Learn strategies for health system growth

- [Heather] Hello everyone and thank you for joining today's webinar, Building your 2023 Growth Strategy. My name is Heather Vollmer with Optum and I will be your host today. Before we begin, please note, the following housekeeping items. At the bottom of your audience console are multiple application widgets you can use to customize your viewing experience. If you have any questions during the webcast, you can click on the Q and A widget, at the bottom of your screen to submit a question. We do capture all questions and will be providing follow up to questions as appropriate. If you experience any technical difficulty, please click on the help widget. It covers common technical issues. You can expand your slide area, by clicking on the maximize icon, on the top right of the slide window, or by dragging the bottom right corner of the slide window. There is a survey widget, which you can use at the end of the webcast, to provide us with feedback on today's presentation. Additionally, this presentation uses streaming audio. You may listen to the audio through your computer speakers or headphones. To ensure the best possible system performance, please be sure to shut down any VPN connections and connect directly to the internet. Presenting today will be Aaron Mock, VP at Advisory Board, and Brian Michaels, senior strategy consultant for Optum. And with that, I will pass it over to Aaron.

- [Aaron] Thanks so much, Heather. Thanks everyone for joining us this afternoon, to speak a little bit about the state of the industry in 2022, heading into 2023, some of the challenges that we are confronting and some of the opportunities for growth that we see. I hope we'll be able to offer a good set of insights, into some of the things that are shaping our future. Just to, sort, of flag where we stand as we go forward, we kind of know that we are in a dynamic where the present feels aggressively urgent, on the provider side in particular, but across the healthcare space as a whole, we are seeing many, many organizations place disproportionate emphasis on the present and trying to address their short-term crises and opportunities. Sometimes, at the expense of long-term strategy. And this just reflects the general state of churn that we've encountered over the course of the last year. As we know, on the provider side in particular, margins are way down. And under those circumstances, there is a tendency to retrench, to focus on those areas where we know we can achieve some modicum of success, sometimes at the expense of those kinds of future strategies. And when we think about growth, when we think about the future, we need to be attuned to obviously the challenges of today, but the opportunities of tomorrow as well. So, keep that in mind, just as a keynote concept for what we're gonna be discussing, over the course of the next hour or so. Now, when we look at the future and some of the challenges that we're seeing, we really see four that are most salient to us. Some that are quite immediate, some are building momentum and soon will be relevant. But the most immediate ones, are those kinds of global stressors related to the economy and related to labor. We also, however, are seeing some challenges in relation to things like demand, the fact that we have multiple health crises going on simultaneously that we have to address and some of the changes in the dynamics around coverage. In particular, the dynamics that emerged as a result of the public health emergency. And when we think about going forward, we have to recognize that, at some point, that public health emergency is going to end. And when it does, we will see some interesting new dynamic dynamics, in terms of demand. And then those areas that are evolving, that are building momentum, include things like, the vertical ecosystem space, the fact that many payers are becoming health solutions companies. They're not just providing, you know, plan resources, but are becoming providers, becoming digital enablers. And ultimately, we see these dynamics emerge in the vertical ecosystem as new disruptive entrants start to play a bigger role in growth. And then finally, some of the dynamics around innovation. We'll speak to all of these in the first half of the presentation, in a little bit of detail, but we'll start with those global stressors. I just wanna flag that, you know, we'll go through these fairly quickly, but I want to offer some insights, that hopefully will be relevant to some of the challenges, that I'm sure you are confronting at present and some of those opportunities for growth, that are available. Now, when we think about global stressors, obviously, first we have to think about some of the dynamics we're seeing in Washington, right? Usually this is a very relevant part of any presentation on the future of healthcare. This year it's probably a little less so. We have, as we all know, a very split government. And although not all of the pieces are in place yet, although they will be soon, I assume, we do know that this kind of level of split, usually precludes a lot of robust activity, from a healthcare perspective. And I don't expect we're gonna see a lot of very robust federal level activity. Most of the activity has happened at the state level, and we're seeing a lot of interesting ballot initiatives, across multiple states around healthcare, many of which are going to be quite relevant for the future. And so, we have to look at the states as, really the playing field for a lot of activity in the foreseeable future, a lot more activity coming from the states, than from the federal government. You can see some examples of the activity that's going on here, both of course, in relation to things like abortion coverage, but also costs management, novel approaches to reimbursement, novel regulatory arrangements around insurance. All that's happening at the state level. Now, at the federal level, we are seeing much more sort of iteration. There isn't big legislation, but there are detailed sort of iterative changes on things that have been concerns for some time and will be for some time to come. So, we see some past legislation, mostly related to areas that have been big targets of concern for the last five years. Things like, price transparency, surprise billing, and to some degree, things like drug pricing. And we've seen some interesting changes, in relation to that through the inflation reduction act, that are mostly aimed at cost management. Now, we do see some policy priorities emerging, related to things like reimbursement rates. As many of you know, I'm sure when the Medicare physician fee schedule came out, it had some pretty steep decreases for physicians. Some of those will be alleviated, although we don't expect that to be a long-term kind of strategy. There have been some interesting changes around things like insurance coverage. And then, going forward, we expect behavioral health to be a big target, given the challenges we know exist around behavioral health. And to some degree, we're gonna continue to see a fairly activist FTC scrutinizing every merger that comes down and probably putting some pressure on some of those mergers and acquisitions and blocking them entirely. Now, as I said, the state is going to be, sort of, a centerpiece. All of this is to say that, of course, since we can't talk about 50 individual states, should be very attuned to what's happening within individual states because we're seeing multiple examples of certain states becoming very engaged in healthcare regulation, far more than they have been in the past, probably reflecting some of the challenges related to cost and the fact that states have been contending with these. So, we anticipate that to be a factor for some time to come, be attuned to what individual states are doing. Now, as much as regulation is important, and we could probably spend quite a lot of time talking about it, it's really the market that is driving a lot more of our concerns at present. And candidly, it's a tough time for growth. We know that, right? You know, we are facing strong recessionary headwinds. You can see some examples of that on the slide here. And of course, under those circumstances, it limits the opportunities that providers have, to pursue an aggressive growth strategy. And we do in fact, see many provider organizations, be they health systems, individual hospitals for large physician groups, stepping back on some of their growth strategy, whether, you know, that means limiting their acquisitional approach or stepping back on plans to build new facilities, or simply taking, kind of, new initiatives that were a little bit more inventive and forward thinking and reevaluating them. We see that quite a bit. When you have the interest rate going up, to the degree it is, it limits one's access to free money. And obviously, portfolios for many large organizations have dropped a little bit. And that's not just fund money, right? That's money that you need to pursue your broader strategy. And under those circumstances, we are seeing that kind of retrenchment. Now, this slide is really sort of speculating, on whether we have a recession or not. And the fact of the matter is, it doesn't really matter to individual provider organizations, whether you call it a recession or whether you don't. The challenges are the same and the challenges are pretty pronounced. When we look at utilization dynamics and expenses, we see some pretty notable issues, that we all have to contend with. So, if you look at just, raw utilization numbers, you can see that, from a data perspective, it looks like health systems are back to where they were, at the pre pandemic level. But that percentage number hides a multitude of challenges, right? If you talk to most hospitals, they'll tell you, you know, their case mix has changed. We're seeing a lot more medical admissions. The surgical admissions aren't back to where they were. And of course, that's how you're going to generate revenue, is through that surgical admissions for hospitals. We're also seeing things like, longer length of stay. A lot of provider organizations are just running into trouble being able to discharge to post-acute care facilities or skilled nursing facilities. And so, patients are staying in the hospital longer. You only get one payment for those patients. And under those circumstances, that's constituting some pretty significant challenges. And then we just don't have the kind of utilization we need on the outpatient side either. You know, things like electives haven't returned to where they were supposed to be. Certain ED utilization is down. That's the reality. So, there are big opportunities to go back and grab those volumes. A lot of people are delaying their care. We have to go out and reach those individual patients and ensure that they're coming back into the hospital and that is an avenue for growth. But there are some challenges at present. And then we have it on the supply side too. You know, one of the more alarming statistics we've seen, in the last couple years, is that statistic on the bottom left, around the increase in median labor expense for adjusted discharge, 40%, right? Over a couple years and it's now even higher. And that has a cascade effect. And you can see it on the right here, right? Most systems have seen some eroded margins. We've just seen some additional data today, around especially non-profit systems, running into pretty significant erosion of margin. Some for-profits have done, okay, some of the not-for-profits have done okay, but very few are doing better than they were prior to 2019. There are some, especially in the for-profit side, very few. And obviously, that has cascade effects, right? If you have health systems running into these challenges, they're gonna go back to payers and ask for increased rates. And that, of course, yields higher premiums. And we're seeing some pressure, just on capital investment as well. Valuations have dropped. There is a pretty significant increase in VC investment overall in the space, but some stepping back, this year in particular. So, this is a challenging situation. It manifests itself most particularly and acutely on the staffing side. And for many provider organizations, this flywheel that you see here, is a palpable reality. What we found and what they find is that, when you lose a, say a nurse on a unit that has a cascade effect and your likelihood of losing more clinical workforce on that unit, increases exponentially. And you can see why, right? The top factors that nurses report for leaving their jobs, include insufficient staffing and workload intensity, as number one and two. Well, those are intimately related. If you lose one, you're gonna lose more, right? And this reflects the challenges, that I was alluding to at the very beginning of the presentation. When you have a situation like this, people have a tendency to make short-term investments, at the expense of their long-term strategy. And in the last couple years, that rise in workforce cost has been related to the acute, palpable, immediate challenges of staffing, right? And in particular, using a lot more agency nursing to support your overall strategy. Now, it's not just clinical workforce, it's all workforce. If I ask any chief human resource officer or CFO of a system where they're encountering challenges around staffing, they'll say it's everywhere. It's everywhere, except perhaps nurse practitioners. But there is enormous challenge, really, it's across the workforce. And this is going to be a strategy challenge for us, for the foreseeable future. We will have to de develop deliberate plans and strategies to address the workforce challenges. Now, interestingly enough, although this has been framed as a great resignation, it's much more a great realignment than a great resignation. There has been some leading edge retirements for certain nurses, you know, who are, you know, close enough to retirement age. And that's true also for physicians. But the vast majority of the workforce, hasn't left healthcare in general. They just have left the areas, on the left of the slide that you see here. Post acute care, in particular, has had real trouble getting adequate staffing, and then hospitals as well. And in particular in hospitals, things like inpatient units, med-surg units, those are running into the greatest challenges. Some physician practices have really ran into trouble with this. Mostly the ones that are a little bit more traditional, in terms of physician practices. But there have also been winners, right? So, we've seen ambulatory, for instance, and especially things like ambulatory surgery centers, have surpluses of labor. Folks are moving there, to that kind of space, in droves. And both the forward thinking health, you know, physician practice or the forward thinking health startup, are well positioned to attract that talent. So, when we think about growth, both the impediments to growth and some of the levers for growth, we have to think very deliberately about the value proposition that we are offering to employees. This is going to be a premium , in the next 10 years, in particular. You have to have the talent in order to grow because that's just the foundation of any kind of growth strategy. And that means, we have to think very deliberately about what is attracting existing staff and what can maintain existing staff. And for traditional providers, whether they're hospitals or post-acute care, it can't just be reversion to the mission, right, to the mission of healthcare. It has to be more than that. Whether it's around flexibility, right? New opportunities for staff to build their own careers. Whatever it is, you have to think very deliberately, about what your strategy is going to be. Now, this represents the challenges of global stressors. We also know that they're challenges around demand, right? Patients are changing and we're still running into huge issues related to a multitude of crises, that are probably factors in constraining our ability to get those patients back in, to ensure that they are receiving their necessary care and that we have good, efficient throughput, for those that we're seeing in hospitals, or physician practices. Covid-19 is still a thing, obviously, and you know, we're gonna see where it goes this winter. Most extraordinarily of these, has probably been the behavioral health crisis, which is much more pronounced, than I think we anticipated it being. We're seeing, not just many more individuals in rising risk categories or low risk categories, simply reporting symptoms of anxiety and depression, but in the high risk category and requiring things like inpatient admission. And we don't have anything near the resources that we need to address that behavioral health crisis. As I mentioned it earlier, it is very possible this becomes an object of targeted legislation. And then there are other factors as well. Of course, the reproductive care access shock is a factor. And then there's a variety of other health concerns that we have to be attuned to. In general, we're coming on an era where patients are gonna be a little bit sicker. We have more comorbid patients than ever before. And we know that the peak of the baby boom, is now 77 years old at the high, the top of the bell curve there. And that means, you know, they're gonna be coming, aging into a a period of time, where they are going to have lots of care needs that we're going to have to address. So, this of course means, in the long run, potential growth, right? These are patients that will need care, that will be care that providers are positioned to offer, as long as we have the resources in place to do so. But they will be more challenging patients, by and large. It's not just the type of patient we're seeing, it's also how they're supported. When we look at coverage at the moment, we kind of see that it's a little unique, partially because, primarily in fact, because of the public health emergency, which suspended rules related to Medicaid and allowed many of those who lost their coverage, as there was a pullback in several sectors during the Covid peak, to get some sort of coverage through Medicaid. Well, at some point, that public health emergency ends, not in January, it turns out, but at some point. And when that occurs, many of those people will move off of Medicaid, either back onto employer-based coverage, which as you can see, drop considerably during the pandemic, or to the exchanges or to nothing, right? So, we know that under those circumstances, that will change the payer mix. In some markets, that's gonna change it positively and it will mean that you're getting more revenue from those commercial pay folks, that are currently on Medicaid. Ideally, that's gonna allow you to recover some margin, if you're in a hospital, for instance. In some, who knows what's going to happen. But we know that this dynamic, is pretty unique at the moment. Now, the other thing I'd like to flag, on this slide in particular, is the rise of Medicare Advantage. Medicare Advantage has been growing by leaps and bounds and seems to be, slowly but surely, replacing traditional Medicare. And we kind of expect that to continue. If you look at the major payers and where they have gone in Medicare Advantage, they have made enormous investments in this and have grown their Medicare Advantage enrollment pretty considerably, in fairly short order. Just look at United there, a 15% increase, in its Medicare Advantage enrollment, just over the course of a year, essentially. And this reflects a general trend, right? Medicare Advantage has, for many providers, been fairly positive, they've been able to be successful on it, certainly on the payer side, this is true as well. And this reflects a large and probably long-term trend, of insurance giants moving into a space, which allows them a little bit more flexibility, in terms of how they're going to manage a large patient population and ideally, manage it in new and interesting ways. So, if you actually look at where these payers are making their money and considering growth, and you see that the traditional healthcare business is still by and large, how payers are generating revenue, but they're moving in other directions. And this reflects, both some challenges for providers, but also some growth opportunities. Now, this is a kind of complicated slide, just to orient you to it. The blue bars here, are traditional insurance, right? Commercial, the light blue bar is government, that means Medicare Advantage. You see that PBM is still a very robust way in which folks are making money. But look at that red bar, in particular on United Healthcare and Optum, that's provider revenue. And that reflects that shift that I was alluding to, at the beginning, as not just the payers, but others start to move into the provider space and reposition themselves as healthcare solutions companies, right? Providing a full range of services, kind of, across the spectrum of care delivery. And that's kind of what we see as a trend going forward. Greater integration, across vertical assets. Now, ideally, this is something providers also should pursue. When we think about the growth opportunities for provider, it is not just being a traditional incumbent provider. It is thinking about how you as well can position yourself deliberately, as a health solutions company, right? Thinking about the opportunities across plan, across digital and really being integrated with other entities, either working in partnership or building out your own, becomes an avenue for growth. Now, that focus on provider, is principally, a focus on physicians. And we know that physicians are kind of a centerpiece of a lot of this, and we'll talk about that briefly, in a good 10 minutes. Now, what providers are traditionally doing, is not positioning themselves, as I said, as vertically integrated entities, but really, still focused on horizontal expansion and horizontal integration, through things like mergers and acquisition. That is gonna continue to be a strategy. If anything, it seems likely to accelerate, just because of the challenges that we've started to see financially over the course of the last year, right? So, the actual number of volumes seems- Actual volume of deals has dropped. And you can see, it's kind of been on a decline, since 2019. Largely, this reflects of course, the challenges of Covid. Everybody had their heads down and was focused on other things, but also the fact that there just aren't that many small deals that you can do out there. That being said, the large deals are continuing, and you can see some examples of that mega merger deal volume on the right of the slide here. So, the total deal volume has dropped, but the size of the deals has grown. Now, interestingly enough, because of FTC scrutiny, we're not seeing a lot of regional mergers. We're seeing a lot of cross-regional mergers start to emerge because it's much harder for the FTC to challenge, say, a merger between Advocate and Aurora and Atrium, which is across different markets, than a merger across continuous markets, which would raise the specter of antitrust. So, we expect this to continue, probably grow, under the circumstances. There are significant reasons to pursue this for growth, of course. In principle, the powerful one is that this allows you a more negotiating power against payers and suppliers, for various contracts. But also, there are of course opportunities for market share that are gonna emerge with this. And we still should see this, kind of, continuing along the lines that it has been. Now, on the sort of broad side of disruption, certainly payers are being disruptive. We do see some providers being relatively disruptive, but we're also seeing disruption come from outside circles. And of course, Amazon is probably the best example of this. It's the one I get the most questions on. What's going on with Amazon, what are they doing? Why are they doing it? Certainly, the acquisition of One Medical, reflects a pretty considerable expansion of Amazon's vision for healthcare, right? Now, they shuttered Amazon care, this was a much, much smaller endeavor, but they shuttered it at precisely the moment when they acquired One Medical, and that probably reflects a broad strategy on their part, to grow in the healthcare space. Now, does Amazon want to become principally known as a healthcare company? Of course not. This is still a fairly small business line, across Amazon's whole array of services. And I'm sure One Medical, you know, we'll be viable, but it's a means for them to do some other things as well, of course, pharmacy in particular, and some of the other things that they do through their traditional business lines. So, we expect them to continue this path. They have power here, of course, they are good at sticking around and weathering certain kinds of storms, but the fact of the matter is, they are not positioned yet to be seen as a very dangerous player in this space. That may change, but they are certainly running in this direction. And of course, every other big tech company has developed some resources related to healthcare and has a healthcare business line. Apple and Google, just as two good examples, did dump these lines for some period of time, but they're back and back with a vengeance, in both cases. So, we anticipate that to be a factor going forward, for sure. Investment generally is reflecting some challenges, as I was alluding to, of course, because there has been some contraction economically in the space. We have seen some decline in funding, both around biotech and digital, which were the, respectively, the two areas that have grown so dramatically, on the healthcare side, in 2021. That being said, there is still more money in digital and biotech, than there ever has been before. And this broadly reflects the fact that, essentially, every tech company is moving into the healthcare space. And this is an area of pretty considerable innovation and will be for some time to come. And pharma itself, from an innovation perspective, is in a similar position. We probably have the best pipeline we've seen in a generation, in many ways. But they're more expensive drugs, they're for rare diseases, right? You have to capture broader populations, in order to be able to create these new drugs, and they're gonna be challenging to build into the healthcare space. And that just underscores what we need, which is a more integrated, deliberate approach to working, for instance, with pharma or working with payers, working clearly across the sector, to achieve the ends that we want to achieve. So, a quick run through the four key factors, that we think are going to be challenging for us, going forward. The fact of the matter is, our responses to these core four challenges, could enable our future ambitions or they could impede them. If we are focused too much on those near-term challenges and opportunities, at the expense of a long-term strategy, our chances to move forward, are going to be quite challenging. And I can tell you, coming out of this, having talked with many chief strategy officers across provider organizations, some are not positioned well, others are very deliberate in running headlong towards the future, in wise and thoughtful ways. But we have to be attuned to all of this. And I want to everyone to keep that in mind, as you go forward. Now, just to flag, there is room for questions. So, if you have questions, please just type them in the chat. We will get to a Q and A at the end of the section. I'm gonna move forward very quickly and allow Brian to take over.

- [Brian] Great, thanks so much. Appreciate the insight there, Aaron. We're gonna shift a little bit. So, we talked a little bit about some of the issues in crisis that we've seen around attrition with staff, but how is that affecting, or how do we anticipate that's gonna affect physicians? And so, when we talk about individual physician alignment, as you can see here in the graph on the left, the percentage of physicians who reported considering career changes, through the decade of around 2011, 2012 to 2021 was significantly higher than the actual medium rate of physician turnover. So, even though many of the physicians say they're considering career changes, very few actually change jobs. While we aren't seeing this massive turnover with physicians, the crisis impacts practices as a whole though, and the workforce crisis is nothing to dismiss. Groups are certainly struggling to make sure they retain medical assistance and office staff, but individual physicians themselves, are mostly following, kind of, the similar employment patterns, that we've seen in the past years. And that ultimately can affect the way that they practice and the environment that they practice within. You know, it influences physician employment choices, given the state of the market, provider executives need to keep an eye on physician staffing. We had a CMO that spoke to us recently, who said it really well. Physicians have been hunkered down for the last two years. We're now worried about the backlog and turnover that could break soon. And so, we are gonna start to see some changes for sure. Now, the real alignment shift that we want to pay attention to, are the practices themselves. So, when I think back earlier in my career, around the 2007, 2008, 2009 range, the big shift we were seeing at that point, was a shift from physicians in their own private practices, to really, in the first time in history, more physicians wanted to be employed by hospitals and healthcare systems. We're starting to see a new shift as well. So, the workflow or the workforce crisis, you know, certainly nothing to ignore. But individual physicians themselves, are mostly following similar employment patterns, that we've seen in the past. But the physician practices themselves are growing and more physicians are being employed, which only increases as they face more workforce challenges. The way that we're seeing these changes, kind of, manifest though, are by corporations. You know, while hospital ownership stay steady, we're seeing much bigger increases, with corporations coming in and disrupting the market and owning practices themselves. In fact, between January, 2019 and January, 2022, employment by corporations grew by 10 times the rate of employment by hospitals. And the practices that remain out there are are either smaller than what hospitals traditionally, or typically go after, or they're big enough to be discriminated about how they want to partner. And what we hear from them, is that they are being that discriminating, often not in favor of hospitals. So, we're seeing some changes that hospital executives obviously are both concerned about and have to be aware about, as far as acquiring practices. So, let's take a look at what corporation ownership and aggregation means, in reality. Let me introduce you to a new concept that we want you to add to your lexicon, and that's the idea of super practices. Non-hospital partnerships and acquisitions, look like a bunch of different things. One of our biggest takeaways from examining the market right now, is that the range of partnerships vary and while in a way that which they collaborate and how they're gonna collaborate, also varies hugely. But we are seeing some themes, as it relates to these super practices. A few characteristics that we're typically seeing within these super practices. They are very well resourced, when it comes to technology. They aim to centralize and standardize their care protocols and referrals. They use a holistic, kind of, multifaceted care team and infrastructure. And some of these involve autonomy trade-offs for the physicians. You know, for instance, giving up referral control in exchange for longer appointments with patients. They're certainly growing rapidly in size. We're also seeing, kind of, a shift where they're heavily involved in Medicare Advantage and they are increasingly aiming to reduce hospital care. So, many of these are new, but the true test of these aggregators, are the national chains in particular, and how well they integrate and practices. So, again, we're gonna have to really be aware of this shift in how we partner. And ultimately, what we really need to understand, inevitably, is the, you know, these practices will, or super practices, will shift their patient's volume. So, who influences where those volumes go, through partnerships. And then the practice will depend on how much healthcare systems decide to either partner with these super practices or fight them. And so, when we start to think through, you know, how do we approach these super practices and how do we approach just physicians, in general, in the market, you know, we really, kind of, have to make that decision in what our approach is gonna be. I think our approach and what we think, is still gonna be a really important factor, when partnering with physicians and working with physicians, in the coming decade. It's still gonna be going out and engaging these physicians and understanding where they're at and understanding what's changing. So, we have our first question, poll question we'd like for you all to answer. So, which one of the following is most central to your organization's growth strategies? Service line growth, physician relationship management, geographic expansion or acquisition? If you guys could take a second and just give us a sense of what your organization's top priority, or top priority here would be. We would definitely appreciate it. All right, we've gotten those answered. It looks like, whoa, it looks like we have a dead heat, a dead tie. So, we're looking at service line growth for the most part and physician relationship management. So, that's interesting. So, when we think about both growing our own service lines and continuing and maintaining relationships out in the market with physicians, we think that there's still a tried and true strategy. The conversation and the language we use may change, but the approach shouldn't. And so, ultimately, you know, we have our strategic priorities, we have those that, kind of, generate out of our organization's strategic plan. Typically, what we've seen in the past, is a very siloed approach to how we do this. We have business development and strat planning, who, kind of, work through, you know, the plan of what we're trying to execute. We have a group of people that are working with physicians, to execute an outreach strategy. And then we have marketing as well, off to the side, working on a consumer strategy, as it relates to growing business. And a lot of times these three groups haven't talked, or have been working very independently of each other. It is our personal opinion that, the way that the growth is best, kind of, accessing and best gone after, from a healthcare and hospital strategy standpoint, is when these three groups are aligned. So, our strategic plan, really should inform what planning and business development is working on, our physician outreach strategy should be in line with what our marketing and consumer strategy is. So, when a consumer's hearing a message out in the market and they go into a physician office and they start to ask questions, our physician outreach group should be reinforcing that message, as they talk to physicians in the market. And so, we should all be working, kind of, together, having our ships, kind of, all sail in the same direction. It helps us be much more efficient and effective, when trying to grow business in general. But when we start to understand what our ultimate strategy is, then we can start to prioritize the opportunities that are truly out there. And that's really gonna be through a lot of different factors. One, understanding the market through data. Understanding the market through what our physicians are doing out there. And then of course, kind of, overlaying what we do well internally, what we have as far as access goes, what we have as far as expertise goes. And when we factor all those in, we can start to understand and prioritize the service line opportunities that are actually out there. And again, we have a bit of a tried and true way of doing this, as far as service line prioritization goes, but again, understanding the market, the markets out, the opportunity with service lines out there, is gonna be important. So, one more question that we have, as far as our poll questions go. On a scale of one to five, how well do you understand your physician landscape, both, kind of, relationships and referrals? One being, not very well, five being very well. Just love to get a sense of what you guys feel, as far as your own knowledge of your physician landscape. So, you can take just a second and answer a couple of these questions, would appreciate it. Great. Okay, so, oh, looks like we have a range of, kind of, the threes, that decently well, mostly, kind of, in that four category, where we think we know what our physicians are doing. No one thinks they don't know what's going on, which is probably good. We definitely, hopefully, have a handle on, at least a little bit of what's going on with our physician practices. So, ultimately, when we talk about execution and how we go out and really understand the challenges that our physicians are facing, understand, kind of, the market in general and understand, you know, how we can still go out and execute on that service line growth, that we're all looking to go after. It's still all about outreach, it's still all about going out and having conversations with our physicians. Some of that's gonna be done with physician liaison teams. Some of that is gonna be done, increasingly more actually, with service line leaders and executives. We all need to be engaging our physicians out in the market. We all need to be understanding how, you know, what's happening. Both from the physicians that we employ, as well as the physicians who may be employed by some of these corporate entities that we talked about earlier. And unfortunately, you know, the shift that we may see from some of those employed physicians that we currently have, to where they're now choosing to be employed by some of these other entities. We won't know that, unless we're out there having conversations. The way that we do that, is still through, kind of, a tried and true process, of really engaging these physicians. It all starts with our plan. It all starts with the messaging. It all starts with us knowing what our priorities are and what's important to us and what's critical for us to grow. It's then, kind of, translating those plans and that strategy into an execution plan, where we're going out with talking points, we're going out with very purposeful conversations with the key physicians that we need to talk to in the market to really, both drive volume, drive business to the service lines that are our priorities, but also, to understand what are the opportunities that are out there, what are the risks that are out there? Who are the forces that are coming into our market? We can't truly understand that, unless we're having these conversations. Once we have these conversations, we gotta be tracking these conversations. They can't just exist and then, kind of, go off into the ether. We have to be doing something about it. And so, if you do have outreach folks that are out in the market, we gotta be listening to the feedback they bring back, into the intelligence they're bringing back. If we have executives who are out and having these conversations, either in their office, up on the hospital floors, or out in the field as well, they can't just sit with the executives that are having the conversations. We have to be sharing this information. The way that we do that, typically, is through some sort of workflow management tool. I can tell you, from my own experience, a lot of what my teams did, was sharing intelligence from what they gathered out in the field, to the executive teams, the service line leaders of some of these critical areas. We have to be managing complaints. We have to be understanding, you know, what are the constraints or what are some of the issues that our physicians and our practices are facing. If we have practices out there that are way understaffed, are there ways that we can help them? If we have practices out there, where we're making it difficult for them to refer patients to us or to get surgery scheduled, or to get their patients seen, we have to understand that, so we can get rid of those roadblocks. Because ultimately, if we already are seeing trends to where physicians are trying to keep patients out of the hospital or out of some of our facilities, we can't make it easier for them to do that. We can't make that decision easier for them to take that business out there. If anything, we have to make it easier. We can't do that unless we know it. And unless we're sharing that information throughout our system. Then, once we do, kind of, go out and have those conversations, we come out and document that information, we're sharing it through our system. We have to monitor the trends that we're seeing. We have to understand if we're making a difference, if we're making an impact. Are we seeing growth? Are we seeing attrition? Are we seeing the growth that we need in certain service lines? Or are we struggling in those service lines, that are so important to us? We can't truly understand and benchmark whether or not we're being successful, unless we're out there measuring and setting a baseline and understanding, kind of, what impact our activity is doing out there. And the way that we do that, is through measuring some sort of ROI. Whether that relates to actual revenue, whether that relates to volume growth, whether that relates to an increase in the number of physicians that we're employing, practice acquisition, whatever it may be. We have to understand where we're at, from a benchmark standpoint. We have to understand where we want to go and how are we performing, as far as those goals go. Now, one of the struggles that we typically see from organizations, is how do we do that? All right, we got an outreach team, it's their job to go out and have conversations. We have service line leaders, they're out there having conversations. Ultimately, we have to make sure we're giving up this responsibility and we're understanding the best approach to do this. And we have to understand what we share, as far as the responsibility goes, to do this. So, you know, from a business and service line leader standpoint, you know, you have to be defining what we want to grow and operationally, are we ready to grow in those areas? If we're, you know, sourcing issues, those business line, service line leaders, they need to be on the front lines of making sure we're fixing that in that stuff. From our outreach leadership standpoint, you know, they have to go out and execute in the field what the service line leads are, kind of, putting as priorities. We need to make sure that our, you know, we have a good solid approach in the field. We have the right people in place, to go out and have those conversations. You know, do we have the people out there that can have the level of conversation we need to be having. Or you know, are they not the appropriate person to be having those conversations? We have to assess the talent of the people having these conversations and whether or not they're capable. We gotta be setting the right goals and we gotta make sure that we're coordinating and communication the- Coordinating and communicating the information that we get in the field, back. But what we share together, is really sharing the market intelligence, figuring out, you know, improvement strategies and engagement with these physicians and really identifying barriers, so that we can grow business. That's a shared responsibility, that we need to make sure we're all, kind of, in on. You know, again, the way that we do this, the core responsibility of anyone doing outreach, and I, you know, a lot of people, when I say outreach, they focus on liaisons. I'm talking about anyone having conversations with physicians, anyone having a growth conversation with a physician, is responsible and is doing outreach. So, whether that's an executive, whether that's a service line lead, whether that's a liaison, whether it's a nurse, whoever it may be, we need to make sure that we're all doing it the right way. And again, that's the activity of getting in front of them, having the right conversation, having clear goals for the conversation that we're gonna have. The last thing you ever want to do, walk into a physician's office and, kind of, have a very broad kind of, what's up, what's going on, you know, how are things going? Physicians don't have time for that. We don't have time for that. So, we have to go in there with a clear goal for what it is we want to accomplish in our conversation and you need to document what it is we took out of that conversation. You know, what's the intelligence gained, what are the next steps, what are the follow up items, what are the opportunities and what are the risks that came from that conversation? And then, ultimately, we need to, at the end of the day, show that we're impacting the business in a positive way. Show that the conversations and the activity that we're doing out in the field, is making an impact in a positive way. 'Cause ultimately, that's what we're trying to accomplish. There's a lot of ways to do that. There's a lot of tools that allow you to, kind of, track that information. I know Optum offers a tool and market advantage, that gives you insights into, you know, the physicians in the market, that are key for growing business. The ability to track, kind of, activity and revenue, as it relates to our activity with those physicians and understand, kind of, how we project growth and how we monitor that on an ongoing basis. Now, again, I think one of the really important things, when we talk and when we get together as a group, is how are we looping in executive leadership into this process? So, sometimes, like I said, executives will be having these conversations. A lot of times it's not our executive leaderships that are having these conversations, but they are the ones who are making key decisions, that could be informed by these conversations. And so, ultimately, we need to make sure that the message that we are getting from these conversations is bubbling up to the right people. It's being shared with the right people. That, ultimately, the way that we find you can do this, is through some sort of activity, regular activity reports, regular intelligence sharing reports, that executives can review on a regular basis. We also find, one of the best practices, absolute best practices that we've seen from organizations out in the market, is a regular check-in or meeting, that the executives are having with service line folks, as well as the liaisons or the outreach folks that are out in the market. You know, if we're getting together on a monthly or bimonthly basis, talking about what we're hearing, talking about what our priorities are, talking about what the risks are, we're gonna be all much more informed. It also tells your organization how much growth is a priority. If we have a regular growth forum, where we're all getting together, having conversations and talking through what's going on in the field and what's going on with the physicians and the key service lines that we're trying to grow, that's signaling to your organization, how important growth is. And it's keeping everyone informed, who needs to be informed in this process. And then, ultimately, we need to make sure that we're sharing reports, we're sharing market intelligence, we're sharing, you know, visits that we're having out in the field and we're escalating and sharing issues that we're sourcing in the field as well. So, we find that this tried and true process, is both the best practice and one that, regardless of what's happening in the market, is still appropriate and still applicable to grow business. Again, the conversations might change, the topics might change and who's having these conversations might change, but the process is still the process. And this is shown to be a very successful process, as long as you execute it and do it. I'm gonna turn it back to Aaron, but I thank you for kind of listening to, you know, how we can execute on the strategy with physicians and I know Aaron has a couple other things he wants to kind of share, for upcoming things that we have in 2023.

- [Aaron] Yeah, thanks Brian. Thanks everyone and thanks for getting tactical there. I'm glad we could, kind of, talk about both the sort of broad field and some of the specific tactics you really need to pursue. Just a flag for everybody, you know, there are lots of resources associated with every slide we covered, actually. Every slide I think we covered, probably has a white paper associated with it, many of which are on our website, advisory.com/healthcare2023, and you can access many of those resources there. So, please keep that in-