Brian Nester 0:03
Gary, there were many different models out there – projections.We use them all. We’re a very data-oriented organization. So, our immediate response to everything is to get the data in front of us. We created 28 different dashboards that we would look at every day.
Gary Bisbee 0:22
That was Dr. Brian Nester, President and CEO Lehigh Valley Health Network, discussing the models from which Lehigh Valley gathered search data, and the 28 dashboards that provided projections and analysis on both Coronavirus and COVID surges. I’m Gary Bisbee and this is Fireside Chat. The conversation included Dr. Nester commenting on the importance of MBA studies to his leadership career and the lessons learned from his three-year tenure as Chief Strategy Officer immediately before being appointed CEO. He reviewed the importance of density and transmitting COVID in Lehigh Valley service areas and how a value-based model needs to replace the prevailing fee for service system to provide a broad base of services to the community, and a solid financial base for health systems. Let’s listen to Dr. Nestor discuss the importance of flexing down and its influence on the mid and long term financial viability of Lehigh Valley.
Brian Nester 1:20
In terms of flexing down very much wanted to have a viable company on the other side of COVID. And remember, in April, we’re thinking that we’re going to be in this for a year. And by the way, I think we will still be in this for a year. So what’s the company look like a year from now if we don’t aggressively lever down or flex down? So we made some very hard decisions in middle of April.
Gary Bisbee 1:41
Dr. Nester believes that quality care lowers costs, and it’s important to push quality goals even higher than Lehigh Valley had pre-COVID.
Brian Nester 1:50
We have to push our quality goals even higher and not because you want notoriety it’s just because in our world here, we’ve proven higher quality care lowers cost, and we should be able to share in that improvement in cost.
Gary Bisbee 2:05
I’m delighted to welcome Dr. Brian Nester to the microphone. Good morning, Brian and welcome.
Brian Nester 2:15
Hey, Gary, thanks very much for having me.
Gary Bisbee 2:17
Absolutely pleased to have you at the microphone. Let’s start by learning more about your background and interests and then move to Lehigh Valley and COVID. When did you first become interested in medicine, Brian?
Brian Nester 2:28
I have to be honest, I didn’t really think too much about it until I was well into college. For some reason or another I wanted to be a professional catcher for the Yankees. My idol was Thurman Munson. I wore his number since peewee league but I honestly really always loved science and certainly in high school and lower school. I was one of those nerds in eighth grade that was actually crossbreeding drosophila melanogaster. You know, the fruit flies. And trying to compete in science fairs. I always liked science there’s no doubt about it. Biology in particular and that kind of led me into the path of profession in medicine.
Gary Bisbee 2:49
What was your first leadership position, Brian?
Brian Nester 3:08
So I was one of those over-achiever kids, so I always just said yes to everything. So my first leadership position was probably as a chief intern in my internship year then I was chief resident in my residency program in emergency medicine. And then ironically, you know, graduating from a marine special residency training program in the early 1990s, there weren’t a lot of freshly newly minted board, certifiable docs coming out. So everyone in my class that graduated, all six of us got administrative roles. Right out of residency, I was assistant director of a 30,000 patient ER at the Delaware County Memorial Hospital outside of Philadelphia. So it was my first, I would say, real leadership job.
Gary Bisbee 3:49
What point did you think, “Hey, I really kind of enjoy this or I’m good at it.” How did you think about it?
Brian Nester 3:55
Again, I am kind of drawn to the things that are challenging and requires a lot of technical, if you will, skill sets. Which obviously you have to procure over years and years and years, but I loved critical care. I loved the ICU setting. I’d like the fast paced emergency department and for me it was that fit my personality. I always kind of joke with my colleagues and friends that are in primary care that “Oh my God, if I had to drive to work and know that I was going to see these 26 people that I already know, I don’t know how I’d get to get through the day.” I think that’s the hardest job out there. Solid primary care is just the hardest job so I’m a little bit more of a moth drawn to the flame and merchant medicine fit my personality pretty well.
Gary Bisbee 4:40
What point did you first think about becoming a CEO?
Brian Nester 4:43
I never thought of that. Honestly, not until probably in the early 2000s. I spent my early career in Philadelphia and academic emergency medicine post at Albert Einstein in Philly, and loved that role. Ultimately I got into research, education, State Emergency Medicine societies and loved it. So just loved embracing everything in my specialty and then realized this is hard work being a shift worker. By the way, good or bad, my wife also is an emergency physician and she was at Jefferson. I was at Einstein and suddenly having Wednesdays off in the middle of the week, were cool when you had no kids. But it was not that great when both of you were half asleep. So I realized I needed to do other things and I started to embrace administration, and then looked for another role that would allow me to grow an administrative role. And that’s what led me to Lehigh Valley Health Network in 1998, to be the Associate Vice Chair. That’s where I started an internship program then a residency program with my colleagues there and that was the first time I started thinking of having a real administrative career.
Gary Bisbee 5:53
You were Chief Strategy Officer for three years or so immediately preceding your appointment as CEO. What did you learn during that time as Chief Strategy Officer that has been useful to you as CEO, Brian?
Brian Nester 6:07
That was a neat period of time between say, 2002 leading up to that and about 2010. I went back to school, to get my MBA, and it’s one of those experiences that changed my life. Frankly, was the best education I think I ever had. An intensive finance program at Columbia in New York. It was a great period of sacrifice, if you will, to go back to school at age 40 and be one the oldest people in the class. But I learned so much. That really pushed me towards a different language around growth and present value, and it brought a new meaning to operational efficiency for me. Did a bunch of transactions, I would say on behalf of the network. A kind of a business administrative SVP and then that naturally led to the Chief Strategy Officer job which really was okay. Now that we have these opportunities and/or we’ve assembled this Medical Group of this size, what do we do next? So it was kind of a natural progression. And what I learned there was, oh my gosh, it was a different vantage point for me. I looked at the economics of what our industry is facing and found it to be unbelievably daunting. And as an ER doc who thinks everybody is going to die in the next minute, I’d started thinking about the future. Like if I have another 20 years to work, or 15 years to work, will we even have a hospital system here? I mean, what do we have to do to maintain that. So then, you know, those big ideas start popping up like revenue maximization is coming to an end for our industry. Fee for service seems to be a sickness, and we have to find a better way. So I think during that strategy period, I began to think about how do we need to re-engineer our health system here to get some additional heft on us a little bit of scale, that might give us the latitude to make other kinds of investments we couldn’t and build an enterprise where we provided value. I’ve been hooked on the ACL model for years, loved the idea of value production, higher quality care at lower cost. I always thought that during those years, I really kind of figured out where I thought we should go before becoming a CEO.
Gary Bisbee 8:17
We’ll get into Lehigh Valley network in a moment, but a couple of questions about being a CEO. So what about being a CEO has been the most rewarding?
Brian Nester 8:26
Most rewarding probably is tinkering with, because there’s no easy way to do this, and it’s probably different for every single organization. To try and tinker with the knowledge you have of the organization. And at that point, I was fortunate. I had 16 years of experience with this organization and knew the people pretty well. Knew what we did well and what we didn’t do well. So I think tinkering with things to keep the place moving forward. And looking back, you enjoy “Oh, we hit it, we made it.” Whether that was a financial metric or a quality metric. I think that’s the most rewarding. It’s the grunt day to day work that upon reflection, you look down the hill and you go, “Wow, we’ve come a long way.” I think that’s the thing that’s most rewarding. I mean, we’ve had some big mergers that have always been very satisfying because we now can care for more people in different communities. That’s always great. I think, though, doing it against all these headwinds, providing care and sitting where we sit from a quality position as we try to benchmark against extraordinary peers and we use the Vizient Group benchmarks. And to be in that class, consistently doing a pretty good job, I think all of that is the most rewarding.
Gary Bisbee 9:42
The flip side of that question is what’s been the most challenging decision that you’ve made as CEO?
Brian Nester 9:48
The most challenging decision and there’s several is trying to iteratively decide what scale means and what transactions liberate the benefits of scale. And I had to learn early on that just adding another campus alone doesn’t get you a whole lot. Our organization has been founded on and is led by a great board that believes that any major transaction or investment has to be financially accretive to the company. And, not and/or, or but, but AND improved quality. And I think that’s the ideology that most hospitals and health systems. But to really do that from a business standpoint is really, really, really hard. And I would tell you that it’s going to get even harder for us. So I think that the hardest decisions have always been around saying yes. We’ve said no to twice as many mergers and acquisitions as we’ve said yes to. Those decisions to say no were so so challenging. I will tell you that most of them, I’m glad. You know, that old phrase that the best deals sometimes are the ones you don’t do. Most of them were like that, but a couple of them, I still need to play out as to whether it would have been better to move forward or not.
Gary Bisbee 11:11
Let’s turn to Lehigh Valley Health Network. Would you please describe Lehigh Valley for us, Brian?
Brian Nester 11:17
Yeah. LVHN in eastern Pennsylvania, we call ourselves a super-regional drivable network. So you can actually drive to each one of our campuses within an hour or so. We’re positioned on the southern border by Route 78, which is one of the largest highways on the East Coast that goes right through our market through New Jersey into the Holland Tunnel. And then to our north, ironically, is Route 80, another huge national interstate that goes through Pennsylvania through New Jersey right over the George Washington Bridge. So we’re situated in eastern Pennsylvania, north of Philadelphia, but really, we have people that commute into Manhattan every day to work. So we kind of joke that we might be the seventh or eighth the borough of Manhattan. We certainly skated by with the COVID crisis not being that. Our colleagues in New York, pray for them every day with a miserable time. So we also have a revenue footprint of about $3.5 billion, $4 billion in assets. We have six major hospital campuses, Children’s Hospital, level one trauma center, and we would say that we are and we used to characterize ourselves as a premier academic community health system. We’re clearly the only capital letter there’s C for community, but we have a robust community academic program, close to 300 residents and fellows, so we’re academic, but we’re not a medical school. We like that sweet spot because we have a lot of quaternary services, but we know what we shouldn’t do and we have great relationships with Philly organizations and other organizations where we send patients on occasion.
Gary Bisbee 12:54
How would you characterize the Lehigh Valley culture, Brian?
Brian Nester 12:57
Yeah, so as a Pennsylvanian, I’m a lifelong Pennsylvanian, the heavy influence this part of the world, the Pennsylvania Dutch, I think it’s a pretty conservative community. It is becoming more ethnically diverse but really only in the urban centers. For the most part, the urban center for us would be Allentown, Pennsylvania; Bethlehem, Pennsylvania; and Easton, Pennsylvania. We are on the continuum of the challenges the rest of the country are on. But we also serve very poor, rural populations. But we have the largest chunk in the middle there is a pretty I would say suburban/urban population. So I would say that our case mix is about average or on the better side of average compared to others. Definitely on the better side of average for many organizations, but that’s how I call us, a pretty well-educated community and a lot of folks really like living here because of its location to access New York, DC, Philadelphia.
Gary Bisbee 13:57
What were Lehigh Valley’s priorities before the COVID outbreak? I’m sure they’ve changed somewhat.
Brian Nester 14:03
Yeah, I tell you that’s a great question. COVID19 actually in the net helped accelerate the objectives that we had and before this in February, we had earned about $55 million in operating income on our way towards about $105 million which would have been about a 3.3% operating margin. And of course, the second half of the year is always biggest for us. So we were on track to do that. Now, how are we doing that? Our goal was to have sustainable 3 to 4% operating margins. After having done a lot of turnaround over the prior five years, we had finally completed our massive investment in EPIC across every single site. We actually accelerated that to get that done and behind us. We had made other big investments in the community. So we were on our way. But to get there, we were in a three year engagement to take about $280 million of expense out of our company, and we were just in the third year of that, as COVID started and we were on track. So we had a lot of energy. It’s 60 different groups meeting to take this money out, and then suddenly COVID hit. So I would tell you that in the very front of our frontal cortex, we had expense management in almost every sentence. And I think that when things got really tough in COVID19, we were able to accelerate some of that. I think that was the direction we were on and then we started to accelerate.
Gary Bisbee 15:28
Well, let’s move to COVID. We’ve certainly learned that the surge is highly variable by region. How did it hit Lehigh Valley service areas?
Brian Nester 15:36
I think that if, and I don’t have any data behind this, just my sense of having some national conversations and what I read and talking to local colleagues at other systems. I think LBH was kind of if you had a scale of virtually no impact was 1 to massive impact like Manhattan, 10. I’d say we were probably a 5 or 5 to 6. How do I calibrate that? You know, we have a sister organization, if you will, that’s very similarly sized to us Atlantic Health System in New Jersey, it’s only 50 minutes away from us. Imagine that 50 miles and the difference between what they went through versus us is extraordinary. And then they’re another, probably 40 to 50 minutes into Manhattan, traveling further east. We got hit at our peak about 210-220 COVID-19 cases in our system, about 1500 total beds. At their peak, as I understand it, they were over 800. Now, if you go 50 minutes to the west of us, there are organizations that had single digits that are similarly sized to us single digit cases. So that’s where I kind of put us in the middle, if you will, and I would say it stretched us on the critical care side. But our definition of stretched versus Atlantic Health’s in Manhattan’s definition is very different. What I mean is we used all of our beds and at some times. All of our beds, we were sourcing ventilators moving them from campus to campus. But we weren’t running out like our peer organizations had to to the east of us. So I think we were put to the test. There’s no doubt we had a large book of patients in our hospitals every day. We actually led the state in testing during the crisis. The testing that we provided through our Health Network Laboratory Medicine company, was about 20% of all tests in the state of Pennsylvania. And that’s actually been doubling in terms of our capacity. I think we got stretched, but we didn’t get pushed to the edge. And we’re very fortunate and blessed that that was the case.
Gary Bisbee 17:38
Well, you were making the point earlier, when we were chatting about the importance of density and maybe that could explain the difference in Lehigh Valley versus Atlantic versus Manhattan?
Brian Nester 17:49
Gary, there were many different models out there projections, Washington State and CHIME and others. We used them all but we’re a very data-oriented organization. So our immediate response to everything is get the data in front of us. We created 28 different dashboards that we would look at every day. And like most organizations, we had a 7am call that went for an hour or two and a 5pm call every day for an hour or two for 60 days. I think the first time we gave our execs a day off was we canceled the calls on Mother’s Day to give them a break. So we had a lot of data in that regard and it was a conundrum. We so wanted to project where this was going to end for us. We had purchased cellular GPS data to measure our own if you will, to create our own model for social distancing by tracking cellular activity in our regions in terms of travel. We learned midway through we put a very aggressive contact tracing workforce in place right away and found that well over 70% of our patients during that phase that were positive had some connection to travel to New Jersey or New York which was stunning to us. And that’s why we saw a hotspot in a little town called Hazleton, which is along Route 80 and a lot of folks travel into Manhattan to work. So we found that interesting. But here’s the thing, if you look at the 200 some cases we had versus a sister company just 50 minutes to the east 800. And by all accounts, everyone was really doing a good job of social distancing. There’s something that occurred to us related to the density of human footprint that just overcomes even really good social distancing. So when you as you all know, social distancing estimates were a core part of many of those projections. So, as we looked at it, you look at a similar organization doing everything about the same. They’re all using social distance in their community. The only thing that’s different is the density, the number of humans per square mile. And we’ve been trying to chase that more as an academic exercise, if you will, to understand what that’s all about. But there is also a learning in that for how we respond when the next wave comes. And as you know, we’re seeing a resurgence across the country. So far we’re stable here in our region. But when you look back now and apply the human density factor to the number of cases that were positive and where they occurred by street and zip code, it’s a big job. Come on, no kidding! It’s in our center urban areas where even good social distancing gets overwhelmed by population density so that has shifted our plans for what we call COVID 3.0. Where we plan so, what if it comes back where are we going to set up our assess and test locations? Where are we going to set up clinics to provide care? Where are we going to deploy our workforce? It’s going to be in those areas that were hotspots and it’s really an areas with dense human population.
Gary Bisbee 20:49
Let’s turn to flexing down. We were speaking about that Brian earlier, but will health systems need to develop a core competency in flexing down?
Brian Nester 20:58
Yeah, I think that’s huge. Flexing up is hard because you only have the workforce you have and a lot of places that got hit pretty hard with COVID had a real hard time getting enough staff. Flexing down though is something that is more in our control. How you respond in terms of those levers to keep the enterprise on financial terra firma are really, really important. I think all of us had the same motive early on. Okay, well, we’re all going to get tested. How do we handle this? Well, we’re going to have to provide extraordinary care. Well, you don’t do that without an extraordinarily healthy and solid and high-quality workforce. And we’d like to continue our mission, so we’re going to need to have a company that provides jobs at the end of this. So let’s make sure that we’re all on financial terra firma. So we got really, really aggressive with flexing down as you refer to that term. We immediately when we closed to elective procedures, rapidly furloughed colleagues here. We got to a peak in mid-April of about 4500 colleagues out of 19,400 were furloughed, about 23% of our whole workforce was furloughed. I would tell you that the federal government made that a relatively easy decision because of the subsidy they had made to unemployment and other benefits. So that was one thing we did right away. The second is in terms of flexing down we very much wanted to have a viable company on the other side of COVID. And you remember, in April, we’re thinking that we’re going to be in this for a year. And by the way, I think we will still be in this for a year. So what’s the company look like a year from now, if we don’t aggressively lever down or flex down? So we made some very hard decisions. In middle of April, we actually took $78 million out of our overhead. It’s close to 20% of our overhead we took out. Now that’s annualized, but we still had opportunity to take that out for three and a half months of this fiscal year through June. We went aggressively to establish other service line cuts. We took another $30 plus million out of our service lines, we, these are all annualized numbers. Another $20 million out of our northern tier hospitals and we just got really, really aggressive. We always maintained pension funding, we always maintained 401k matches. The goal was if we were really aggressive in nonwage expense reduction during this time, we could pull out on the other side of this with a company that looks pretty much like it did pre COVID. And that’s what actually happened and we feel very fortunate in that regard. I think we’re starting this new fiscal year and we’ve only had a total of about 150 people that have lost positions in our organization. Each one of them we miss terribly and it’s hard to cut anybody, but I think we came out, because of really aggressive flexing down better than we were initially projecting.
Gary Bisbee 23:55
What are you thinking about 2021, Brian? Is all the economic damage going to be in fiscal year 2020 or do you think that you’re still going to be feeling it in 2021?
Brian Nester 24:06
If we don’t get a second wave that necessarily mandates shutting down services like we had to during the first wave, if it’s a manageable wave that doesn’t have to shut elective procedures down, things like that, I think we’ll do just fine. I think then most of the damage is in the rearview mirror in the last quarter of fiscal year 20, which for us run a fiscal year, July through June, which just ended for us. Then we have contained the damage, mostly. The residual nature of what we’re dealing with is that we again, some of those dashboards we put together across hundreds of service lines, each one has its own story. If you think about mammography, screening mammography, literally for us on a couple days went to zero cases during the shutdown. I would tell you, that was the fastest to return when elective procedures were up. We were at about 110% for several weeks. That’s related to a backlog of patients. So you wonder how long is that going to last? Diagnostic mammogram, completely different story. We have completely different. Express Care not coming back, emergency department very slow. Doctor’s office visits? 95% of where we were pre COVID. But about 20 plus percent of that business is actual virtual. That could be phone visit, e-viisit, chat, could be virtual visit by video. Very different complexion to our business, but when we snapped the line for this year’s budget, we snapped it at about 90% of last year’s volume and slowly over the year trying to get back to 100% of last year’s volume. So I think if those numbers hold, like our six week projection, we use six weeks of data there, we could be okay. We’re hoping to be okay in 2021.
Gary Bisbee 25:52
How about CapEx? Will CapEx need to be cut somewhat?
Brian Nester 25:56
Yeah, we did. Honestly, we did a basically a ratio of one to one of capital expenditure to depreciation this year. We tend to spend more money I think, than our peers and for us, that’s a reduction. But we have major projects underway like the building of a brand new hospital campus that we never stopped. Of course, we had debt financing for that and bonds that were, you had to spend it on those projects so we continued them. But we’re actually hopeful that if we are on track through this fiscal year, through the first two quarters, we’ll probably starting to 3 of 21 start to plow more money into our capital investments. We have a very competitive market here. We believe in having robust asset placement of services because it’s a means to engage patients and keep them highly engaged in their care. If they’re engaged in their care, they will have better clinical outcomes. Better clinical outcomes equals lower cost and lower PMPM at the pump and that’s at being a value production organization that’s really important to us because we’re moving more into risk contracting every year.
Gary Bisbee 27:01
Brian, I’d love to get your thinking about telemedicine and assuming that there was a substantial increase in telemedicine at Lehigh Valley because of the COVID crisis.
Brian Nester 27:11
Yeah, real silver lining for us. For most organizations I’ve talked to it’s just exploded for everyone. We had a pretty robust telehealth program about 100,000 teleconsultative interactions each year, but that’s across 30 teleconsultative services plus a tele ICU. So the potential was so much greater than that. We wanted to do more of that pre COVID. But we also knew that we had to start monitoring patients in the outpatient space. And we had had a three year goal which ended this fiscal year to get to having 1000 people contemporaneously monitored by some device every single day in our community, which is not a gigantic community. Our core region is just less than a million people. So that’s people still robust and we were struggling. Pre COVID we were at about 600 to 700 and we were probably not going to hit that goal. Everything changed. We decided in the first week of the hit here to really double down on our tele infrastructure. We bought hardware. Had to put in to improve our capacity. And sure enough number of remote patient monitoring, we have over 1000 people. We hit that goal within by the beginning to middle of May. We were at over 1000 a day being monitored. Many of them COVID people that were we were discharging home on pulse oximetry, and doing other things. But the real big win, which was a surprise to us was we’d struggled with getting people in our community to do video visits. We were doing only about 90 a month even though we had a robust infrastructure to do it. We’re now doing over 1000 a day. Truly, there was an adoption that none of us predicted during COVID where people really used video visit to stay connected with their doctors. So we’re excited about that we’re bullish that maybe this has caused a cultural change in our community. We got high satisfaction. And right now, although that number had been even higher than that, and it’s drifting down a bit now that our practices are open, I think virtual visits in our community will be here to stay. And there’ll be a whole a whole lot easier to grow other teleconsultation activity.
Gary Bisbee 29:19
Brian, this has been a terrific interview. I had hoped to get to business model effects on large health systems where you’ve been a leader and thinking that through. We’re going to have to put that off till the next interview. Hopefully, you’ll agree to do this later in the fall. But let me ask one final question, if I could, which is, people are talking about the quote-unquote, new normal. What changes do you think will happen to the health system as a result of COVID?
Brian Nester 29:49
Again, I have a pretty strong bias of the doomsday that there’s a lot of lurking bad things out there for hospitals, health systems. Whether it’s new competitors in the marketplace or it’s declining reimbursement or who knows? Those things are going to really push health systems to have to reduce expenses and have to get more efficient. I think that everything got magnified as a result of that and organizations who maybe were thinking, I think we can hold on to fee for service another 10 years as our way through this and we have more time to think through it. I think if you’re thinking that you’re in a really unique market, or your heads probably in the sand. I think we all took huge financial hits here. How we get back to being the organizations we need to be for our communities, again, different story in every market, and we have a good market here we have we’re fortunate to have pretty healthy market here, it’s going to be really hard for us. So we’re doubling down on expense reduction. We’re going to have to. I think we have to take further risk in value-based contracting. I think we have to push our quality goals even higher and not because it’s you want notoriety, it’s just because in our world here, we’ve proven higher quality care, lowers cost, and we should be able to share in that improvement in cost. We could do everything right still and depending on what happens in the polarized world of Washington, DC, we could still get killed. But people are counting on us. And I think the best way to be good to your community is pick expense them and make sure your hospital is on terra firma, and could live into perpetuity. And that’s going to be making really, really hard decisions, hard financial decision. I know most of the people I talk to cross country are thinking along that index. Now I’m a little bit on the more aggressive end of that. But I think if anything, this woke us up and said if you had thought you had time, you’re done.
Gary Bisbee 31:50
Brian, that’s well said. I love your thinking. Terrific interview. And again, we hope you’ll agree to join us later this year where we can dig deeper into some of these thoughts about the business model.
Brian Nester 32:01
Thanks so much, Gary. I always love talking with you.
Gary Bisbee 32:05
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