Author: Kelly Wisness

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Why Hospital CFOs are Leaving Millions on the Table and What the Best-Run Health Systems are Doing Differently

In this episode, James Jacobi, VP of Employee Benefits at Hilb Group, discusses something that hits every CFO and finance leader in healthcare directly, the runaway cost of employee benefits.

Highlights of this episode include:

• A different way to look at how we talk about cost of healthcare in the industry
• How healthcare and pharmacy costs are outpacing GDP and wage growth
• Difference of benefit strategy versus just buying insurance
• How it is still relevant to a self-funded CFO
• Where to learn more

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome James Jacobi. James is a VP of Employee Benefits at Hilb Group with over 17 years embedded in the HFMA and deep experience working with hospitals, health systems, and healthcare vendors. In this episode, we’re discussing something that hits every CFO and finance leader in healthcare directly, the runaway cost of employee benefits. Most organizations treat this as a line item to manage at renewal. My guest today says that that’s the wrong frame entirely, and the proof is in the numbers. Welcome, and thank you for joining us, James.

James Jacobi: Thank you so much, Kelly. Really excited to be here. And yes, that is the message today. I’m going to give you a different way to look at how we talk about cost of healthcare in the industry and how it’s increasing and what it really means for your business from a P&L financial perspective, but also from a people perspective and how we can kind of tie some themes here together today. So, here’s quick math that should be keeping every CFO up at night. Right now, healthcare costs to employers are growing at 6% annually after a decade of 3%. Pharmacy costs are growing at 9 to 12%. Why is that a problem?

Because GDP is only growing at 2.5, maybe, and wages went up 3.4. So, we are seeing a huge outpacing in insurance premiums that are outpacing compensation and business growth. That’s not going to work now or it’s definitely not going to work in the next 5 to 10 years. So, here’s a number to kind of put all that in context. The average annual premium for an employer-sponsored family right now is $27,000. That’s roughly the equivalent to a full annual wage of a worker earning 15 an hour. Your benefits line item is not a cost center. It’s a structural drag on your ability to pay your people, compete for talent, and grow your company.

The biggest piece of this is pharmacy. It’s driven primarily by GLP-1s that you probably have seen everywhere by now. You may or may not have a family friend, and you might be using it yourself, but it is the fastest growing thing that’s impacting costs. Drugs went up from less than 1% of employer pharmacy to spend to over 20% in five years and that continues to grow. One employer said GLPs went from the 32nd most expensive drug on their formulary to number one in a single year. So, I want to be clear. What I want audience to hear today, whether you’re a hospital CFO listening to this, you’re ahead of a clinic, you’re a president of a service provider helping the healthcare industry. This all works for you. Doesn’t matter if you’re at 40,000 employees or 50 employees. What we’re going to talk about in this podcast is real. There’s real data, and it’s going to give you some strategies on how you can tackle this to lower your costs and take care of your people.

Kelly: Wow, looking forward to that. Well, let’s go ahead and jump in and learn more, shall we? So, James, you said healthcare and pharmacy costs are outpacing GDP and wage growth. Why is this happening? And why isn’t it slowing down?

James: The problem is this is not cyclical inflation. This is compounding. It’s a structure problem. And this is happening for a few different reasons. One, there’s a lot of provider consolidation happening, more M&A year after year. So, there’s fewer larger health systems that have more pricing leverage with insurers. Hospital prices have driven faster than any other component of medical spend over 25 years. Pharmacy is exploding. Like I just said, GLP-1s alone are reshaping the entire pharmacy cost curve. This is not a blip. The GLP market alone is projected to grow from $22 billion of last year to over a $105 billion by 2030 in the next four years, which is insane, right?

Kelly: Right.

James: Yeah, utilization rebound. There’s a lot of things that happened post-pandemic that we’re still dealing with. Deferred care from that time period is still coming through the system. People who skipped procedures and screenings in 2020 and 2021 are now showing up sicker and with more complex conditions now. Another piece is AI-assisted billing optimization, which is huge. It’s what everyone’s talking about right now, is how do you put this into practice? How do you put this into your revenue cycle? Well, new AI platforms are helping provider systems optimize their billing, which is adding more pressure on claim costs at the employer level. So, there’s just a lot of compounding math to this. But it’s not going anywhere. And there’s a way to get ahead of it, which is we got to start looking at how we break this apart and your benefits, which is where you’re paying everything from.

Kelly: Wow. Those are some big numbers there. So, when you talk about having a benefit strategy versus just buying insurance, what is the actual difference? And what does a real strategy look like?

James: Absolutely. So, this is kind of a fun conversation. When I talk to a lot of leaders or executives, a lot of people have this misunderstanding that when you’re buying insurance, you’re just choosing between which insurance company that you want to have, like a Cigna or an Aetna or a United Healthcare, right? And like, “Oh, we switched, and now we must save money.” Well, maybe it did. But that has actually zero to do [laughter] with how you build a strategy for optimizing your spend. A big point I want to make here is you may not know this, but someone, usually on your CFO or your CHRO, would probably know this.

But there’s really two ways that most companies buy insurance. It’s usually called fully insured or level funding. Both of those methods, what that really means for you as the employer is you’re basically paying a prepayment. You’re prepaying every month that premium. You’re paying the carrier money ahead of whatever claims come in from your people that year. So, you’re always spending money first before you kind of see what the total bill is for yourself at the end of the year. And then you kind of add it up and see where you’re at. The problem with that model is that the insurance company takes every amount of savings that they had. And if you were healthy that year, let’s say you didn’t have that many claims come in, but you still paid a lot of premium, there’s a surplus there. There’s a gap. You pay more premium than you needed to take out. The insurance company keeps that. They don’t give it back to you. All that profit goes to them. Same with pharmacy, if you were able to not spend a lot on pharmacy, if you found different prescriptions that were less cost, and there’s rebates involved in all that, the insurance company gets to keep that with their PBM partner. You get nothing.

So, if you’re a hospital CFO, you probably might know this, but what we call an option door number three is alternative funding. And what that really means is that it’s the first step of leaving that system we just described and getting to a different place where you don’t pay premiums right away. You only pay when you have claims. And you get to see every piece of data that you have. Under door one and two, the insurance company isn’t sharing that information with you. If you’re level funded, they’ll send you monthly total dollar amounts of claims dollars for pharmacy and medical that you spent. But that’s it. It’s very surface-level.

You have no idea what’s happening with your people. You don’t know if they’re healthy or if they’re not. You don’t know what they really need. You don’t know anything. They don’t tell you that. But under alternative funding, you get to have lots of different options in what you can see, how you can measure stuff. And this is the beginning of how you start tackling this big problem that we’re talking about today, because now we can break apart dollars that that made up the whole before and start optimizing each piece. And what I mean by that is you can optimize, for example, your pharmacy. You can get a different PBM that costs half as much. You can find drugs that work just as well for half as much. You can get all the rebates from those. All that surplus goes back to you, the employer. That’s one example. There’s stop-loss insurance that is baked into your premium. You can carve that out, and you can get a much more competitive version of stop-loss. So, it saves you a lot of money there. The TPAs you work with are less expensive than the carrier that managed that for you before. The other last piece, which we’ll get into in a little bit, is population health management programs. Everything from preventative wellness to more complex chronic conditions, with maybe cancer, for example. We can build and have customized health programs for your specific people that lower the cost of care, give them better quality of care, which in return reduces your risk. This is huge risk mitigation right now that I’m talking about, which then lowers your cost for insurance and your premium. So, it comes full circle, and it actually impacts your health system if you’re a healthcare CFO too. This actually helps you on that front as well. But this is stuff that you can’t do if you’re under option one and two. And that’s the biggest misconception that I hear when I talk to executives is, “We got to go a little bit deeper, guys. It doesn’t work that easy.” And we’re breaking out a lot of topics today, but this is the beginning of how you start to look at a real strategy to lower your costs and really take care of your people.

Kelly: Yeah, I mean, you’re blowing my mind right now, really, James, with that option. I’m like, “I want door number three,” right? [laughter] It seems like everybody should want door number three.

James: You should want door number three. Yeah.

Kelly: Yeah, exactly. It makes sense. So, for the hospital CFOs listening who are already self-funded, is this conversation still relevant to them, or have they already solved this problem?

James: It’s 100% still relevant because even if you’re self-funded– and you likely are, if you’re not, then we have a problem already. [laughter] But there’s a whole spectrum of what alternative funding can be, right? You may have heard some of these before. There’s these things called captives, right? Captives are basically you’re a member of could be hundreds, if not thousands of companies that are in this captive, but because of the membership and the volume and the purchasing power, you’re able to get and negotiate better rates for your pharmacy, better rates for your medical, better stop-loss. And just through that mechanism, you can lower your cost. So maybe some of you listening are in a captive. You don’t have to be in a captive. You can do bits and pieces of this. You can basically rent a provider network, whether you want to use Cignas or Aetnas or United Healths or whoever that you work with. You can rent their network. You can have your own PBM pharmacy program. You can have your own stop-loss program. You can piecemeal this stuff together to make up your own strategy is the thing here. So, the key is if you already are self-funded, you want to be looking at all these components, population health programs for sure. After you do pharmacy and stop-loss, that’s the next thing you want to look at because you want to start looking at, do we have wellness prevention, preventative health programs? Are we having company contests and incentives to help employees take care of their health? They could be gift cards. They could be giveaways. There could be iPads, whatever it is, but are we throwing some fun things in the mix for our culture to incentivize people to go get an annual physical, go get your blood tested, go get your check in your cholesterol and your BMI and just go get checked up to see what all those numbers are and just make sure you’re good. Just by doing that because you’re doing preventative wellness and medicine, it’s going to catch anything serious earlier, right? People have problems with health because they waited too long to know that they had a problem, right? So, if you just do that, you’re already mitigating risk for your company and for your people.

And guess what? Not only that, but there’s other programs that that come into play once you go alternative funding. You can have maternity programs. You can have cancer programs. You can have whatever, you name it. You can you can have all these specialized complex programs that provide even more access and more care, better care to the top doctors in the country that you may not have gotten through your regular insurance product that you had before. So, you want to look as a CFO at all these things to be like, where can we optimize? How are things performing, and baseline that every year. And there’s going to be a place where you can shop that out and maybe get better pricing, renegotiate, talk to your broker, ask your broker questions of like, how else can we better our people? Where can we give them more value? Where can we cut costs? It’s got to be an annual strategic conversation just as much as it is about how we’re going to grow revenue in our company and how we’re going to grow our profits and make people happy. It fits in that conversation.

Kelly: Definitely. Yeah, that makes a ton of sense. I mean, I’m not really hearing any downside to door number three, to be honest.

James: Well, it’s wild because this alternative funding conversation, it’s been around, but it’s only getting louder because of the data, because of what we all know to be true. It’s healthcare costs are exponentially growing. It’s out of control. Pharmacy is out of control. It’s outpacing GDP and wage growth. So, you got to deal with it, right? If you don’t deal with it now, it’s going to be worse than later, right? So, if you don’t deal– if you don’t deal with it now, it’s going to be harder for you to deal with this later. Might as well get ahead of it and start having some really tough strategic conversations and maybe you don’t understand some of this stuff. It’s okay. It’s time to learn because this is stuff that’s going to help you guys run your businesses better.

Kelly: Yeah, no, I completely agree. So, you mentioned population health as a risk mitigation strategy. What does that actually mean in practice, and what should a CFO be looking for in their current program?

James: So, population health is not necessarily a wellness perk. It really is a risk management strategy. You base, like I said a little bit before, you baseline your population. You can identify where your risk is concentrated and build programs that intervene before that risk becomes a catastrophic claim. And if you’ve been watching your insurance over the last few years as an employer, as a leader, you know this to be true because it only takes one, right? It only takes one or two people that have a huge accident. It could be cancer. It could be some catastrophic claim that blew through your stop loss, right? And then, the insurance carrier flagged that and they’re like, “Okay, well, we’re going to raise your rates next year.” A lot, maybe. And it impacts everybody then, so that’s what I’m talking about, right? Can you prevent that all the time? No, but that’s the whole point of doing preventative population health programs in the first places. The difference between door number one and door number two right, is that’s a vanilla insurance product. It’s not meant for you and necessarily your custom people at your work. It’s just a vanilla product that anyone can get. It doesn’t necessarily cater to your needs at all.

But in Door 3, alternative funding, now with pop health programs, you can do that. We can customize health programs exactly to your people, especially once you do the baseline stuff, once you do the preventative wellness stuff and the checks and make sure you’re driving people there. Because you know just by having people do that, one, you’re going to get more data on your people. You’re going to know exactly how healthy you are when you run year after year. And you’re going to know if there’s– because you’re going to see this in reports, right? You’ll get claims reports coming in, prescription reports coming in from your pharmacy partner, your [stop loss?] partner, like, “Hey, there’s prescriptions for GLPs in here. There’s prescriptions for cancer treatment in here.” You’re going to see this stuff. So, you’re going to know kind of what’s going on with your people. So, if you see that stuff, we can start to build pop health programs around that.

So, for example, let me land the plane. Let’s say someone unfortunately has cancer, right? And they’re diagnosed, and they need to have some really expensive medication and really expensive chemotherapy and treatment and such. There’s programs like Mayo Clinic. We have a partnership with Mayo directly as a broker. We have our partnerships with folks like Mayo where they’ll say, “Hey, send us your employee. We’ll do a concierge service. We’ll fly into Phoenix. We’ll spend a few days with them. We’ll do every test on Earth to see how they’re doing. And we’ll give it a second opinion on what we think they should really do with this.” And we just had a call with them about a week ago. And I mean, there was one example where this employee was diagnosed stage-4 cancer by their local provider, and they were going to recommend serious intensive chemotherapy right away. They went to Mayo for a second opinion, did that whole few day visit. Their recommendation, their findings, “You don’t have cancer at all. In fact, it’s this other stuff that you have because we looked under the cover. We tested everything. You actually have this, this and this. You don’t have cancer.” Yay, right? And by the way, you just saved yourself $200,000 that you would have to pay for chemo and all this other stuff. So, you’re welcome, right?

And that helps the employee, obviously, but it also helps the employer. And so not to mention, when you work with the Mayos of the world, they have the best procedures. They have the best equipment. They come out with new technology that can lower costs of claims even more. So, it’s just you want to have– if I’m the CFO, you want to have your broker and their partnerships and who they have relationships with– I’m talking about here. I’m just using Mayo as an example, but there’s lots of examples like this where if you have the top, top, top doctors with the top programs, you can get access to those through your benefits platform. Not necessarily you have to go through the carrier to get that. You can get through your benefits provider, your broker, because they have all these relationships. You can start to [attack?] cost of care, quality of care, lowering your cost, risk mitigation that way. And that…it’s huge. It can drop your premium cost 20-30%. I mean, it’s a big number.

Kelly: Yeah. No, it sounds like it.

James: It’s a big number. Yeah.

Kelly: Yeah. So, whether someone is a hospital CFO or maybe they’re running a 200-person healthcare services company, what should they actually do with all this really great information? And where do they start?

James: Great question. So, if you’re in the seat where you get hit with a surprise renewal and you didn’t know it was coming, sorry that that happened to you. But the good news is that you don’t have to live that tape-on-repeat-every-year anymore. What you need to do is to start getting proactive. The real message here, Kelly, is we’ve got to start being proactive with this versus reactive. We know the economic status out there. We know the external pressure is upon us as a business with this stuff, and we know it’s not going to change. In fact, it’s probably going to get worse. The storm’s going to get worse.

Kelly: Yeah. Definitely.

James: So, let’s get proactive. And you should start to have these conversations at least six months before your renewal, because you need to start talking strategy and looking into different options at that point. Most employers wait 60 to 90 days and then they’re already behind the gun. I will say in many cases, insurance companies will give the broker the renewal quotes for their employer two to three months out, and that still may happen to you. But my point is don’t wait for that to come in. Have the plans and strategy ahead of that so that when the numbers come in, you know what to do with them versus react to them. Make sense?

Kelly: Right, yeah. Makes a lot of sense.

James: Yeah. So that’s one. Two, ask your broker these three questions. What funding model am I in right now, and have you modeled alternatives for our organization? Who is keeping my pharmacy rebates, and what would it look like to carve out my PBM, if you haven’t done that yet? And three is what data do I have access to about my own population’s health and claims drivers and what am I not seeing? Those are three really powerful questions that you could ask your broker that you should know the answer to that will help you start to think about which lever you should start pulling with your overall strategy with this stuff. Again, you don’t have to do all these programs in one year. In fact, we would recommend you don’t do that. The beauty of going down the alternative funding path of door number three is you can really build a three, five, seven year plan out with this stuff because there are big levers to pull and it actually takes a lot of work to make a program good in each one of the things that we hit on today.

So, you don’t want to do everything all at once. But as you continue to sophisticate your own custom alternative funding benefit program, you’re going to know that you’re tackling cost of care. You’re going to know you’re improving quality of care for your people. You’re giving them better programs and you know for sure you’re reducing your risk and you’re lowering the cost to your company. Which at the end of the day, whether you’re a small company, we could be talking about a couple hundred thousand dollars, which is a big deal. Or if you’re a mid-sized company, like 200, 300, 500 employees, we’re talking a couple million potentially, which is a big deal. And if you’re a 30,000-40,000 employer health system, we’re talking tens of millions. It’s big numbers that impact your budget.

So, think about this set lastly as, benchmark your performance. If you haven’t done repricing and renegotiations with these components in the last two to three years, you better get on it because you’ve already probably lost some money you could have had in your pocket. Make sure you’re at least repricing, rechecking stuff every two to three years, benchmarking it.

And finally, the last thing is make sure that you’re connecting all the things we’re talking about to your talent strategy. Because at the end of the day, I don’t have to tell you this, it’s always competitive to get the right talent in your company. It’s tough to get the right clinicians, the physicians, the senior executives, you name it. It’s tough to get great talent. So, we’ve got to have a great benefits program that keeps our people and attracts people. Work with your talent attraction team, your HR team, whoever that is. Maybe if we save a lot of money, we can put that into wage increases or more comprehensive benefits or executive benefits or whatever. This is a mechanism that can really enrich the quality of your company for your people.

Kelly: That’s really great advice. Thank you, James. And thanks for sharing your insights with us on why hospital CFOs are leaving millions on the table and what the best run health systems are doing differently. And James, if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

James: Yeah. Hit me up on LinkedIn. I should be easy to find. Just type in James Jacobi. Would love to connect with you there, or jjacoby@hillgroup.com and would love to hear from you and talk with you about strategy.

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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A Modern CFO Playbook – OPM for AI, 340B and Patient Engagement

In this episode, Jack Risenhoover, healthcare attorney and chair of Velocity Health, discusses a modern CFO playbook for using “other people’s money” to support AI, 340B, and patient engagement initiatives.

Highlights of this episode include:

• How covered entities should strategically respond to protect margins while the rule remains proposed
• How hospitals and FQHCs can comply efficiently while protecting operational efficiency and patient privacy
• How forfeiture-based structures influence decision making compared to traditional benefit plans
• How AI is being applied today to address classic 340B challenges such as duplicate discounts, diversion risk, and HRSA audit preparedness
• What specialized capabilities are required to manage orphan drugs and high-cost specialty medications
• How hospitals should integrate 340B optimization with broader reimbursement strategy

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Jack Risenhoover. Jack counsels boards and CEOs with health systems on technology solutions and compliance matters. He connects with the sacred mission and importance of the 340B program with rural and underserved communities. He has been a senior healthcare technology executive since 1997 with responsibilities ranging from sales and marketing to operations and administration. Jack has founded and led several healthcare technology startups, most recently a leader in 340B optimization, AI enhanced patient outcomes, and specialty pharma capture. Jack has been a principal, managing director, and entrepreneur in residence for Princeton Capital Partners, Georgetown Advisors, and Georgetown Capital Partners.

He serves as corporate counsel for Patton Trial Group in Newport Beach. Jack began his career in financial services and venture capital at Merrill Lynch. His professional credentials include member of the California Bar Association, JD from Vanderbilt University, MBA from the University of Oklahoma, and a bachelor’s in management from Pepperdine University.

In this episode, we’re discussing a modern CFO playbook, Other People’s Money for AI, 340B, and Patient Engagement. Welcome, and thank you for joining us, Jack.

Jack Risenhoover: Thank you, Kelly.

Kelly: Well, let’s go ahead and jump in. So, CMS’s July 2026 proposed 2027 OPPS Rule would significantly cut Medicare Part B payments for 340B acquired drugs. How should covered entities strategically respond to protect margins while the rule remains proposed?

Jack: It’s a tough one and maybe one of the two or three most challenging and controversial issues for nonprofit hospitals and clinics as we move forward. The proposal itself is really damaging because of the shift and the decrease in the pricing targets. So, the response to it on the legislative front is probably bigger than any single place is going to be able to make a difference. But if you expect that that is what’s going to happen, it makes the back end of your 340B program tighter and even more important than it has been in the past. And so, the trade-off on the legislative side is supposed to result in some greater reimbursement in other categories to help offset what they know is a pretty good slice of the 340B cash flow in 2027 and beyond.

Kelly: Yeah, it should be interesting to see what comes with that. So, manufacturers such as Eli Lilly have begun enforcing detailed claims data submission requirements, cutting off 340B pricing for non-compliant entities. How can hospitals and FQHCs comply efficiently while protecting operational efficiency and patient privacy?

Jack: Wow, that’s another difficult one. The aggressiveness of the manufacturers and some of these unilateral proclamations that they’ve made, I originally didn’t think two or three years ago when the first ones came out, I didn’t think these were going to withstand judicial scrutiny. And I was wrong about that. There’s a split at the circuit court level. So, you have part of the United States that’s enforcing these unilateral restrictions and part of the United States that not. And we’ll see how this unravels. What Lilly did was to take it to a new level. And they’ve been followed by eight other manufacturers to date, probably growing weekly because I would expect most of the 30 or so that have done this in one form or another to be a little bit of a copycat on the Lilly strategy. And so, the idea is that they’re requiring some new and different data fields, but on the in-house transactions, which they weren’t looking for previously. So, it makes a little bit of a different effort than what we were doing for clients in the ESP front, although the process is the same, the data elements are different, so it may as well be a completely new reporting scheme.

To me, you just don’t really have any choice. You have to surrender to the hostage takers because the cash flow is vital to the continuing operations. And so what we’re recommending is for clients to look at the data that you have available, try and find a reliable, predictable way to submit it in the same ESP approach. And then to look for things that are in the background of your programs, to find other ways to generate additional cash flow to offset the squeeze from these different both government and manufacturer pressures.

Kelly: That is truly just so interesting to me, David. Thank you for explaining that. So how do forfeiture-based structures influence decision making compared to traditional benefit plans?

Jack: Oh, but they do. This is where retention becomes truly powerful. Most traditional benefit plans provide value regardless of whether the employee stays for the long term. An employee may receive higher compensation, employee retirement contributions, bonuses, or other benefits, and still leave for another opportunity. There’s nothing holding them in place. And what happens is the organization absorbs the cost and loses the employee anyway. A forfeiture-based structure operates differently. The employer funds the plan. The employer owns the plan. The asset remains on the organization’s balance sheet where it continues to grow and compound. And the power of compound interest is amazing. The employee earns the right to receive the benefit only by fulfilling the long-term commitment established in the agreement. If the employee leaves before that date, the benefit is forfeited. The organization keeps the asset. The employee receives nothing. That creates a completely different decision-making process. Remember when I said that choosing between two futures, one if I stay and one if I leave?

It’s the starting point for everything that you have to do with your 340B compliance is the first piece. And then the second piece is what are the opportunities that you can use? The advances in technology or AI, or some of the new capabilities that are coming out from TPAs or hub services? What do you do to drive better patient engagement over a longer period of time and at least optimize the cash flow that’s going to be available for the program in the near future?

Kelly: Yeah, I know optimizing that cash flow is really important, especially now. How is AI being applied today to address classic 340B challenges such as duplicate discounts, diversion risk, and HRSA audit preparedness?

Jack: Well, I think there’s a couple of fronts on that. The reality is the AI deployment in 340B is immature or not at all. And so, with the landscape changing so quickly, it’s important to let your IT team have some flexibility in evaluating the AI platforms and tools that are available from an analytics standpoint, and then as well on the patient education and patient engagement. And so, if you think about this as a teeter-totter, the more important advances in AI have been with conversational AI or clinical AI, which don’t sound like they’re really a central part of the 340B program. But in my opinion, they are the levers that allow you to do a better job of documenting and tracking your patients through the real world of pharmacy, and then being able to use the technology to provide the documentation from a compliance standpoint that will help your TPA capture as many of these prescriptions as possible without running afoul of– the duplicate discounts is a good example of something that pharma barks about in some of the changes that they’ve tried to deploy in the last couple of years.

But really, the bigger mismatches on the transaction side aren’t that pharma is paying for the same transaction twice. It’s that they’re not paying on eligible transactions even once. And the reason for that is that the data sources that are available in 340B have some blind spots from an IT perspective. And it’s not that the 340B industry from a technology standpoint isn’t doing a good job with what they have. I think, by and large, they do. But there are old practices and there are new opportunities, particularly around how you describe your referral network and the data that you use to identify prescriptions from outside providers that are part of your larger continuity of care initiatives. And most of the healthcare providers that we work with, they’re really oriented toward a lifetime patient relationship and how do they use the new engagement platforms to stay in touch with patients when they’re beyond the walls of the hospital or the clinic. And that has profound implications for the continuity of care prescriptions and the capture opportunities in 340B.

Kelly: Most definitely. And kind of just echoing what you said earlier about AI and 340B just being rather immature or nonexistent– so I’m sure that’s going to change as time rolls on. Orphan drugs and high-cost specialty medications present both significant opportunity and complexity within 340B. What specialized capabilities are required to manage them effectively?

Jack: Well, this is one of the more peculiar– one of the more peculiar areas. It’s undergone some regulatory and litigation changes in the last 10 years. And it’s another area where the rules are different depending on the type of organization you are. And so the ones that were added under Obamacare that became participants like rural referral centers, they’re excluded from this, and yet they still have a lot of opportunity related to orphan drugs because the manufacturers have voluntary programs. So I think on balance, there are areas where the conflict between hospitals and pharma has been strenuous and certainly complicated to unravel and unlucky that we haven’t been able to get at the same table and find clearer, easier ways to implement the program with the congressional intent and not have as much of the delays and  although those are great for– they’re great for Velocity because the world is so difficult that it requires a lot of experience and water under the bridge with these particular topics. Orphan drugs are a great example of that. The quantities are small, but the dollar values are so big that most places, if you have an active patient engagement and continuity of care program, or sometimes it’ll fall within a medication therapy management initiative, those all have implications from a 340B eligibility and compliance perspective. And the orphan drugs are one where it’s uncommon for those prescriptions to be in the small places. So about half of our relationships are in small places and half in big or half rural, half urban. And the resources that you have available to track this and then to follow up with the wholesalers, it’s a really good category to check with your TPA and make sure that you have the settings set up correctly and that you’re providing the tracking information in order to monitor the pricing with the wholesalers and see if you are receiving the open pricing on the orphan drugs that’s available to you, even though the statute is now pretty clear. The interpretation of that is that for certain types of entities, they’re not eligible. So, it’s a little bit of a twist where technically you’re not eligible, and yet you still have access to the pricing from many of the orphan drug manufacturers who are trying to do the good thing and pass along part of the profits from that therapy segment. And so, it’s a complicated area and certainly one worth looking into.

Kelly: It sounds very complex. And I’m sure having a partner who is well-versed in all of that is essential. So, with DISH percentages and program qualification remaining critical, how should hospitals integrate 340B optimization with broader reimbursement strategy?

Jack: Well, this is something that came on our radar four or five years ago, where we had a number of clients and relationships, especially in the larger hospital arena, where their DISH percentage or the percentage of uncompensated care and the 11 3/4% metric is something that gets measured a little bit in hindsight. So, if you don’t have the ability to pay attention to those metrics on a monthly or quarterly basis, it can sneak up on you. And the consequence is really deadly. You’re ineligible for the program if your percentage falls below that as a DISH hospital. So it’s tricky to look at the initiatives that you have to make sure if you’re in that sort of 10 to 14% range, if that’s the area, the fluctuations that can happen from year to year with different types of Medicaid and Obamacare coverage, the Affordable Care Act coverages influence all of that a lot. And so there are a number of strategies. If you’re paying attention to those metrics on a more frequent periodic basis, there are a number of things that you can do to make sure that you’re providing the level of care in the community. So, this is an area where you can line up your health equity and access initiatives with your 340B eligibility. And on the margins, it’s not usually a very– it’s not a very complicated decision. It really makes sense to have some outreach and engagement in the community in ways that if 340B didn’t exist, you wouldn’t be motivated to do it. And so, it’s one of the most fun things that I’ve been able to work on the last couple of years with some of our clients has been around their health equity initiatives and why those programs were important for sustaining their eligibility in the 340B program.

Kelly: No. It sounds very interesting. Well, thank you, Jack, for sharing your insights with us on a modern CFO playbook, Other People’s Money for AI, 340B, and patient engagement. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Jack: Kelly, the easiest thing is to shoot me an email. It’s jack@velocity.health.

Kelly: Awesome. Thank you for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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Building Trust in Clinical AI–What Hospital Leaders Need to Know About Evidence‑Based Decision Support

In this episode, Dr. Claudine Lott, Physician Executive for Commercial Transformation and Implementation at Elsevier, discusses building trust and clinical AI, what hospital leaders need to know about evidence-based decision support.

Highlights of this episode include:

• What ClinicalKey AI is
• How AI enhanced clinical decision support tools can help organizations improve both clinical efficiency and financial performance
• How AI-powered tools can support clinicians in real time to reduce errors, avoid denials, and strengthen the overall revenue cycle
• ROI opportunities for health systems adopting AI-powered clinical intelligence
• How AI-powered tools remain evidence-based, transparent, and aligned with clinical best practices
• The most common misconceptions hospital leaders have about implementing AI and clinical workflows

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Dr. Claudine Lott. She is a board-certified family medicine physician who is passionate about developing and implementing tech-based clinical solutions that improve both patient outcomes and provider experience. As physician executive for commercial transformation and implementation at Elsevier, she supports the development and deployment of their reference products for healthcare providers, including ClinicalKey AI. Dr. Lott received her medical degree from the University of Massachusetts Medical School and completed her residency at White Memorial Medical Center. She served as a primary care physician at the federally qualified Santa Cruz Community Health Center, where she was promoted to site medical director. She then joined Healthcare Startup Crossover Health, where she contributed to the development and expansion of their virtual care model, as well as the creation and deployment of their Patient Engagement Technology Platform. Since joining Elsevier in July 2023, Dr. Lott works cross-functionally to support key initiatives, including customer implementations, product development, and change management.

In this episode, we’re discussing building trust and clinical AI, what hospital leaders need to know about evidence-based decision support. Welcome, and thank you for joining us, Claudine.

Dr. Claudine Lott: Thanks for having me on. Appreciate it.

Kelly: Well, it’s great to have you. And let’s go ahead and jump in. So, what is ClinicalKey AI, and how are its new capabilities designed to reduce clinician burden and improve documentation accuracy?

Claudine: So ClinicalKey AI is Elsevier’s flagship generative AI tool that’s designed for clinician use to quickly surface the latest evidence at the point of care to support clinical decision-making. And just to take a step back and provide some context, so here at Elsevier, we’re an almost 150-year-old publishing company. So, for almost 150 years, our role has been as a provider of scientific information and clinical evidence that clinicians can use in their decision-making and in their patient care. And as we’ve moved into more and more clinical solutions, that’s always been kind of our guiding North Star. And so with generative AI coming on the scene, we’ve really thought about, okay, how do we use this emerging technology in our role as a provider of clinical evidence, scientific information to really further that goal of getting clinicians what they need to make decisions and take the best possible care of patients as quickly, accurately, and effectively as possible. And rather than just sort of slapping generative AI on everything because that’s sort of the new thing to do, how do we really leverage this new tool to solve that problem? So ClinicalKey AI is a conversational search tool. The clinician’s able to ask a question in natural language, almost like they might ask a colleague. And then the system goes and searches a curated set of content that we’ve given to it. So that includes much of our Elsevier clinical content, but also some non-Elsevier sources as well, and searches for information and then surfaces that for the clinician. So, it’s not replacing their clinical knowledge or decision-making, but it’s really supporting them by getting the information that they need and we’ve been developing and iterating on this tool for several years now, constantly thinking about how do we make it better and more suited to this clinician use case. So constantly thinking about how we expand our handpicked content sources, thinking about making sure that we always have traceability so clinicians can see where the information is coming from, citation verification, and always thinking about technology upgrades. So, things like privacy, security, and supporting HIPAA compliant use.

Kelly: Wow, that ClinicalKey AI technology sounds really fascinating. So how can AI enhanced clinical decision support tools help organizations improve both clinical efficiency and financial performance?

Claudine: So clinically, the biggest win is what we might call speed to evidence. So, we’re in a situation now where patients are increasingly more complex. Medical knowledge is expanding exponentially. And so, getting that information that is really tailored to the clinical situation as quickly as possible is going to enhance clinical efficiency so that AI enhanced decision support can really surface the most relevant trusted information. In seconds, really supporting those consistent decisions under time pressure and given all those other complexities. In terms of how that clinical efficiency translates into financial performance, I think this is something that we’re going to see continuing to evolve as more and more organizations are integrating these types of tools. So certainly, it makes sense that improving clinical efficiency, improving the quality of care is going to translate into financial performance, but sometimes that ROI can be a little bit difficult to quantify. So, I think that we’re going to see those benchmarks continuing to evolve as more and more institutions are implementing these tools.

Kelly: Yeah, and I love what you said at the beginning, that speed to evidence. I love that. So, what should hospital healthcare system operation leaders look for in the first six to 12 months to know an AI tool is truly delivering clinical value?

Claudine: Yeah, I think this is a great question and something that a lot of both vendors and organizational leaders are really thinking about. Because again, these tools are still new. We’re still seeing how they affect healthcare and how they affect the clinical workflows. And so, we’re still really figuring out how we quantify this sort of clinical value. So, thinking about sort of what can you look for at that 6- or 12-month point to know if your tool is delivering that clinical value. For things like time-saving, improvement of quality of care, those things can be hard to really quantify. And also some of the benefits of generative AI tools, as we mentioned, is that helping clinicians provide faster and better care, it leads to a better experience for those clinicians, for that care team, really addressing that sort of fourth leg of the quadruple aim. But again, that’s something that can be hard to quantify. So, in thinking about, okay, what are some of the metrics that we can sort of look at those sort of checkpoints to see the value that these tools are providing? Certainly, usage metrics are one aspect in terms of just seeing how many providers are using the product, how often are they using it. But that’s only sort of one aspect of it.

Given that there’s more of a– there may be more of a qualitative improvement, some customers and organizations that we’ve seen have chosen to use surveys. So, for example, we had one customer who was utilizing ClinicalKey AI, who did a survey to ask their users after they had trialed it for a given period of time to rate the improvement in their ability to conduct patient care, their confidence in their clinical decision making, and their time saved. And so, they were able to, through that sort of surveying of the users, to sort of quantify the improvements they were seeing in all those areas in that way. And this is also a place where having a clinical champion really involved in the implementation process and in the adoption of these tools can help because checking in with those champions can really connect you to understand, again, some of those sort of improvements in experience that can be a little difficult to quantify. And I think it also comes down to for organizational leaders thinking about what is the problem that the generative AI tool was implemented to solve. So, as I kind of mentioned before, we don’t just want to throw a tool at clinicians just to give them something AI because AI is sort of new and exciting now. We really want to think about, “Okay, what problem are we solving with this?” And from there, then at those checkpoints, I think you have a place to go back and say, “Okay, here’s the problem we were trying to solve. What progress have we made on that?” And use that to kind of quantify the value?

Kelly: Yeah, I know it is difficult to quantify that value there, at least for now. So, it sounds like you guys are making progress with that. So how can AI-powered tools support clinicians in real time to reduce errors, avoid denials, and strengthen the overall revenue cycle?

Claudine: In real time, AI-powered decision support can reduce errors by helping clinicians quickly sort of cross-check their decisions against trusted evidence, or by getting them information that they need to make that decision quickly, especially in an environment that’s high-pressure and time-constrained. In thinking about aspects of revenue cycle management like coding integrity, managing denials, having that grounding in clinical evidence is so vital. Having that documentation that’s based in clear and trusted evidence that’s traceable is really going to provide that sort of grounding and foundation for the decisions that are being made and then the documentation that’s going into that. And that’s going to really support those aspects of the revenue cycle.

Kelly: Yeah, thank you. That makes a lot of sense. So where do you see the strongest ROI opportunities for health systems adopting AI-powered clinical intelligence?

Claudine: So, I think there’s three sort of big ROI opportunities that I see. So first of all, speed, as we’ve discussed, just making decisions more quickly frees up more time for patient care, can help with reduction of administrative burden, and just really free up clinician time. So that just speed is a huge part of it. And then I think the second part is the accuracy and that strong evidence base that I mentioned. So, making sure that decisions are based in strong clinical evidence and that that is really documented in a well-supported way, that’s going to not only support patient care but also those aspects of revenue cycle management that we mentioned. And then I think another opportunity is thinking about standardization. So, there’s definitely an art to the practice of healthcare. So, we may still see some variation in the way that different clinicians might approach the same problem. And having an evidence-based tool has the potential to support more sort of consistent practice patterns across settings. So, I think that standardization and ability to make sure that all care team members have access to evidence on which to base their decisions is another significant opportunity.

Kelly: Sure. Sounds like there are quite a few really strong opportunities there that you shared with us. So how is Elsevier ensuring that AI-powered tools remain evidence-based, transparent, and aligned with clinical best practices?

Claudine: So, as we mentioned, we really anchor clinical key AI in peer-reviewed, copyright-cleared medical evidence. So that includes full-text journal articles as well as journal abstracts, clinical practice guidelines from different organizations, full-text medical textbooks. And we’re constantly thinking about curating that content set, what we need to add, what we want to expand on, how we want to adjust it to make sure that it’s really providing what clinicians need. And we also keep the content current. So, we have a content pipeline that updates every 24 hours. So, the outputs are really reflecting the latest evidence and guidelines as much as possible.

And we’ve really tried to build in that transparency, that traceability, so that the clinician can really see down to the paragraph where that information is coming from. So, they can have that trust. They know that the citation is not being hallucinated or made up by the AI. They can have that trust in where the information is going from, and they can also do a deeper dive if there’s a topic that they want to explore further. So, it really gives them that ability as well. And we use a clinician in the loop approach with a rigorous evaluation framework to continually test the system, follow up on feedback that we get with users, and really just make sure that we’re maintaining and constantly improving the quality of the insights we’re providing.

Kelly: Well, it sounds like that trust is very important to your team there, and that’s appreciated. And you all take that responsibility very seriously.

Claudine: Definitely.

Kelly: Yeah. So, Claudine, from a physician executive’s perspective, what are the most common misconceptions hospital leaders have about implementing AI and clinical workflows? And what advice would you give them as they evaluate solutions?

Claudine: So, there’s three main points about successful adoption of clinical generative AI tools that we’ve seen from our teams and customers, as well as what we’ve been hearing from others in the industry. So, I think these are a great starting point for organizational leaders who are considering implementing a generative AI tool. So first and foremost, as we mentioned before, really knowing the problem that you’re solving with the generative AI tool. So, if you have a generative AI tool, but it’s not solving a problem for the clinician, it’s not making their experience and their care better in some way, nobody’s going to want to adopt that. Nobody’s going to take the time out of their schedule to learn and integrate something new. So really knowing the problem that you’re solving and making sure that you have a tool that fits that.

And so, for us at Elsevier, as I mentioned, we’re seeing this problem of increasing patient complexity, increasing medical knowledge beyond what anyone can sort of memorize. And so, thinking about, okay in our role as a provider of clinical content, how do we use this technology to really solve that problem? So that’s the first part. The second aspect is making sure that the tool is accessible and easy to use, that it’s really embedded in the workflow. Because even if you have a tool that does solve a problem for the clinician, if you’re going to implement something that they have to leave their workflow to try to utilize, that’s not something that they’re going to want to adopt. And certainly, if you’re implementing something because you want to increase their speed and efficiency, if it’s an inefficient process, that’s not going to be helpful at all. So, for us, that consideration goes into things like making sure that our product is integrated into the EHR, having an API option, and basically just making sure that the tool is really in the workflow where the clinician is making that decision.

And the last point is really coming back to this point about trust, because I think some of the misperceptions about clinical AI tools themselves are really related to a lack of understanding of how these tools work. So not understanding that a standalone general use large language model is going to answer clinical questions just based on its training. It’s not actually going to be going out and searching. Whereas a tool that pairs LLM capabilities with retrieval is going to actually be searching and surfacing information in that way. Knowing that some general use tools are drawing from perhaps the whole internet or from sources that are unclear as opposed to a tool that is really clear about where the content is coming from. Risks of using a tool that the privacy protections are not clear. So, all of this sort of lack of understanding contributes to lack of trust, and that’s going to make sure that, again, this is not something that is going to be widely adopted.

And I think that here this is a place where organizational leaders need to think about support from both internal clinical champions and strong vendor partnerships. Because those internal clinical champions, as I mentioned, they’re going to have that deep clinical expertise of the workflow. They’re going to know those problems that the clinicians are facing. And they’re able to be a voice to their peers to say, okay, here’s how this tool works, here’s why it’s trustworthy, and here’s how it’s going to solve the problems that you’re facing. And that’s going to really lead to more successful adoption.

Similarly, having a partnership with a vendor that’s trustworthy, that you’re able to work with them, you’re able to provide feedback and get support for your implementation and your adoption efforts are also very important. And we at Elsevier, as a vendor, really do try to be partners to our customers in that way in supporting them and helping them understand our tools, how they work, how they can benefit them. So those are kind of the three main points that I think are really helpful in thinking about implementing generative AI tools in the clinical setting.

Kelly: Right. It sounds like having those champions and partners are really key to success there. So, Claudine, looking ahead, how do you see AI shaping the future of hospital operations and financial sustainability? And what role will Elsevier play in supporting that transformation?

Claudine: Well, it seems like AI is here to stay, right? So, I think we’re going to, in the future, see AI continuing to lead to changes in really every aspect of healthcare. In terms of clinical decision support, I think we’re going to see these clinical generative AI tools increasingly becoming like a standard layer inside these clinical workflows, so helping clinicians find information, make those quicker decisions, supporting their documentation, but really just with an increasing integration and seamlessness as these tools become more integrated and more widely used. And I think Elsevier’s role is going to be to continue to build on what we’ve been doing all along. So again, constantly thinking about how do we deliver responsible AI solutions that clinicians can trust grounded in that evidence, not replacing their clinical judgment, but really getting them the information that they need in our role as this provider of trusted clinical content and just continuing to think about usability, what features are needed, what content is needed, and how do we continuously think about supporting the clinician with this new technology.

Kelly: Thank you, Claudine, for sharing your insights with us on building trust in clinical AI, what hospital leaders need to know about evidence-based decision support. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Claudine: They can definitely connect with me on LinkedIn.

Kelly: Awesome. I will do that as well, and thank you all for joining us for this episode of the Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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People Stay Where Their Future is Strongest

In this episode, David Alemian, Creator of the Alemian Retention System, is discussing how people stay where their future is the strongest.

Highlights of this episode include:

• How aligning an employee’s financial future with their tenure can change long-term retention behavior
• What distinguishes a short-term incentive from a true long-term retention structure in financial terms
• How forfeiture-based structures influence decision making compared to traditional benefit plans
• What financial modeling should hospitals use to project the long-term impact of retention strategies
• How hospitals can implement retention strategies without increasing net operating costs
• What separates organizations that successfully retain top talent from those that just continue to struggle

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back David Alemian. David is America’s foremost expert on retaining highly skilled professionals and the creator of the Alemian Retention System. His work defines a critical reality for healthcare leaders, People Stay Where Their Future Is Strongest. He is the author of People Stay Where Their Future Is Strongest: How Organizations Retain Highly Skilled Professionals and Build Lasting Advantage. A definitive framework that explains why highly skilled professionals leave and what determines whether they stay long-term. With over 30 years of experience in financial and workforce strategy, David reframes retention as a financial discipline. He shows how workforce instability erodes margin, disrupts operations, and weakens long-term performance. His work has been featured in Medical Economics, MD Magazine, and Physician’s Practice. He has authored more than 300 articles and produced over 400 educational videos on talent retention and organizational performance.

In this episode, we’re discussing People Stay Where Their Future Is Strongest. Welcome, and thank you for joining us again, David.

David Alemian: Well, hi, Kelly, and thank you for having me. It’s so good to be back.

Kelly: Yes, it’s great to have you back. Well, let’s go ahead and jump in. So, David, yeah, you focus on aligning an employee’s financial future with their tenure. How does that change long-term retention behavior?

David: Great question. People are wired for the future. From the time we are very young children, we quickly learn to think about the future. It becomes imprinted on our brain. We’re asked, “What do you want to be when you grow up? Where do you want to live? Who are you going to marry?” It’s always looking toward the future. Employment is the same thing. Highly skilled people don’t make career changes on a whim. They think about it, and they think hard. And here’s what they think, “Is my future better here where I am? Or is my future better if I move to another organization?” Most major decisions are based on the future. When an employee considers staying or leaving, they are literally comparing two possible futures. One future is built by staying with their current employer. The other future is built by leaving and going elsewhere for another opportunity. The future that appears stronger usually wins. It’s that simple. For those who are listening to this, think about your own life and the decisions surrounding your career. Did you think about your future? Chances are very high that you did because our brains are wired for the future.

What’s really kind of cool is it’s one of the things that we all have in common. Here’s the difference. Traditional retention strategies often focus on the present. They focus on culture, recognition, wellness programs, team-building activities, and workplace perks. Those things are good, and they matter, but they do not fundamentally strengthen an employee’s long-term financial future. When an organization helps employees build a stronger financial future by staying, retention becomes much more stable because the employee has a compelling reason to remain committed for the long term. People stay where their future is strongest. And that’s what I mean by that.

Kelly: I love that. I mean, and I wholeheartedly agree with it, and it makes a lot of sense that focus on the future. You’re right. We do all have that in common. So, what distinguishes a short-term incentive from a true long-term retention structure in financial terms?

David: Okay. Now, most retention strategies are expenses, higher salaries, bonuses, 401(k) contributions, retention payments, enhanced benefits, and similar programs all have one thing in common. Once the money is spent, it’s gone. The organization incurs the cost, whether your employee stays or leaves. A true long-term retention structure works differently. The employer funds and owns the plan. The employee never owns the asset. The asset remains on the organization’s balance sheet where it continues to grow and compound over time. The employee agrees to remain with the organization until a future date is established in the agreement. It could be 10 years from now. It could be all the way until retirement. It could be anything in between. If the employee fulfills that commitment, the employee receives a substantial financial benefit. If the employee does not fulfill their commitment and leaves early, the benefit is forfeited. The organization keeps the asset. That distinction changes everything. Instead of creating another expense, the organization creates a growing and compounding asset while simultaneously creating a powerful incentive for the employee to remain long-term. Traditional retention strategies spend money. This strategy builds an asset.

Kelly: That is truly just so interesting to me, David. Thank you for explaining that. So how do forfeiture-based structures influence decision making compared to traditional benefit plans?

David: Oh, but they do. This is where retention becomes truly powerful. Most traditional benefit plans provide value regardless of whether the employee stays for the long term. An employee may receive higher compensation, employee retirement contributions, bonuses, or other benefits, and still leave for another opportunity. There’s nothing holding them in place. And what happens is the organization absorbs the cost and loses the employee anyway. A forfeiture-based structure operates differently. The employer funds the plan. The employer owns the plan. The asset remains on the organization’s balance sheet where it continues to grow and compound. And the power of compound interest is amazing. The employee earns the right to receive the benefit only by fulfilling the long-term commitment established in the agreement. If the employee leaves before that date, the benefit is forfeited. The organization keeps the asset. The employee receives nothing. That creates a completely different decision-making process. Remember when I said that choosing between two futures, one if I stay and one if I leave?

Kelly: Right, yes.

David: The employee is no longer evaluating only what might they gain going elsewhere. They’re also evaluating what they will lose by leaving. As the asset grows and compounds, the financial consequence of leaving becomes increasingly significant.

Kelly: Oh, yeah.

David: Yeah. Absolutely. An employee may receive a recruiting call from a competitor offering a higher salary. The employee now has to compare that offer against a growing future benefit that could be worth substantially more. People become far less likely to leave when doing so requires walking away from something meaningful they have spent years building toward. In other words, you’re giving them something to lose by leaving. At the same time, the employer benefits because the asset continues to grow, regardless of whether the employee ultimately stays or leaves. That creates a powerful alignment of interests between the employee and the organization.

Kelly: I mean, it seems like a win-win, right? I mean–

David: Everybody wins.

Kelly: Everybody wins. Right. So, David, what financial modeling should hospitals use to project the long-term impact of retention strategies?

David: It’s actually relatively easy for a hospital, or any organization, for that matter, if they’re tracking [inaudible] turnover, to figure it out. The starting point is understanding the true cost of turnover. And most organizations underestimate turnover because they focus primarily on recruiting and hiring expenses. Those costs are only part of the picture. I mean, how do you deduct lost productivity? I mean, these are– okay, for a nonprofit hospital, that’s not a big deal. But if you’re a for-profit hospital, what you can deduct and not deduct is really important. But hospitals should also evaluate lost productivity, onboarding time, training costs, overtime, temporary staffing, management distraction, reduced continuity, and, this is key, the impact on patient care. And that’s another key issue here because, if patients have to wait too long, or if there isn’t a specialist to help that patient, or they can’t get the care they need, they go elsewhere. And the hospital loses that income that would be generated by that patient.

Kelly: True.

David: Those revenues. Once those costs are understood, leaders can compare them against the cost of a retention strategy. It costs somewhere between eight hundred thousand and a million on average to replace a physician, depending on your specialty and location. And for other skilled employees, the general rule of thumb is– it can cost more than double the salary to replace someone with skills. Now, you multiply that by the percentages of turnover that hospitals have– and the question is not simply, what does retention cost? The better question is, what does turnover cost? When organizations perform that analysis, they often discover that preventing turnover can generate a significant financial return. You see, turnover is not just an HR issue. Not anymore. It is a financial issue. It is an operations issue. And so many hospitals operate on such slim margins–

Kelly: Definitely. Yep.

David: –absolutely, that when you get rid of– when you mitigate turnover cost and literally take a portion of that cost and turn– or all of it, for that matter, and turn it into a growing and compounding asset on the balance sheet, it becomes amazing what it can do to the bottom line. And like any financial issue, it should be evaluated based on its impact on the organization’s performance and long-term profitability.

Kelly: Yeah, I mean, the true cost of turnover is key. I mean, I agree with everything that you’re saying here. So how can hospitals implement retention strategies without increasing net operating costs?

David: Oh, they so can because they already have a turnover cost. They know it. They track it. I’ve sat in on so many conversations where they talk about turnover cost percentages. And I’ve always heard them talk about, well, the turnover cost for this group, our nurses is X, and the turnover cost for this group is Y and so on. But I’ve never heard them talk about turnover in the cost of dollars. I actually, on my website, I have a free turnover cost calculator that people can go and visit and download. And they can adjust it to however they want it to work. But they will end up with right in the ballpark of what turnover is costing them. And that website is talentretentionplans.com. And it’s just so that they can get that if they would like to do that. Now, if you can take a portion of that turnover cost– and every financial professional will tell you, if you’re in business, whether you’re a for-profit or nonprofit, you have to know your costs. You take a portion of that and put that into this plan, and it mitigates the turnover cost. And remember, this is key. We’re not spending the money. We’re literally turning it into an asset on the organization’s books and the organization’s balance sheet.

It’s one of the most important questions that hospital leaders can ask. Most retention strategies are treated as expenses. This is not an expense. Higher salaries, larger bonuses, increased 401(k) contributions, retention payments and benefits. They all require the organization to spend money today. Once that money is paid, it’s gone. And employees can still leave. A different approach is to create a retention strategy that is structured as an asset rather than an expense. Under this approach, the employer funds and owns the plan. And the employee never owns the asset. And the asset remains on the organization’s balance sheet where it continues to grow and compound over time. Now, imagine what that would do if for your key people, your doctors, your nurses, your technicians, your physician assistants, and all of the people that, shall we say, that we use to build the insurance companies, if they remained in place, and they didn’t leave, wow, look what that would do to your bottom line. And that’s where the money to fund the plan comes from. We’re simply taking a cost and turning it into an asset. And now the employee agrees to stay, and they have a serious, substantial reason to stay should they fulfill their end of the agreement. That alone creates a powerful retention incentive.

But there’s another feature that makes this approach particularly attractive from a financial standpoint. Because the asset compounds over time, it can grow to a point where the employee receives a significant financial benefit that they were promised, while the organization simultaneously recovers its investment in full. In many cases organization can recover more than it invested. That means the strategy can achieve something very unusual. The employee receives a meaningful long-term benefit, the organization recovers its investment in full and then some. The plan can actually generate additional value for the organization. From a balance sheet perspective, the net cost can approach zero while improving workforce stability. That stability changes the game. Instead of asking what will retention cost us, leaders can be asking, how can retention strengthen both our workforce and our financial performance? Most retention strategies, as I said, create an expense. This strategy creates a growing and compounding asset.

Kelly: Yeah, positively affecting the bottom line for sure.

David: Absolutely, it does.

Kelly: Yeah. So, if you were advising a hospital CEO preparing to retire in the next few years, how would you structure retention to protect their legacy?

David: Every CEO wants to leave an organization stronger than they found it. It’s just the way they’re built.

Kelly: Yeah, of course.

David: Yeah. One of the greatest threats to a CEO’s legacy is instability after they leave. Key people depart. Institutional knowledge disappears. Performance suffers. Momentum slows. I would focus on strengthening retention among the hospital’s most valuable professionals before the transition occurs. The objective would be to create continuity, preserve expertise, and maintain organizational stability. A strong leadership legacy is not measured only by today’s results. It is measured by how well the organization performs after the leader is gone. Retention plays a major role in making that possible. The most successful leaders don’t simply build organizations that perform well today. They build organizations that continue performing long after they leave.

Kelly: That’s their legacy, right? They’re part of it.

David: Legacy. Yeah.

Kelly: Right. So, what separates organizations that successfully retain top talent from those that just continue to struggle?

David: Organizations that continue to struggle with retention often focus primarily on current conditions. Organizations that succeed focus on the future. The best organizations understand that talented professionals are constantly evaluating where they can build the strongest future for themselves and their families. When employees believe their future is stronger somewhere else, they leave. They’re out of there. When employees believe their future is strongest right where they are, they stay. That is why I often say that people stay where their future is strongest. The most successful organizations create a future that employees do not want to walk away from. They understand that retention is not simply an HR issue. It’s a financial issue on both sides of the equation. It’s an operational issue. It’s a leadership issue. And increasingly, it is a competitive advantage. Organizations that understand that principle and build their reputation strategies around it consistently outperform those that do not. In today’s healthcare environment, retaining highly skilled professionals is one of the most effective ways to improve stability, strengthen performance, and protect the bottom line.

Kelly: Well, thank you so much, David, for sharing all these insights with us on people’s day where their future is strongest. And also, we’re going to link to that free turnover cost calculator that you mentioned. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

David: Oh, the best and fastest and easiest way is connect with me on LinkedIn. I’m the only David Alemian on LinkedIn, so I’m easy to find. And if they go to my profile, they’ll see my email address is there, my phone number is there, my websites are there, so they can find me. I’m really passionate about this. And if people have if your listeners have questions, I’m happy to spend time with them and answer any questions that they may have. Because good health starts with good healthcare, and nothing is more important than quality healthcare.

Kelly: Completely agree. Well, thank you so much. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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LinkedIn Tips for Healthcare Finance Leaders

In this episode, Lauren Schafer, Founder of Lake House Digital Media, discusses LinkedIn Tips for healthcare finance leaders.

Highlights of this episode include:

• Why it is important for hospital finance executives to have a strong LinkedIn profile
• How a hospital finance leader can start building a LinkedIn profile
• How finance leaders can contribute to the overall marketing and social media efforts of the hospital
• Other than LinkedIn, how hospital finance leaders can help their professional profile
• The biggest mistakes someone can make on LinkedIn
• The best practices for LinkedIn

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Lauren Schafer. Lauren is the founder of Lake House Digital Media, a boutique agency helping life sciences, tech companies, and growth-minded founders build authority that actually drives demand. Lauren blends SEO, thought leadership, LinkedIn strategy, and event marketing to help complex companies become the obvious choice in their category. You’ll walk away with practical ways to earn trust faster and turn visibility into real momentum. In this episode, we’re discussing LinkedIn Tips for Healthcare Finance Leaders. Welcome, and thank you for joining us, Lauren.

Lauren Schafer: Thanks for having me, Kelly.

Kelly: Well, let’s go ahead and jump in. So why is it important for hospital finance executives to have a strong LinkedIn profile or identity?

Lauren: Financial leaders are just like anybody else on the leadership team, and that means having a really strong professional presence on LinkedIn is critical for correct positioning. It’s both for their current role, to build their own network, and for future opportunities, but it also is letting you build the hospital’s network, that healthcare network and presence to build more brand awareness and trust.

Kelly: Most definitely. Agree with that. So how would a hospital finance leader start building a LinkedIn profile if they have limited experience on LinkedIn?

Lauren: So, the biggest thing there that a lot of people miss, or they skip because they’re like, “Oh, I’m not so sure yet,” is they skip putting their photo on there. It sounds so basic, but at the end of the day, people want to know who they’re doing business with. And so, the biggest thing is make sure that you’ve got a profile picture and that it’s a current picture, right? It’s not you, maybe 20 years ago, 15 years ago, a little bit thinner, a little bit different hairstyle, but it needs to have the current position that you hold, the company that you work for, and your name, and absolutely your full professional name. So, one of my biggest pet peeves is if people do like John S., and I’m like, if they’re trying to find you, there are millions of John S’s out there. So, you need to put that full name. But then some next steps that would just kind of ease you into doing things on LinkedIn is set a timer a couple days a week, maybe two or three times a week to just log on for even 15 minutes, turn those notifications on, so if someone sees that you’re getting active and reaches out, that you don’t miss it.

But also, a good next step to start expanding their network if they haven’t had a lot of experience is connect with your employees, connect with people that are on your board and your own networks. So, start leading by example. Your employees do more on LinkedIn, but also just start connecting with people and then slowly start commenting when you’re comfortable on other people’s posts. It’s going to help you get more views. It’s going to help where you’re working, get more brand awareness, and you’re going to develop relationships through that. You don’t have to have these long, drawn out thesis type of comments, but even just like, “Hey, congrats on the new role,” or, “This is a great resource for our community.” Something that is thoughtful, but it can be short and sweet to start building that relationship on LinkedIn.

Kelly: That’s all great advice. And I do agree that the photo is key. So how can finance leaders contribute to the overall marketing and social media efforts of the hospital?

Lauren: So, the biggest thing, especially when you’re looking at LinkedIn, it is a social media network, but it’s business-minded first and foremost. And a lot of people are looking for thought leadership. They’re looking for trust and who do I know there? If something comes up, whether they are looking potentially to apply for a job or to do business with you, to be in partnership with you. But when you start having posts on there from your brand– and even little things like the employees start to share the post. Employees’ share get two times the amount of clicks that a regular company brand page gets. So, it indicates to other people, “Hey, I like working here. I don’t mind telling people that I work here, and I’m trusting the content when I’m sharing it.” So that’s a big thing, is to get your overall marketing efforts to make sure that your healthcare institution is posting optimally at least twice a week. You don’t need to post every day. But getting that brand awareness out there and then enabling your employees to say, “Hey, we want the shares, let people know if we’re sharing some–” maybe a great new project at the hospital, some new cutting-edge technology, or just a feel-good post, maybe how you’re giving back to your community. All of that is adding more brand awareness, more trust signals, and keeping you top-of-mind, so then when people do have a choice and they need something that your healthcare institution provides, you will be top-of-mind.

Kelly: I completely agree that the employees getting involved is really key to getting out the word and helping with that brand awareness of the hospital. Lauren, other than LinkedIn, how can hospital finance leaders help their professional profile and the hospital’s professional profile?

Lauren: So, a couple of things on there. You’ve got LinkedIn as a great resource, sometimes to amplify the other efforts that you’re doing. So, if the hospital, for example, has put out a press release, or if they put out some new thought leadership on an experimental– anything that they’re trying, some new technology, sharing it on LinkedIn is great. If they’ve got those resources that are on the webpage from the hospital, if they’re on a podcast, something like this, where they’re sharing new developments and things, to share those both from your website, if they’re on podcasts, to make sure that you’ve got a presence where people are looking now. And people are looking so much at AI now. So, AI is indexing posts on LinkedIn now, and it’s one of the most cited LinkedIn places, when people are putting those questions in Google or in the search engines, and those AI answers are coming back. So, it’s making sure that your healthcare institution is where people are at. If there’s video, do you have a YouTube channel? They’re free to start. Or if there is something new, a ribbon cutting with you or one of your partners, share that. You want consistent signals, both on your website, for it to be up-to-date.

You want to reach people where they’re at, whether that is searching online, whether it’s on LinkedIn, or even simple things like having just a good community newsletter. As much as I would love for people to be on LinkedIn all the time on social media, because it’s what we do, the one place that they are sure to check almost every day is their work email. And it is, one, just sending a newsletter, sharing latest developments, any big staff changes, community involvement. People open their work emails, and it’s a great place and an easy place to make sure that your institution is staying top-of-mind.

Kelly: Yeah, those are such great ideas, Lauren. Thank you for sharing those with us. What are some of the biggest mistakes someone can make on LinkedIn?

Lauren: Oh, that’s a great question, Kelly. I would say, first and foremost, having either no photo or an outdated one. So, let’s say that you have a photo that you really like, but it’s maybe 10 to 15 years old, and maybe you’ve got a little bit more gray hair, or maybe your weight is different, either way. But let’s say that someone connects with you, that maybe they want to do a new project and they’re interested and is your hospital a good partner for them? And you set a time to meet at a conference, or you set a time for coffee, and you show up and you look nothing like your picture, regardless of the integrity you have, the trust, all the things about your reputation, that first impression of you is going to make them hesitate because you don’t look like your picture. So that is my biggest pet peeve. But then a few other things is if people comment or ask you a question, if you have posted, but then you check out for a couple weeks, if you don’t respond to their comments, that’s a big mistake that people make, because then people will be less likely to comment on your post the next time. And then one other one, and then I’ll wrap this one up, is people forget that even though LinkedIn is a business platform, first and foremost, it’s a social media platform. And so, their algorithm still will reward social interactions and conversations. It’s a two-way street.

So, a lot of people go on, they’ll just post, “This is the great thing we’re doing. Look at what we’ve got new. These things are all great. Look at my promotion.” But then they post, and then they check out of LinkedIn. And other people that are congratulating them or asking questions feel ignored when you don’t respond back, or if they post something, you don’t reciprocate by commenting back. So, a big mistake that people do make is forgetting that it is a social network first and foremost, even though it’s a business platform. But to be able, it’s a two-way street.

Kelly: Definitely is. And those are some great mistakes that you pointed out. On the flip side, though, what are some of the best practices for LinkedIn that you can share with us?

Lauren: So, a lot of people that are on there are leaders in the business community. They are leaders in healthcare, and they are on there in a business mindset, right? So, some of the best practices is to make sure, are you posting thought leadership on there? Let’s say that your institution is growing, or if they’re investing in a certain area, and here’s why, and here’s either an unmet need in your community that it’s going to answer, or whatever the value is to your community and to those that you want to be in your network, the more that you can share thought leadership and show value is a great– this is a great place to do it, not only for those on LinkedIn, but again, it’s being indexed by Google. It’s being indexed and cited on AI. So, a lot of things, even if they’re just on LinkedIn, can suddenly show up in a quick excerpt that is back on an AI, an AI question that somebody asked. But it’s also another great practice is to highlight your staff. If you’ve got someone new coming in on your leadership team, it’s going to be great to announce that you guys are expanding or that this person has joined your team, if they have a new award, a new certificate. It’s great because it both is great from an HR perspective to welcome them and show that hospitality and recognition. But on the flip side, it’s also great doing other things. If you’re very involved in something that is philanthropic in your area, it’s showing your community that a place you work cares about where they’re doing business. They care about the people in the community. And all of those things just nod to your brand recognition, your brand awareness and reputation, and making sure that you have a positive association with where you’re working out in the community.

Kelly: Those are such great tips. Thanks for sharing those with us, Lauren. Any final thoughts for hospital finance leaders?

Lauren: I think here’s the thing is everybody really loves to work for a successful organization, right? But people have choices where they work for recruiting. And if something happens in their lives, a lot of communities, they have a choice of what hospital or healthcare institution that they’re going to go to. So, staying top of mind is so key in this situation. Having a good association with your brand, both for employees, for recruiting and everything, but also so that you get those patients, you get the customers and clients, in that when they have a choice and something happens, and they have to make a quick decision, there’s no choice other than where you are. So, I think that’s our final thing, is there’s a lot more to it than just posting on LinkedIn as a social media platform. It’s more about growing that brand awareness so that where you are always is top of mind for everybody.

Kelly: That’s wonderful. Thank you. Thank you so much, Lauren, for sharing your insights with us on LinkedIn tips for healthcare finance leaders. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Lauren: Well, obviously, LinkedIn is a great place. We’re on it all the time. So, we’re Lake House Digital. Lake House is two words on LinkedIn. I am on LinkedIn as Lauren Miller Schaefer. And also, if you wanted to go to our website and get in touch, we are thelakehousedigital.com, and we would love to hear from you.

Kelly: Awesome. Thanks for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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The Financial Safety Net for Healthcare Leaders

In this episode, David Beahm, President and CEO of Blanchard and Company, Inc., discusses the financial safety net for healthcare leaders.

Highlights of this episode include:

• What the structural gap is that most healthcare CFOs and executives aren’t accounting for in their portfolios
• What diversification means in practice for a chief medical officer or a hospital executive
• The most common blind spots for high-income healthcare professionals
• ETFS and paperback gold vs. physical ownership
• What you need to know so that your wealth is both protected and accessible
• Industrial demand from AI infrastructure and green energy initiatives

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome David Beahm. David serves as the president and CEO of Blanchard and Company, Inc., the largest and oldest retail investment firm specializing in precious metals and rare coins in the United States. With over a decade of executive leadership at the firm, David stewards a legacy that began in 1975, shortly after his predecessor helped spearhead the grassroots movement to re-legalize gold ownership for private American citizens. Under his leadership, Blanchard has surpassed 800,000 clients and $1.3 billion in recent sales, maintaining a premier partnership with legendary numismatist John Albanese. David is known for his “Advisory-First” philosophy, moving the industry away from high-pressure sales toward sophisticated long-term wealth preservation and portfolio diversification.

In this episode, we’re discussing the financial safety net for healthcare leaders. Welcome, and thank you for joining us, David.

David Beahm: Thanks, Kelly. Thanks for having me.

Kelly: Yeah, well, let’s go ahead and jump in. So, hospital endowments and executive compensation packages are heavily tied to equities and bonds. And when markets correct, healthcare institutions feel it hard and fast. From your perspective, what’s the structural gap that most healthcare CFOs and executives aren’t accounting for in their portfolios?

David: So, I think the gap leads to risk in what most healthcare CFOs and the executives that work with the endowments, they underestimate the concentration of risk, and they kind of disguise it a little bit with what they call diversification. But really, on paper, if they own equities and bonds, when the day’s over with, that’s still tied to the same system. So, when you see liquidity tighten or confidence break, like we saw in 2008 and then again in 2020, that correlation that just is one. So those assets individually basically are tied to one another, and they move with one another. So, the gap right there is really the absence of a counterweight, such as gold. And because some of these portfolios lack assets that sit outside of that stock and bond financial system, what physical gold can do is actually provide them with a little bit of insurance to make sure that when those traditional types of portfolios come under pressure, it’s not as critical when you own something like gold in there. So as long as you are truly diversified and have exposure to something outside of the stocks embalmed realm, you can bridge that gap.

Kelly: Right. I know diversification is really key there. The word non-correlated gets used a lot in finance, but what does it actually mean in practice for a chief medical officer or a hospital executive sitting on a $50 million endowment committee?

David: So, when you start looking at non-correlated assets, you start thinking about a theory, and it’s really the behavior of certain assets under stress. And so, when you see an endowment or really just stocks in general drop 20% or so in a short window, some of these assets, they just move together because people are forced to sell, people are forced to raise money for margin calls, or they need liquidity. And so, everything is fair game. So, when you look at that type of movement and gold does behave that way, gold is a source of liquidity, but it’s a little bit different because it’s not dependent on earnings or credit markets such as stocks and bonds. So, for a hospital executive managing a $50 million endowment, non-correlating assets mean owning something that will hold value or even appreciate while some of the other assets are declining. So, gold’s not going to outperform assets every single year, but it provides that insurance policy and it’s there when you need it.

Kelly: Yeah, that makes a lot of sense. Thank you. So, healthcare leaders are often incredibly sophisticated when it comes to clinical risk management, but personal wealth planning is a different discipline entirely. What are the most common blind spots you see when high-income healthcare professionals come to Blanchard for the first time?

David: I think the blind spot that we see is, just in general, just the retail investor, is the overconfidence in that system we were talking about a little while ago. You spend your entire college in the finance world learning about stocks and bonds. And then, the last day you learn about gold. So, nobody really knows about it in the United States. It’s not all over the world, but in the United States, it’s not owned by as many as it should. So, healthcare leaders, because they’re trained to manage risk, they need to make sure that they have an asset that will perform or at least provide insurance. So, we consistently see a few things. One is people being overexposed to paper assets that, again, are all tied to that economic system we were talking about. And then almost more importantly is liquidity– the misunderstanding that gold is not liquid, and it is liquid, especially in a time of crisis. And then the third is, what do you really own? A lot of retail investors, a lot of managers, fund managers– that’s not really clear on what they own and what exposure it is through any sort of financial asset that they may have. So the ownership, clarity, the misunderstanding of liquidity, and then again, going back to being exposed to stocks and bonds, their traditional assets, those are the blind spots that we see.

Kelly: Yeah, I appreciate you sharing those blind spots with us. ETFs and paperback gold products are easy to buy inside a brokerage account. Many executives already hold them and think they’re covered. Why isn’t that the same thing as physical ownership? And why does that distinction matter, especially during systemic financial stress?

David: The gold market loves ETFs. When they came into the marketplace, they added a lot of demand that wasn’t there. And partly because of what you just explained, it’s easy to get in, it’s easy to get out. What our investors do is they’re looking for a long-term hold, and really the true proxy to owning gold or being exposed to gold is actually owning physical gold. So, ETF serves a great purpose, but you do have some expenses that you don’t have with owning gold. You have management fees. You have marketing fees. You have storage insurance, which you do have with owning physical gold. But those funds that are needed to actually run the ETF or taken off of the asset. So, in our mind, physical gold is really the only way to truly have a gold position. And again, you also have mining shares out there as well, exposed to the price of gold, but not– you have to worry about management, mining collapse, geopolitical risk in that area. We just feel that physical gold that we actually send to clients or arrange for storage for them is the true way of being exposed to gold.

Kelly: Very interesting take on that. So, there’s a liquidity question that comes up with physical assets. How quickly can I actually get out if I need to? How do you answer that for a healthcare executive who needs to know their wealth is both protected and accessible?

David: That’s one of the biggest things misunderstood about the physical gold market is liquidity. And physical gold and silver, for that matter, are really liquid assets. As a matter of fact, just a side note, our pilots carry gold with them when they’re overseas flying combat missions, because if they go down and they need to get from one place to another, they use gold to do it. So, for a healthcare executive, the key is structure. Really, if the metals are properly allocated, which we can help with, they’re properly stored, which we can help with and documented, they could be converted to cash fairly quickly. I mean, within a few business days, depending on where the assets are. So, what I would just emphasize is not just liquidity, but it’s the certainty of liquidity. And in a stressed market, the ability to access your gold or your capital without relying on market stability is certainly a significant advantage.

Kelly: Yeah, no, I totally agree with that. So silver is having a moment driven by industrial demand from AI infrastructure and green energy initiatives. How does that factor into the broader portfolio strategy?

David: Yeah, so silver has been on a tear because it’s uniquely positioned right now because it’s kind of in that intersection of the investment world, but also in the industrial complex. So, it’s more of an industrial commodity than gold is. The demand for the infrastructure for the AI and energy and all the electronics. We’re having emerging technologies seemingly every few months and silver is going to play a real big role with all of that. So, from a portfolio or investment standpoint, silver has just a little bit more dimension than gold, but we view silver as a complement to gold. And what we advise is to have both in your portfolio. You can say, well, why would I do that? You’re just talking about diversification. Well, that’s truly within the precious metals complex being diversified is having some exposure to gold and silver. While they do typically run together, there are certain times where one outperforms the other. So, it adds a– silver has an element of growth potential that’s really tied to real world demand. And having the right allocation of both of those working together strengthens your overall portfolio.

Kelly: Definitely. Well, thank you so much, David, for sharing your insights with us on the financial safety net for healthcare leaders. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

David: So first, our website, blanchardgold.com. And then also we have portfolio managers that help advise. So, we don’t just sell this product, we form relationships with people and we’ve been around for 50 years. So, we love talking to people on the phone to get a feel for what their goals are, what their drifters are, and that way we can put them into the right asset class. So, I would encourage anybody to call our 1-800 number. It’s 800-880-GOLD, 4653. So, it’s 800-880-4653. And we can help with any questions and hopefully help some of your listeners get involved in an asset that maybe they were a little unclear about before.

Kelly: Wonderful. Thank you for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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How to Identify Nursing Home Abuse, Prevent Negligence, and Evaluate Care Facilities

In this episode, James Morgan, Founding Partner of Lanzone Morgan LLP, discusses how to identify nursing home abuse, prevent negligence, and evaluate care facilities.

Highlights of this episode include:

• What is nursing home abuse and neglect?
• Most common types of nursing home abuse and neglect.
• Why are nursing home residents getting neglected?
• How are nursing homes usually paid for caring for its residents?
• The difference between nursing homes and assisted living facilities.
• What family members can do to prevent abuse from happening in a nursing home.
• How do people know if a nursing home is good or bad?
• If someone suspects that a family member is being abused in a nursing home, what should they do?

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome James Morgan. Jim is a highly respected nursing home abuse attorney, an elder abuse lawyer in California, and the founding partner of Lanzone Morgan LLP. For more than 25 years, Jim has dedicated his legal career to representing victims of elder abuse, nursing home neglect, and assisted living facility misconduct, helping families hold negligent care providers accountable. He has helped secure millions of dollars in settlements and verdicts for elderly victims and their families while pushing the long-term care industry to improve safety and accountability. He graduated cum laude from Jacksonville State University in 1991 and went on to graduate Magna cum laude from Washburn University School of Law in 1997. Jim is currently licensed to practice law in Arizona, California, and Nevada. He’s also licensed with the United States District Court, Southern District Court of California, the United States Ninth Circuit Court of Appeals, and the United States Supreme Court. Jim has also served as president of a national organization of attorneys dedicated to suing nursing homes for elder abuse.

In this episode, we’re discussing how to identify nursing home abuse, prevent negligence, and evaluate care facilities. Welcome, and thank you for joining us, Jim.

James Morgan: Thanks for having me.

Kelly: All right, well, let’s go ahead and jump in. So, let’s just start off with a pretty basic question. Jim, what is nursing home abuse and neglect?

James: Well, that’s a good starting point. Nursing home abuse and neglect can be anything from as minor– I shouldn’t say minor, but anything that doesn’t necessarily cause major injuries but is certainly concerned about somebody’s dignity, which is maybe not being showered timely, not getting changed in a timely manner if you’re sitting in your urine and feces and you can’t change yourself and make it to the restroom. Those are dignity issues, and that’s the result of neglect. If somebody is sitting in their urine and feces for hours not being changed, it may not lead to long-term problems, but it could. And then neglect can also lead to very serious injuries, such as infections from what I just described. Also, falls, fractures, falls with subdural hematomas or brain bleeds that may lead to death. And of course, probably the number one type of case we get, which is terrible bed sores from somebody sitting in the same position in bed for hours upon hours and not getting turned and repositioned. So, neglect ranges from everything from dignity issues to very serious injuries and death. But the bottom line is nursing home neglect is when nursing home residents are not getting proper care to meet their needs.

Kelly: Okay. Thank you for explaining that for us. So, what are the most common types of nursing home abuse and neglect that you see?

James: The two top cases that we take are the falls fractures or falls leading to other serious injuries and bed sores. Those are by far the most common types of injuries that lead to lawsuits. And when I say bed sores, what I’m talking about are wounds that happen at pressure points in the body when somebody’s sitting in bed. So, the most common type of pressure sore that we see is on the coccyx area where your tailbone is pushing down you’re not being turned and getting any pressure relief.

So, you get a terrible pressure sore on your coccyx or on your heels because those are also bony prominences where people can get bed sores if they’re laying in bed all the time. But other types of nursing home abuse and neglect cases are dehydration, malnutrition, especially if somebody’s on a feeding tube. Elopement cases. Elopement cases are when somebody wanders out of a facility. They might have Alzheimer’s or dementia, and they should be in a locked facility or somewhere where they’re kept safe, but they wander out of the facility and, unfortunately, can get injured. And then there’s probably fewer cases of, but certainly problematic, are the actual physical abuse of the residents, either just physical assaults or some type of sexual assault. So those are probably the most common types of neglect that we see here in our law firm.

Kelly: Wow. That’s very sad, but thank you for giving that information to us. So why are nursing home residents getting neglected?

James: Most of the neglect that we see in our cases stems from understaffing issues. Understaffing occurs when the nursing home tightens its budget to save costs and make more profit. Most nursing homes are privately owned. They’re for-profit enterprises, so people are trying to make money. And the way to make money in a nursing home is to fill every bed because that’s where you’re getting your revenue and to cut costs. And labor is by far the highest cost of running a nursing home.

So very simply put, the way to make money by owning a nursing home is to fill every bed so that you can make as much revenue as possible and to take care of those residents with as little labor as possible. When that happens, it could be a recipe for making money. But unfortunately, it’s also a recipe for neglect of the residents when there’s not enough staff to meet their needs.

Kelly: Yeah, labor does make sense to be the highest cost there. So how are nursing homes usually paid for caring for its residents?

James: Okay, so skilled nursing facilities are primarily paid by Medicare, Medicaid, private pay, or insurance. Private insurance, or maybe somebody has long-term care insurance. But the private pay and the private insurance are the lowest number of residents getting paid paying for the nursing home care that way. By far, most of the revenue in nursing homes comes from Medicare and Medicaid. Now, Medicare pays the highest amount of money to the nursing home to care for the residents. So nursing homes want Medicare patients. So, here’s what happens. An elderly person is living at home and they have a stroke or a heart attack or a fall with an injury, and they go to the hospital.

And they’re in the hospital for a few days, recovering from whatever happened. And the doctor says, “We really don’t want to send you directly home. You need some physical therapy to gain some strength. You might need to be on an IV antibiotic for a little while. We want to send you to a nursing home for some rehab.” Okay? If that person has Medicare, Medicare is going to pay for that nursing home stay. Nursing homes love this because Medicare pays the highest rate of reimbursement. So if a nursing home had its way, every bed would be filled by a Medicare patient because that’s how they’re going to make money.

That’s how they’re going to make the most money. Now, the problem is that Medicare will only pay the nursing home for about 100 days of physical therapy. After that, the resident is going to have to go either on Medicaid or private pay or insurance. And so the nursing home will want to get rid of a resident right at that 100-day mark after they’ve gotten all the money they could possibly get out of Medicare. And then all of a sudden, they might tell the family, “Hey, you got to go. They’ve reached their peak. We need to discharge them by tomorrow.” They a lot of times will give you short notice. And the nursing home doesn’t– and even if the family says, “Hey, they’re not quite ready to go home. They need some more physical therapy. They need some more care.” The nursing home’s not going to want to keep them because if they end up being a Medicaid patient, then Medicaid reimbursement is quite a bit lower than the Medicare reimbursement. So, what the nursing home wants to do is get rid of that person who ran out of Medicare days, get them out of the facility, and fill that bed with another resident who’s on Medicare. So, they can keep getting the maximum reimbursement for that bed.

So, what you’ll see in nursing homes sometimes are called Medicare wings, so where everybody on a certain hallway is a Medicare patient. And those hallways are typically staffed well because the reimbursement is good on that wing. And then you’ll see other wings that are what’s called long-term wings for long-term care residents whose stay is being paid by Medicaid or private insurance or private pay. There is a drastic difference between the Medicare wing and the long-term care wing. And when I say drastic difference, what I’m talking about is staffing and care. So when somebody comes to me with a case, it’s typically somebody who is in that long-term care wing because that wing is staffed less than the Medicare wing. We do not get a lot of cases from people who are on the Medicare wing because those wings are typically staffed better because the reimbursement is higher. So that was a long answer to tell you that most of the nursing homes pay comes from Medicare, Medicaid, private pay, and private insurance.

Kelly: That makes a lot of sense. Thank you for sharing all that with us. So are nursing homes and assisted living facilities the same thing?

James: No, no, they are not. Skilled nursing facilities– or when I say nursing home, I’m talking about a skilled nursing facility. And that’s basically a step down from an acute hospital, okay? So, when somebody leaves an acute hospital, a lot of times they will go to a nursing home, also called a skilled nursing facility, for rehab because they need more care, right, coming right out of the hospital. And the skilled nursing facilities have just what that’s described as: the skilled nursing. So, they’re going to have nurses on staff, and they’re going to have people with more medical experience at the nursing home. An assisted living facility is a step down from that. It’s somebody who doesn’t need quite as much medical care and is fairly independent, can get up themselves, can wash themselves, take a shower themselves, usually, can dress themselves, feed themselves. Assisted living facility residents simply don’t need 24-hour nursing care. But one of the big differences also is that all of those ways I described how nursing homes get paid is completely different at an assisted living facility. Assisted living facilities are primarily reimbursed by private pay. Okay? That means the families pay for the stay at the assisted living facility or long-term care insurance. Medicare does not pay for care at assisted living facilities because they don’t pay for– they only pay for the skilled nursing care, not assisted living care. So primarily private pay and primarily people who are less in need of services are the ones who are living in assisted living facilities.

Kelly: Okay. Thanks for describing those differences for us. And so, what can family members do to prevent abuse from happening in a nursing home?

James: The best thing a family can do to prevent abuse and neglect in a nursing home is to be present and to visit as frequently as possible. And not only that, but to visit at different times of the day. So, for example, I’ve had clients say, “I come every day after work, so I get there at 5:30 every day, and they’re dressed, and they’re ready for dinner. And everything looks good. So, I had no idea anything bad was happening until one day I went at lunch, and I saw that their breakfast was still sitting there. Nobody helped them eat breakfast. They’re not dressed. They’re sitting in a soiled diaper.” And so, what happens is that the nursing home staff will learn the routine of the family. If the family comes at the same time every day, that’s when the patient’s going to look like they’ve been taken care of. So, the family is going to think, “Oh, this is what’s happening 24 hours a day. Everything is great,” but that’s not necessarily the case. So, the family, if at all possible, needs to visit frequently and at different times of the day to see what’s happening morning, afternoon, and evening. Not only that, but you have to be a squeaky wheel. When something’s not right, you got to speak up and you got to say something. And when I say, “You got to say something,” I’m not talking about just to the CNA or the certified nurse assistant who’s providing direct care, who’s maybe changing the sheets or changing the diapers. You’ve got to make complaints to the head nurse or the charge nurse or the director of nurses or even the administrator because a lot of times these CNAs are overworked, they’re working a shift or maybe a double, and they’re going to be out of there. They’re not going to make any changes to the care of a resident systematically. They may change what they do on a particular shift. But when you need a change made, like you need your mom or your grandma’s medication given on time every day and that’s not happening, you need a systemic change there not just a change with one CNA. So you’ve got to make those complaints to the director of nurses or the administrator in order to hope that any systemic change is made with respect to the care of your loved one. And if that doesn’t work, then you make a complaint to the state and you tell the state what’s– your complaint is, and you call the state and you ask for a formal complaint investigation. And the state will go in there and they will investigate what your complaint is, and they’ll either substantiate it or they won’t. But that’s a good way to get the attention of the nursing home.

Kelly: That’s really good advice. Thanks, Jim. So how do people know if a nursing home is good or bad?

James: Well, I tell people my two favorite online resources for finding information out about nursing homes. And these resources will give you information on what the patient’s rights are, what the state and federal regulations are that govern the care that’s supposed to be given in a nursing home. And they’ll give you some history on the nursing homes. So, you can look up what complaints have been made against nursing homes. What complaints have been substantiated against nursing homes? How many complaints does this nursing home get compared to other complaints? I’m going to give you three total things to look for, but I’m going to tell you two websites that are super helpful to me and that I always recommend people look at. One is a California website, but it’s useful for people all over the country because a lot of the information on there refers to federal regulations, and federal regulations will govern all nursing homes, not just the ones in the state of California. But that nursing home is– I’m going to say it, and then I’m going to describe it. It’s canhr.org. C-A-N-H-R, dot org, and that stands for California Advocates for Nursing Home Reform. That website is great for all kinds of information, not just California-specific information.

But the other website that’s fantastic, believe it or not, is medicare.gov. And if you go to Google and you just type– in Google, type in Nursing Home Compare or Medicare Nursing Home Compare, either one, and the first thing that’s going to pop up is Medicare’s website that talks about nursing homes. And you’re going to be able to look for nursing homes by zip code or city. When you find nursing homes, you’re going to be able to click on them, and you’re going to be able to find out who owns that nursing home, what complaints have been made against that nursing home, what the staffing is. Medicare has a star rating, one to five stars. I don’t always look at the star rating because the star rating is based on information that the nursing home provides to Medicare. But it’s helpful more for me to look at the complaints against the nursing home and see what complaints have been substantiated against the nursing home. But let me give you one more thing to look up because you asked, “How do you know if it’s a good or bad nursing home?” I’m going to tell you something to look up that’s going to tell you if a nursing home is bad, okay?

And what I mean by that is they have been put on notice by Medicare that they may lose their federal funding unless they straighten up their act. So, I always tell people to go to Google and type in, “Special focus facility.” The special focus facility list will come up, and that will be a list of nursing homes that are of special focus to Medicare because Medicare has warned them they’ve got to straighten up their act, they’ve got to take better care of residents, or they’re going to lose their federal funding. They’re going to lose their Medicare funding. If you see a facility on that special focus facility list, I would absolutely not let a loved one go to that facility. That is the best advice I can give as far as knowing whether a nursing home is good or bad. You can’t tell by the outside of the nursing home. If it looks nice, to me, that just means they’re spending all their money on gardening and making it look pretty. You got to go in there. You got to see, “Does this place smell? Does it smell bad because they’re not changing the residents timely? Is it hot because they don’t have air conditioning?” Because believe it or not, not all nursing homes have air conditioning. So, other than just walking in and using your best judgment, those are the websites that I would go to to get information on nursing homes.

Kelly: Wow. Thanks for providing those great resources, Jim. We appreciate that. And lastly, if someone suspects that a family member is being abused in a nursing home, what should they do?

James: So back to what I said earlier, make a complaint to the director of nurses and the administrator at the nursing home, not just a verbal complaint, put it in writing. Make sure you have a letter or an email that you send to them. Or sometimes they’ll give you their cell numbers. You can put it in a text. But I always ask clients who call me, “Did you complain to the director of nurses or the administrator? And when and what did you say?” Because you need a trail of documentation showing that you put them on notice that certain things weren’t being done and certain changes needed to be made. So, I always say, “Make a complaint and be able to trace that complaint.” If that’s not sufficient for taking care of the problem, then you go to the state, and you make a complaint to the state, and you ask the state to do a complaint investigation. In California, it’s called the Department of Public Health. It’s something similar in every state, but you can go online. And you can go to that Medicare website that I told you about, Nursing Home Compare at Medicare.gov. And there will be a link to how to make a complaint against a nursing home to the state.

And so, looking at those websites and getting that information and making complaints, and if the abuse is bad enough or not being addressed still or somebody’s been injured, then you can always look for an attorney and consult with an attorney to say, “Hey, is this right? Am I wrong? What can I do? Does this rise to the level of a lawsuit? Should we do something more?” But if you type in, “Nursing home abuse and neglect lawyer,” wherever you are, I’m sure you’re going to get a lot of attorneys’ offices popping up. And talk to a law firm that specializes in that type of litigation. My advice is don’t talk to just somebody who does all kinds of personal injury, auto accidents, and falls. Talk to some law firm that specializes in suing nursing homes and assisted living facilities.

Kelly: Thank you so much for providing that for us, Jim. And thank you for sharing your insights with us on how to identify nursing home abuse, prevent negligence, and evaluate care facilities. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

James: They can go to our website, number one, which is lanzonemorgan.com, L-A-N-Z-O-N-E M-O-R-G-A-N, Lanzone Morgan. Or they can call us 888-887-9777. But if you look up Lanzone Morgan in Google, you will certainly find us pretty easily. I think we’re the only firm in the country named Lanzone Morgan.

Kelly: All right. Thank you for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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