Episode 7:
High Tolerance for Ambiguity and a Passion for Complexity
Peter Fine, President and CEO, Banner Health
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In this episode of Fireside Chat, we caught up with Peter Fine, President, and CEO of Banner Health. We discussed visibility, healthcare affordability, and using clinical data responsibly.

Peter Fine was appointed president and CEO of Phoenix, Arizona based Banner Health in November 2000. Banner Health is one of the nation’s largest secular, nonprofit healthcare organizations operating 28 hospitals, with one more being acquired and three more opening later this year, and other services in six states. Banner employs more than 52,000 people, has more than $9.5 billion dollars in revenue and is Arizona’s largest private employer.

Prior to his appointment, he was executive vice president and COO of Milwaukee, Wisconsin based Aurora Health Care, a large integrated system serving all of eastern Wisconsin. His previous position with Aurora was president, West Allis Memorial Hospital. Before joining Aurora, Mr. Fine served in several hospital leadership positions, including president and chief executive officer of Grant Hospital and senior vice president of operations at Northwestern Memorial Hospital, both in Chicago, and assistant administrator of Porter Memorial Hospital in Valparaiso, Indiana.

Mr. Fine received his bachelor’s degree from Ohio University and his master’s degree in healthcare administration from George Washington University. He is a fellow in the American College of Healthcare Executives and previously served as a member of their Board of Governors. He is also a member of the American Hospital Association, Health Management Academy, Greater Phoenix Leadership, and serves on the board of directors for Premier, Inc., Greater Phoenix Leadership, and Banner Health; previously he also served on the boards of Accuray, Translational Genomics Research Institute, and the Heard Museum. In addition, he has served on the Arizona Commission on Medical Education and Research, the Citizen’s Task Force on the Maricopa County Health Care System, the Citizen’s Finance Review Commission for the state of Arizona, and Governor’s Transformation Advisory Committee.

A number of prestigious organizations have honored Mr. Fine including, Modern Healthcare with the 100 Most Influential People in Healthcare Award (2011, 2014, 2015, 2016, 2017, 2018, and 2019), Modern Healthcare and Healthcare Information and Management Systems Society with the 2010 CEO IT Achievement Award, Phoenix Business Journal’s Most Admired CEO Award 2010, Arizona Business Magazine with the Lifetime Achievement Award in 2015 and Healthcare Leadership Award in 2010, B’nai B’rith International with the National Healthcare Award in 2007, The Maricopa Community College Foundation with the Heroes of Education Award in 2006, and the Distinguished Alumni Award by The George Washington University Healthcare Alumni Association, 2005.

Transcription

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Peter Fine 0:00

So the lesson learned, and I use this term all the time at Banner. Visibility breeds credibility, credibility breeds trust. If you want to be trusted, you better be visible.

Gary Bisbee 0:13

That was Peter Fine, President and CEO of Banner health. I’m Gary Bisbee and this is Fireside Chat. Peter is an accomplished storyteller and you’ll find the episode chock full of stories and lessons learned from them. Look for Peters responses to questions about why providers are managing risk and what are the financial and care benefits. We had an active discussion about the value and promise of clinical data. What is the strategy and performance advantage partnerships and how to invest capital and where we explored what role utilization plays in healthcare affordability and cost? Peter shares his view of leading in an industry in the midst of disruption and reinvention. Let’s welcome Peter to the show. Welcome to the podcast, Peter.

Peter Fine 0:55

Thank you. Thank you.

Gary Bisbee 0:56

Good to have you here. We’ve done what three or four or five fireside chats through the last several years. So this is a real fun chance to do this as an audio. At any rate, you’ve had a magnificent career. And I think it’d be interesting for our audience just to track kind of where you started in terms of healthcare administration and how you evolved through to Banner and we can talk more about Banner later. But what was the decision point to move into healthcare?

Peter Fine 1:28

Well, it goes back to early stages. From an education perspective, after I graduated college, I decided I wasn’t sure what to do. Frankly, just like the rest of us, just like most people. So I spent a year in Aspen learning how to ski. Well, that was my primary goal at 22 years old, with very little career ambition, other than that, but then I got interested in health care through my mother who was the office manager for an internal medicine doctor for 25 years. And while I was very interested in medicine, and I was interested in medicine, from the perspective of being able to do things for other people at a time of need, I was also very business oriented. I started reading Fortune magazine at 10 years old. And so I was just very interested in business. And I saw this opportunity to satisfy my business interest. And I feel good interest in doing something for the greater good from a medicine perspective and saw healthcare administration as a way to marry those two things up and ended up getting into George Washington for my graduate program and healthcare administration. And then my career just proceeded from that and took many, many twists and turns along the way.

Gary Bisbee 2:49

What was your first actual job working in a hospital?

Peter Fine 2:53

My first actual job was that administrative assistant in the admitting department in a small hospital in New York City that’s not there anymore. And you’re learning it from the ground up. That was a year after graduate school. My second job was at a 300 bed hospital in Valparaiso, Indiana, where my wife happened to grow up. And I was 26 years old. The administrative team of that place was the CEO, the CFO, the chief nursing officer, and one lonely assistant administrator at 26 years old, which was me. I have no idea why he was willing to hire somebody. Virtually no experience. But it was an interesting learning experience. on how to run an organization, this guy was pretty interesting. My first interview, I walked him into his office at 7:15 in the morning, we were out walking around at 7:30. He walks me back downtown, the doctor’s lounge tells me to have a seat. And this is back in the day when doctors lounges were actually populated by doctors. And had about a dozen doctors in there and had me sit at the table and said you know what, I’m going to go make some rounds. I’ll come back and get you later. So here I’m 26 years old. It’s my first interview. I’m in a doctor’s lounge with a dozen doctors who just had their way with me. And it was obvious which I didn’t know until later on his way of testing to see if I could stand dressing. Interesting interview technique, as you might expect. He actually ends up hiring me. But the funny story behind it is around December 30 of 1977 my wife was seven months pregnant. I’m in this hospital in New York City, a giant snowstorm and I get stuck at the hospital for two days and she’s seven months pregnant. I can’t get home. I get home and I was just tired of all the weather, and issues. So I had met this guy once before when visiting her parents. And they arranged for me to go in and see him. And he didn’t give me the time of day. And I went on with graduate school and residency and all that. And so I wrote him a letter on December 30, 1977. I said, I don’t know if he remembers me. But here’s who I am. Here’s what I’m doing. If you ever have a need for an assistant administrator, I’d love to talk to you about it. And, sure enough, about three weeks later, he contacted me because he was looking for an assistant curator and proceeded from there. But the interesting thing is, and this is why people should have the guts to do things that they might feel uncomfortable and doing. Years later, when I was leaving, I was looking for something in my file. And there was my resume with a note on it. And it just so happens that when he got my resume and was actually reading it, his assistant administrator walked in and resigned, just as he’s reading my resume. And, and I don’t think I would even have been in the picture, if he hadn’t read anything. So it’s worth taking the chance, this random letter that I sent to him with my resume on December 30. ended up in a good situation.

Gary Bisbee 6:26

I’ll say, You can’t, you can’t make that up.

Peter Fine 6:28

So you know, he said, it was a great learning experience, because this guy came into the office every day, six days a week if he was home on the weekends, at 7:15 in the morning, was out on the floors by 7:30 and roam the halls, the floors, every place from the doctor’s lounge to the loading dock to the pathology department to the radiology department, and never came back to his office before. Before 9:30, when he came back to the office, I shared a suite with him at 9:30. He’d go to the coffee shop next door and sit in a very visible spot having a cup of coffee for another half an hour, and people would see him and people would come up to him and people would talk to him. This guy knew more about this place than you can imagine. He knew everybody. So the lesson was learned. And I use this term all the time at Banner. Visibility breeds credibility. credibility breeds trust and we want to be trusted, you better be visible. This guy was trusted. He made tough decisions and didn’t have a problem with making tough decisions. But people trusted him because he was visible.

Gary Bisbee 7:31

That’s a great lesson.

Peter Fine 7:32

For sure. A great lesson at an early age. You know, 26 years old.

Gary Bisbee 7:36

What was the first position you had in a multi hospital system?

Peter Fine 7:41

Well, that was years later in about 1995. So 17 years later into my career. And I was running a hospital in Milwaukee. Small, relatively small hospital in West Allis, Milwaukee, West Allis, Wisconsin, which was a suburb, next to Milwaukee. And a standalone hospital didn’t have much features, and we ended up coming into Aurora health care. And Aurora was on a mission to build a big, big system.

Gary Bisbee 8:21

Ed Howe was the CEO?

Peter Fine 8:22

Ed was the CEO, and he started building that organization in 1984, through a merger with another hospital. And he was on a mission. And he was definitely on a mission. And it was interesting, another lesson learned there. And I use a term all the time called tune out the static, every decision has noise. And it’s either internal noise, or it’s external noise. It’s competitive noise, it’s public noise, it’s newspaper noise, but somewhere there’s noise. And he had this capacity, he was so focused on building the system, he had this capacity to tune out the static. And all of this noise and static that surrounded the aggressiveness of building his system. He just didn’t care about it. He said, I’m gonna pass, I’m gonna build this system. So it was another great lesson to learn from somebody who really wasn’t a great teacher. But you learn through observation, kind of like the first gentleman I talked about. If you’re wise in sometimes keeping your mouth shut and keeping your eyes open, you can learn a lot. And in this case, I learned the lesson about noise than static that matters and noise and static that just doesn’t matter. And tune out the stuff that doesn’t matter and pay attention to stuff that does. And he just built this system and gave me opportunities. Ultimately, as the executive vice president Chief Operating Officer, which was the role I had before I came to Manor in 2000. What was behind Ed’s thought about why he wanted to build them on a hospital system, he saw value in building a healthcare organization in which multiple things could be provided within that organization. And therefore, you could become far more efficient and effective in providing health care services as a result of that.

Gary Bisbee 10:19

Do you agree with that?

Peter Fine 10:20

I do agree with that. It depends. Many systems are holding company models, in which I believe it is very hard to get at the effective and efficient capabilities. Banner from day one, when I came here has been an operating company and an operating company has, I think, greater control over the process ease that it has, and the expense base that it has. Banner has to be a very tightly controlled operating company, because our payer mix is not great. And therefore, we have to watch our expense base very closely, along with our ability to grow. But I think he was on the right track. And it was kind of my first lesson learning about that. And it was there for him, whoa, let’s see about part of Aurora for five years in Milwaukee for seven, but part of her for five years. And it was a great lesson to understand how you attack the cost base of a system that wants to grow and has opportunities to grow, but also has to manage his cost base along the way.

Gary Bisbee 11:34

Well, fundamentally, you’re the first CEO at Banner right?

Peter Fine 11:40

I came in 14 months after the merger. So there was technically a CEO for 14 months until I got there.

Gary Bisbee 11:47

So you came in with the philosophy of operating the company not a holding company right from the beginning. Today, nationally, we’ve seen the operating margin of our health system go below 3%. How does that in the holding companies are having some difficulty with that? I would guess the operating company, I mean, at least you know how to deal with expense management, would you agree with that?

Peter Fine 12:18

You know, when I first came, I published 13 ground rules, and the ground rules for here are the ground rules for an operating company. And I published it throughout the organization. And I said in case anybody’s curious, we’re an operating company, and this is how an operating company behaves. And we have followed through with that. All along. Until the last few years, in which our pair mix changed a lot. We took on a major relationship with the academic enterprise associated with the University of Arizona, we took on insurance risk. And all of those things, those three primary things have affected our ability to manage our costs and have caused our overhead costs to creep up and our losses to become greater from an operating margin perspective. I mean, we’ll you know, we’ll barely hit 2% this year. Now, we will improve upon that in the next few years because the things that were causing that we’re affecting an appropriate change both on the insurance losses and the academic environment losses. But they have taken a toll and pear mix Arizona is richer, it’s our primary market, we’re in six different states. But Arizona is probably 88% of our business. And revenue and expense base in Arizona is not a great pair mixed market, a lot of Medicare, a lot of Medicaid. And our commercial insurance present position has dropped significantly over the 19 years I’ve been here. So it has become harder for us to cost shift to the commercial insurance component, because the commercial insurance component has gotten smaller.

Gary Bisbee 14:02

So 40 of the largest health systems would be listed companies on the s&p 500 if if they were for profit companies, so you all are running huge companies in this country that has some ramifications in terms of how the community looks in this case, banner. Does that work in your favor?

Peter Fine 14:30

Well, it depends. It depends upon how you’re perceived. And how you behave. Your behavior drives your perception of how people look at you from the community. I think we have in almost all of our markets very good perception from the community. We’re very focused on doing things into the community and providing the necessary resources and services to meet those particular needs. But just because we’re big doesn’t mean we’re good. We have to, we have to behave in a certain way, as an organization to do that, but the customer base is changing. And the community is changing when people have $300 deductibles. And that was all they had. They behave one way, but now they have $1,000 co-payments, they behave an entirely different way. Right? So we’ve had to learn how to adapt.

Gary Bisbee 15:23

Right, you could describe that as your business model is having to change in response to these What are examples of how your business model has changed. In response to these various environmental factors?

Peter Fine 15:37

We’ve had to build a series of ambulatory businesses, some by ourselves some in joint ventures that bring us closer to the customer. Before they be have to enter the intense environment of a hospital, we have a very big urgent care company with somewhere around 50 sites, we have a growing and in getting larger business in partnership with SELECT Medical and rehabilitation medicine, we’re building three rehab hospitals down here in the Arizona market, and have have combined our outpatient therapy centers. And we have about 37 of the 38 of those now, we’ll probably have 65 in the next couple years. And so we have a good partner there. We own 51% of the company, they own 49%, and they manage it. With a giant joint venture with quest diagnostics. It’s a huge, huge reference lab, that we also own a majority of the majority of that we have a surgery center company that’s our own, that we’re running in partnership with a company called Atlas partners. And we own our own imaging company that is wholly owned by us now through acquisitions that we did, with about 23, freestanding imaging sites and growing. So we’ve invested a lot the last few years in access points associated with ambulatory business, and have selectively added in patient environments, or enhancing patient environments, growing same store sales campuses or building new campuses, in markets that tend to be more commercially insured. So we can get a better balance in the mix of our payer mix. And we’re involved with a number of acquisitions, as well of hospitals, both in the state and outside the state that complement our access points that we have in strategies that we have.

Gary Bisbee 17:47

So half or more than half your revenue from ambulatory care these days, probably not that much?

Unknown Speaker 17:54

Not quite yet. Probably at 19% of it is through various value based risk taking insurance products, some that we own, you know, very big Medicare, Medicaid managed care companies, and some in which we are taking risk on Medicare Advantage in from contracts that we have with humans and Blue Cross and United.

Gary Bisbee 18:19

So roughly 20% of your revenue is some kind of risk base. So how do you develop?

Unknown Speaker 18:25

Part of the reason that we built the ambulatory business is because we’re taking risk. We wanted to put people through our ambulatory environment and then manage them, right or inpatient environment witness, right.

Gary Bisbee 18:36

How do you develop an expertise in managing risk? And that’s not a typical provider expertise?

Peter Fine 18:42

What isn’t? We had a real company, that as part of a company, we had a part of the organization that had been taking risk based contracts for years, from insurance providers in the Arizona market. So there was a base of experience. We then acquired in 2008, a Medicare Advantage company in an acquisition that we did 20,000 enrollees grew it to about 70,000 enrollees. And we learned a lot the hard way, by the way, we learned a lot about the risk in the mistakes that you make along the way. So it’s been a learning experience for us, but would cost us a lot to go through that learning experience. And learn where to take risk. We’re not to take risk in that has helped us now as we were going forward in considering our own Medicare Advantage. The provider owned a Medicare Advantage plan.

Gary Bisbee 19:41

So what’s the real advantage? To take risks to manage those people might not actually understand that?

Peter Fine 19:48

Yeah, well, you know, there’s a value we think in getting the first dollar coming in the funnel. Not being the recipient of $1 somebody wants or just happens to want to give us at the bottom of the funnel. We want the dollar coming in. Because if you can manage this properly, there’s a return on that investment of the management, that throws off a value equation associated with an operating margin, you might not otherwise be able to have access to if you’re just the recipient at the bottom of the funnel of $1 than insurance company wants to give you, right. But if you can learn how to take risk, there’s a few percentage points there. And remember, for most healthcare organizations, they’re working on small percentages of 1, 2, 3, 4, or 5%. There are a few that are in highly insured commercial markets that can do way better. But for most of you can gain an extra 3% on a big book of business. So remember, when you’re talking about taking on risk, you’re talking about taking on percent of premium? Well, if you’re taking on 87% of premium, and you can make a 3% margin on a billion dollar book of business, you’re producing resources that can come back into the organization that you might not otherwise have access to.

Gary Bisbee 21:11

Right. It’s a low margin business. So you’re needing to act accordingly. Does by you’re taking more by banner taking more risks, does that put you in a competition with health insurers?

Peter Fine 21:25

It depends if we’re taking risk from a health insurer. So they’re delegating risk to us. It doesn’t put us in competition with them, it actually gives them the ability to offset the risk to us and let us manage it. If we have our own company. That’s a different story. And most of our risk businesses and Medicare Advantage anyhow, we have a joint venture with that now, which they own 49% of the market and we own 51%. We own 49% of our joint venture of his book of commercial business, and it’s selling pretty well. So we have different joint ventures along those lines.

Gary Bisbee 22:08

Can we turn to clinical data, which just in the last couple of days has become an issue because of the Google relationship of Ascension. But even before that, it seems clear that whether you want to call it precision medicine, or personalized medicine, there’s a number of different uses for clinical data that are becoming maybe valuable from an efficiency standpoint, certainly from a quality standpoint. And the question really is, do you think that we’ve treated the value of the clinical data, as responsibly as we should?

Peter Fine 22:45

I don’t think the word is responsible, I think it is more an intellectual question of how to use data. We have been very, very poor. In using the mounds of data, we have to drive our thinking and drive our outcomes. When we created this partnership relationship with the University of Arizona four and a half years ago, for 30 years, one of the goals we had was to have their research component be able to have access to our incredible amount of data within the system our size, and be able to provide us guidance and thinking on how to approach certain clinical issues. But we haven’t been able to take advantage of it for many, many different reasons. But that has been the history of healthcare delivery, an incredible amount of data, but nobody that has been good at erasing that data, cultivating it, and then using it in a way that actually influences outcomes in actual care. You know, I, 11 years ago, had cancer, traumatic seven, seven months of treatment. It took its toll on me, no question about it. But they, you know, they just threw the kitchen sink at me. And, you know, tried to kill every bad cell, but kill the whole lot of good cells along the way with radiation and chemotherapy. If there was better data, to be able to look at me and target the use of treatments it might not have been as traumatic for me. And we maybe could get a better result. I had a good result. But there could have been somebody just like me that had bad results. And we don’t know why. Right? And without the ability to do very, very unique data analysis. We’re not getting the full value of the amount of information that’s available. I had a conversation with our board now back two years ago, and I asked them a simple question. What is the most important human asset that we need in this organization? And you had all kinds of responses from we need more nurses We need this kind of specialty physician, so forth. And I said, you’re all wrong. And they said, Well, why? What do you think is the most important asset? And I said data scientists, and finding PhD data scientists. I told them was a solution to a successful organization, 10 years out. And we’ve been trying to find those and find those people who can actually help us look at the information base.

Gary Bisbee 25:28

We had a session at the CEO Summit last July on genomics. And I thought it was interesting in that a lot of health systems see the value of that going forward. But they haven’t yet set up the mechanism internally to process the data and do the analytics. What do you think about genomics and how big a factor is that kind of being in a delivery of care?

Peter Fine 26:00

I think it’s getting to be a huge factor in the delivery of care. And people haven’t set things up because they don’t know how. They’re low margin businesses. So how you take what’s left over in a low margin business that also has a high capital need, and distribute it and make the decisions and where best to use those dollars, you’re still left with a system that has, as making continues to make significant investments from a capital perspective in bricks and mortar. Whether it’s ambulatory bricks and mortar or inpatient bricks and mortar. I mean, we’re building a new hospital right now in a market that we think there’s a great opportunity for us. And so you’re still having those investments. And so this debate internally in an organization that has existed for years of how do you invest capital? And where do you invest that capital, and people have invested it more traditionally, because they understand it, and not invested enough in things that they haven’t understood as well? Or that haven’t matured far enough to actually make those investments? Or they just don’t have the internal talent to actually do that? And that was my comment about data scientists. You need people who have a greater capability to think about issues intellectually different than what has been traditional within our healthcare organizations.

Gary Bisbee 27:31

Peter, could we turn to affordability, which is, of course a contemporary issue, and not without good reason. So how do you think about affordability? in particular, what can we do? What can health systems do to approach that issue?

Peter Fine 27:47

Well, the cost of healthcare is, quite frankly, not driven in my mind, by one thing, it’s the usage of services. And everybody wants to say, Well, you’ve got too much… too many people, you are spending too much capital on bricks and mortar.” And in trying to attack the healthcare delivery system, as is inefficient. Quite frankly, I think it’s less about how our cost to deliver the service. And it’s more about the necessity to deliver the service. You can’t control the cost of health care in this country until you attack the usage of healthcare. And then attacked in many ways. It’s getting people to move to an outpatient environment, less expensive outpatient environment, from an inpatient environment. You know, being one, and being knowledgeable enough to understand when it’s necessary, and when it’s not necessary to do certain things and create the right incentives for people to to think about that. You know, I had a discussion with a former CMS leader of CMS A few years ago, and I was in his office and I said, I got the Great answer for you. If all you do is have every Medicare enrollee submit a health care power of attorney in a living will at the time that they enroll with Medicare, and you upload that. And my people on the floor is at the time of a stressful situation, can access that information and can say to relatives, here’s what your mother and father wanted to have done at this point in time, you will save 10s of billions of dollars. But they can’t get there. Because it’s a policy and in the policies run through Congress and Congress will never allow that to be a policy that Medicare can actually implement. But they’re their means to control the usage of healthcare without limiting necessarily access to health care. And that’s how you’re going to save cost, we can restructure We can, you know, look for fat in the system, we can cut resources, you can cut the payments to hospitals and doctors by 50%. I don’t know what gets you other than people that are disenchanted. And our reimbursement system makes no sense. Nobody would go to a whiteboard and create the healthcare system of today on a whiteboard for the future, nobody would do it. It makes no logic, logical sense, until we deal with that until we recognize that there needs to be universal coverage in this country, in Medicare for All is not the answer, because Medicare pays us 91 cents on $1 of cost, you can’t make that up in value, right. And so you have to come up with a way for everybody has access to health care, in a country our size with our wealth, it is ludicrous that we have populations that don’t have access to health care. And so you have to change the structure in a wholesale way. You can’t just trim it at the fringes. And right now, you’re trying to trim it at the fringes and creating a great amount of disruption that aren’t necessary. And in some cases, people just don’t care. If I can create a niche little product that creates disruption so hot that it disrupts the rest of the system, like medical education. Nobody wants to pay for medical education in this country. Nobody cares if academic enterprises are struggling, or don’t have the means to appropriately educate our students, or one step away from bankruptcy because of that, nobody really cares. Because that’s somebody else’s problem. And so we try to make pieces of the healthcare system be somebody else’s problem. When we record we have to recognize it’s all of our problems. And it needs to be reinvented, but it can’t be reinvented at the fringes, we have to reinvent it in a thoughtful and logical way. and accept the disruption that comes with a wholesale change. You know, you go back to Medicare, Medicaid being created in the 60s, that was a highly disruptive change. Yes, not liked by a lot of people but it has done good things. I think it has done good things and hasn’t cost a lot of money. It has cost a lot of money. But it has given people their disadvantage or elderly access at a time of need and gives them some sense of security, which is what it was intended to do. It’s not surprising that it’s expensive, right? Because the baby boomer population is causing usage. And again, usage is the driver of cost. And this is

Gary Bisbee 32:53

Why we need to put you in office as a Secretary of HHS Peter, that’s a solution.

Peter Fine 32:59

Well, I’m probably probably too mouthy to be able to get away with that.

Gary Bisbee 33:02

Well said though. Well, just to wrap up, this has been terrific. Thanks so much. What do you advise a young person comes in and says, Hey, mister Fine. Should I go into healthcare? Should I go into healthcare? leadership? What’s your advice and counsel?

Peter Fine 33:18

I’m a big believer that disruption creates advantage. And this is a business, an industry that is in the throes of major disruption, and major reinvention. When disruption of reinvention occur, it creates opportunity. And it’s a matter of what your tolerances are. So my advice to anybody getting into healthcare today, you have to have two things, you have to have a high tolerance for him of ambiguity and a passion for complexity. Because that’s the world we live in complex problem solving, and unclear solutions to a problem. And you have to be able to be comfortable in a complex environment, in an environment that has just tons of ambiguity. And if you’re going to go into the business side, you just have to recognize that. And if you can recognize the advantages that come from disruption, because they’re going to be survivors, and they’re going to be people that go away, and survivors are going to be the ones that recognize the advantages of disruption, and figure out how to grab onto those advantages. And others will disappear. The medical field is different. If you go into medicine, and interestingly, there’s still an amazing number of applicants for medical schools.

And I would have thought that would be changing but there’s still thousands and thousands of people applying for medical school slots. But it’s a different business. And you have to recognize that going to medical school and thinking You’re going to come out as a solo practitioner, like you might have seen 50 years ago, isn’t going to be what’s going to happen. Because you can’t manage those practices anymore, you’re going to have to become into large specialty groups or large, multi specialty groups like ours, that we have. But medicine is a different business. And the people that are going into medical school are different candidates. They want to have a different life. And, and they have to recognize that being a physician is a different product than it used to be when physicians are coming out. But if you want to be in a feel good business, it’s a feel good business. Sometimes you don’t feel good when you’re running, because it’s so frustrating many times, and I’m clearly at the latter stages of my career than the early stages. But if you know what you’re getting yourself into, and you want to be in a feel good business, then it’s not a bad place to be. But you have to have those capabilities to enjoy complex decision making and be comfortable with ambiguity that exists all around you because you have a system that wasn’t created for today. Right and nobody would create it on a whiteboard for tomorrow. Right? And that causes those problems.

Gary Bisbee 36:26

Peter, this has been terrific. Thanks so much for your time this morning.

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