. So, yeah, you're definitely right. Revenue cycle is so much more than just billing and collecting. It really starts, uh, from the time the patient, you know, seeks help or seeks a care that they want to get through calling or making an appointment. And then it just ends, uh, on the back end. Finally, when that cash hits the bank for the service that's provided.

Speaker A: Absolutely. And when we look at having these health centers really take a deep dive into the small things of the organization, they can really identify some really key revenue drivers just by making maybe small tweaks, not these major initiatives just to really zone in on these small, small steps that can really impact the revenue and especially when margins are so tight and you have this, uh, legislation that we really don't know where it's going to be ending up at. Uh, it's really important for the health centers just to take a second look at that. And that's such a good perspective. Thank you, Jeff.

Speaker C: Yeah, no worries. Yet now is the time to button it up. You're right. Because with work requirements and different things like that, we just don't know how that's going to impact Medicaid and things like that. So now's the time to get all these things shored up. Absolutely.

Speaker A: And you know, that's a great segue into our next topic of, uh, provider productivity. And it really starts with that encounter. And really how do we drive those encounters is because we all know more visits equals more revenue. Uh, but what I really want to know is how are these interactions going between the management and their provider group? Um, I know it's a hard conversation to have to have more visits, but again, as we know, the more the visits, the more revenue coming in. So what's the latest on that? What's the latest on provider productivity that you're seeing?

Speaker C: Yeah, that's a great question. I'm glad you asked that because there's a lot of. This is a, uh, situation that really can make or break an organization. There was even a health center in the country that had a recent lawsuit where the providers actually sued the clinic because they were asked to do visits in excess of what they thought was fair to ask. In some cases, that's an example where the conversation's going very poorly. Um, but however, in a lot of health centers, we're start to see more momentum about. Let's just get the conversation into the room. Let's just start now. In a lot of cases, providers, and I'm over generalizing here, but providers generally don't like to get direction from non providers and they push back a little bit on that. There have been a lot of CFOs over the years go into the provider room and say, hey, sorry, we need five more visits a day. And that just doesn't go over well. That that conversation is. I don't know that it's ever worked and I've seen in my career, but however, you can sit down and have the conversation to say, you know what, I teach my CFOs and even the CEOs that ask me this is to put it on themselves, what can I do? Productivity does lead to more revenue. And you brought up a great point, Chase. More visits equals more revenue. But what can I do as an administrator to really help and facilitate these issues? And in a lot of cases, I facilitated, uh, a conversation one time that got fairly heated between administration and the provider group. And looking back on it now, I can kind of chuckle. But really it was about communication. The communication had broken down. There were really some things going on that the administration was not doing to really allow the providers to have the ability to be a little bit more productive or have more visits in a day. And once that conversation got going, once the situation where we all got in a room, we're all trying to do the, we're all trying to be sustainable, we're all trying to serve patients, we're all trying to make sure this health center is viable into the future. And in that providers are on that page too. So we have a common goal. How can we work together? Just get the conversation going and started and discuss this. There was a health center in Georgia here recently that made the change to go to complete 100% productivity based pay. And at first I was kind of like, oh my goodness, this is not going to go for well, this is going to be um, a nightmare in the provider room. But really the management team did a great job of laying it out and saying here's kind of our vision, here's what we think, here's what's possible, here's what we can do. They've implemented it now. That's been implemented now, I think a little less than a year, not quite a year yet, but everybody, it's a win win. There have been a couple providers that have pushed back and don't like it, but seems like the clinic is generating more revenue now from their encounters the providers. If you look at the average comp, the pay has increased so they've been paid for their productivity and they've got this. So really that might not work for everyone, that might not work for every clinic, but it doesn't happen unless you have that conversation. There are a lot of CEOs and CFOs in our industry that are, I mean, uh, just going to call it what it is. They're afraid to talk to their providers about that. Uh, they're afraid they're going to leave. Uh, especially in rural clinics where, where man, it's hard enough to recruit a doc as it is and I'm going to go to that doc now and talk about productivity. I'm going to go talk about something that might upset him or her. Well, I don't want to do that because man, it took me six months to get somebody to come work for us in the first place. Don't be scared of having the conversation. That doesn't mean you're going to demand a certain level or whatever, but at least have the conversation because if we all get on the same page then you know, it really can lead to A ah, really increased revenue and increased physician provider satisfaction. So it's definitely something I've been encouraging my clinics to have. But you got to have it the right way. It's not about demanding. It's about sitting in the room and saying, okay, let's all get on the same page and figure out what we can do to make this place sustainable.

Speaker A: Wow. It's really just starting that conversation. As you mentioned, Jeff, and I've seen time and time where a lot of the management group is hesitant to have that conversation with their provider group. And I think if there's a big takeaway here, just let's just have that strategy and just get the conversation out there and get it going. Because we're all serving that community, we're all serving the demographic, we're all serving the patients. We just have to get together to say, what is that best route forward? And something I'm curious too about, Jeff, you know, being, uh, in Missouri, we have a luxury of having the author of the Great Game of Business here very locally. And what they talk about is open book management and letting the employees and letting the team really have that ownership over the revenues and the financials. What do you think about that with providers and management? How have you seen that go?

Speaker C: Yeah, you know, Chase, great question, great comment, because I'm all about that. I think open book management, especially with your provider group, makes sense, is, you know, we, here's, here's open financial records, here's open encounter records, here's productivity records. Because I've seen in the past, and again, and I'm not a provider, I'm an, I'm a, I'm a cpa. So, you know, full disclosure. I don't know what it's like to make a medical decision for a patient. I don't know what it's like to have productivity pressures on me. So, you know, full disclosure off the bat. But I've seen a lot of times that providers can be pretty, pretty competitive with each other. And if you put a list of, hey, here's. We have 12, 12 providers. Here's the list of visits, here's the list of our visits for the year and all this stuff, it can become almost a competitive thing to say, hey, I don't want to be 11th or 12th on the list. You know, I want to be up here. But you also have to kind of realize too, and work some what I would call relative value units or RVUs into the equation too, because you. It's very possible a lot of clinics will have this where some of the hard cases, some of the patients who maybe have multiple things wrong with them that, that take some really a higher skill level to give them advice on their care versus somebody that may just have a cold or the flu or something like that. Um, sometimes there are health centers that have what I would call go to providers for those hard things. That. Why we have to factor that in. So, yeah, my visits may look lower than my peers, but I'm also dealing with some of the sickest patients that we have at the clinic. So it's really good to kind of keep those things in mind and show that you can. With a relative value unit score, you can really kind of show true productivity as opposed to just simply. How many visits did I get in the last period?

Speaker A: Yeah, absolutely. I think that's a great way to kind of merge the quantitative and qualitative data and really have a good interpretation of that. Um, that's amazing. And you know, something else that we see a lot is culture and culture inside health centers. And I think it's just a great segue into this as we're talking about that relationship between the providers and the management group and the community we're serving. So, you know, I know every time I hear you talk, we talk about culture and how important that is, Jeff. Um, and that's. That's really what we drive home to a lot of health centers. So tell me, why are you so passionate about the corporate culture? And how do you see that affecting that sustainability we're talking about moving forward?

Speaker C: Yeah, I noticed. I've noticed this and I've. And I, you know, I am very passionate about it, and it seems like I can work corporate culture into about any speech they ask me to do. So they might ask me to do a speech on, hey, what do you think about, you know, Medicaid, cost reporting? And I'll somehow work culture into it, you know, um, but because it just is. It makes or breaks an organization. You know, I've been around and for, you know, I'm getting older and I've been doing this now for over 30 years, and I, And I just see how culture makes or breaks a community health center, and it's interesting to go. You go into an organization and maybe the. Or maybe the health center is struggling. Right? I mean, we're not, we're not, um, financially as stable as we'd like to be. Maybe our results aren't great, and we're really worried about sustainability. So maybe we bring in somebody like myself or others to come in and help Us think about what do we need to be doing. I have made suggestions to multiples of these organizations that are struggling. And I will get back with. Oh, Jeff, that doesn't work for our clinic. Oh, Jeff, we just, uh, there's no way we, we can't have that conversation with our provider group. Um, Jeff. Yeah, we're only 5% Medicare. We're not worried about getting our rap rates on Medicare Advantage or things like that. Just let's move on to something else. And what it means, what it says to me is that their culture is broken. Um, we don't have accountability in our organization. We just let folks do what they do and we just move on. And we just hope and pray that we can survive. Um, we don't have a strategy for how to move forward, and we don't have, you know, we don't have open communication between our entities. I was in a clinic not too long ago where the CEO and CFO couldn't stand each other. And I had to have two separate meetings because those two individuals could not be in the same room at the same time. And that, I mean, what a horrible example for your staff. And what a, what a, what a, what a broken culture that they have. And you have to be able to have this culture that is open to innovation, open to doing things better. It's interesting that you can take a clinic that's struggling and they may have two or three sites that do well and a couple of sites that struggle, and they're like, you know, hey, as long as we've got, overall, as long as we're breaking even or a little bit above that, we're just happy with that. Will you take that to a health center that's got a great culture, that's got a culture of, uh, excellence, a culture of accountability. And it just drives them crazy that those two sites are struggling now, that maybe those other three sites are doing really well and are paying the bills. And maybe they got a pharmacy that is really high performing. So they really, from a financial perspective, they can afford to have a couple clinics that struggle. Uh, but that just bothers them. And it's like, why aren't these two places doing better? So they will spend effort after effort to make sure those two clinics are doing well. And that's the difference between a poor performing financial health center and a, uh, and a high performer. You hear a lot of excuses from the low performers. Well, our payer mix is not good. Um, we're not in an expansion state for Medicaid. Um, man, we really Struggle to find providers or man, our, our. Our behavioral health practice is not doing well. Our dental is not. And you hear a lot of excuses. Here's why. I'm not doing well. And I would challenge them. And I always do it politically correct, and I always try to make them think.

Speaker B: I rarely.

Speaker C: I'm not. I struggle with sometimes being a direct communicator in some of the circumstances, but I always try to encourage them to say, okay, but your neighbors 50 miles down the road have got it figured out. They're doing okay, they're doing well. So how. They've got the same circumstances you do, so what are they doing that you're not doing? How can we learn from how they handle stuff? And. Because if we just make excuses, if we just say, you know what, I can't help this. I mean, it is what it is, then we're not really focusing on the ways that we can improve and be better. And so I really preach that message everywhere I go. You want to have a culture of strong communication between departments. You want to have a culture of accountability on every level. You want to have a culture of just being pleasant. Great customer service, both internal and external. I really believe that there's a direct correlation between a clinic's no show rate and their customer service. You know, if I'm not treated well at the clinic, if I'm not getting a warm fuzzy when I walk in the doors, then, yeah, why would I want to go there? I mean, if I can find somewhere else to go, man, if I can somehow suck it up and not have to worry about, you know, uh, seeing that I'm going to stay away from there. But if I feel warm and welcome, if I feel that, man, I'm there, I'm going to make my appointment. I'm going to make it a priority in my day to make sure that's there. Now, there are things that happen. There are things outside the clinic's control. They can't always control that. But I see a direct correlation between those two things. And a lot of times we just don't talk about that in health centers, about how important that culture is about. We want to be an employer of choice. We want to be the place where all the patients in the community want to go see us. Uh, because, man, we treat you like you are. We roll out the red carpet for every patient that walks through the front door. And I've seen health centers just transform their image by just doing some of those things and take care of that and are now thriving today.

Speaker A: It's Incredible. And, you know, it goes back to the earlier parts of our conversation, Jeff, where when we look at financial sustainability and we look at the. Having those conversations with the, uh, providers and management, you know, it really has to have a good culture foundation. Um, and if it doesn't, it can make those conversations very, very difficult. But when, when it does, and when everything's humming and when you have that excellent excellence mindset, and when you want to be that employer of choice, and when everybody from the front desk to the provider to the management to the nurses, when everybody is on board with that vision, that same culture, it's almost these issues and challenges work themselves out because everyone is on that same page and understands the vision, understands the mission. And it's just, you can, you can feel it when you walk into a health center, when they're on board with that culture.

Speaker C: So, absolutely. I, I have a client that went to a daily huddle, and I'm like, isn't that kind of a waste of time? But they get everybody together the first part of the morning, and hey, if you've got a problem, if you got an issue, air it out there, talk about it. Let's get it out on the table, let's discuss it. Some of these things only cost, you know, take four or five minutes. But they have these daily huddles where everybody gets a chance to talk and, hey, what's the goal today? What are we doing? What, what, Is there anything big going on today? Do we have any kind of struggles we have today? Or, uh, is a clinic going to be super busy? Are we not? But they. What it did is it got everybody on the same page. And you can kind of feel it when you walk in there. It's like, you know, you're right from start to finish. From the, from the, from the entry level employees all the way up to the CEO, you just get a feeling like, man, they all want to be there. They all love their jobs, they all want to do that. And, you know, you're in town and you got a place to, you got choices to go see the doctor. You choose them because it just, it just feels. It just feels good. And we don't. A lot of times, it's funny having a CPA talk about this, but it is the difference sometimes in financial sustainability and not being sustainable. Um, and I seem like I get more passionate about it every time I talk about it.

Speaker A: Absolutely. Well, Jeff, as we wrap up the conversation today, you know, we've talked a lot about financial sustainability into the future, how to really Take a look at those small things. Uh, we've talked about getting the conversation out there with provider group and management and just having that conversation on open book financials, revenues, encounters. And then we really drilled into culture, which is just a phenomenal foundation to really start addressing some of these larger challenges. Um, so if I'm a health center leader listening in, uh, on this conversation, uh, what piece of advices would you give me? What resources may I lean out to to really help drive the culture, drive the financial sustainability in my organization?

Speaker C: Well, a couple things. One is that the tone at the top is a real thing. I mean, it's been proven is probably not the right word, but it has been shown to be effective. And it's all kinds of studies done on that, that when you have a CEO who's on fire for the organization, I mean, who's really passionate about it, who really treats their employees well and really values input and, and uh, holds, holds people accountable, which is part of it, that trickles down to all the rest of the employees. So don't think for a minute there that you can't change the culture. A, uh, CEO that's on fire for the organization can absolutely change the culture of the organization. The other thing too is really focus in and evaluate your folks that you have over your revenue cycle and say, do we have the right people in the right seats on the bus? Are there? Do we need to augment, um, our acumen levels in that area? In a lot of cases, even though we might have to upgrade our levels of employees that we have over certain areas, like maybe billing or, or maybe have some front desk help or whatever, we determine maybe our breakdowns in the revenue cycle. Investing in that, in, uh, many, many cases results in actually revenues that exceed what that investment is. So you know, pharmacy, making sure your pharmacy is running correctly, making sure you've got somebody who understands how to run a pharmacy to do that, all these things are very important. Making sure you've got the right people in the right seats on the bus. And if you don't have that, then go out and try to find, uh, that person to really help you lead your organization. And if you get the right people in the right seats, man, and get everybody on the same page, you can really move mountains.

Speaker A: Jeff, thank you so much for joining us today. Always a pleasure. We always have great takeaways and we really appreciate your time.

Speaker C: Yeah, I really appreciate you having me on. Thank you very much. And hope, hope, um, you know, certainly, you know, hope, hope everybody's sustainable into the future health centers need to be here into the future. It's a big part of healthcare. And so I, I am rooting for all of you out there. I hope that all of you are sustainable going forward.

Speaker A: Absolutely. Uh, everybody listening? We will go ahead and have Jeff's contact information in the description of the podcast today. Uh, please subscribe. And, uh, thank you again for joining.