Insights, Strategy, and Vision from the CEO Chair

Aaron: 0:48

Welcome to the podcast. In today’s episode, mike and Jason sit down with Shery Roussarie and Kelly Macken-Marble in our first of two episodes. Roussarie and Kelly Macken-Marble in our first of two episodes. Both women have held numerous leadership roles in the practice, vendor and hospital settings in the Midwest. Most recently, they co-authored a book about their leadership journey within the industry. We discussed the challenges of remaining independent physician practices, how to collaborate collectively and other helpful insights from these fantastic leaders. Are you ready for this vital conversation? Let’s get started Before we get into our interview.

Jason: 1:36

Kelly Macken- Marble and Sherry Roussarie are former clients of ours. We were engaged in 2018-2019 timeframe for about three to four years as a partner to help form a clinically integrated network called Integrative Care Partners with several practices in the South Bend market where we helped facilitate startup and ran the administrative side, if you will contracting, analytics, et cetera in tandem with the employees that were on part of each of the practices within ICP or integrative care partners. That engagement did cease in 2021, I believe, but there are former clients we have kept up with. We developed a good relationship and became admirers from afar, especially after they wrote the book that we’re about to discuss.

Aaron: 2:30

And I think it’s important to be clear that the partnership didn’t break up because there was some kind of falling out. There was a significant market change in the area that kind of made the whole thing redundant.

Jason: 2:43

That’s correct. So, in essence, one of the founding practices. There were actually a couple of mergers that took place during that time and parent companies outside the state of Indiana in fact, and so it was just a natural transition of dismantling and disengagement, if you will, between us and ICP Still very good relationships with those involved. Just a natural transition.

Aaron: 3:09

Yeah, I think it’s important to be honest and upfront about the relationships that we have with some of our guests. So thank you for explaining that, jason, and with that, let’s go to this great interview with Kelly and Sherry.

Jason: 3:32

All right, let’s start with a brief background from you both, as you both each have a unique perspective of starting your healthcare management careers Kelly from the clinical side, sherry from the marketing and payer side of things. Let’s start there. Maybe, kelly, if you’ll kind of get started, give us a little background on how you arrived to the position you’re in today.

Kelly: 3:54

Sure, my dad was a cardiologist. So out of six kids I think it was all assumed we would work in health care and most of us did actually. So I started out in nursing nursing background, went to nursing school, actually worked in the ICU, bedside, nursing in the ICU for a period of time and then had this personal experience with a daughter who was sick, and we’ve got to experience health care all over the country actually and it really helped me see health care from a different perspective, all the things that were broken with health care and made me think maybe I had more to offer on the administrative side. So chose to go down that path and went back to school, got a bachelor’s degree in healthcare administration and then a master’s degree in organizational management, and have really spent the majority of my career in healthcare administration.

Jason: 4:51

Fantastic, fantastic and Sherry about yourself.

Shery: 4:54

I really started my career out in the not-for-profit arena, started with Easterseals and March of Dimes, working in those markets, and then moved into healthcare marketing.

Shery: 5:06

So first ER services, primarily to businesses and that sort of thing, and then moved into women’s health services and then a brain injury rehab health services and then a brain injury rehab and after a time I decided to go back to get my MHA and MBA and then from there moved right into managed care. My administrative residency from my MHA MBA led me into managed, where I got to really study what was happening in the hospital settings and payment and reimbursement from the health plans through the managed care piece. And then I moved into running IPA networks in the Houston area and then eventually to a PHO in Indiana and from there it was really a natural migration into physician group leadership. So it was a very natural background that gave me knowledge of the business, of the business, learning about physician reimbursement under capitation models. I learned healthcare plan contracting and I think the most important experience I gained was the value and the importance of independence and interdependence among the healthcare parties.

Mike: 6:30

I guess this is for both of y’all I apologize, it’s not on the list when I hear both of y’all kind of go through that. What always amazed me when we were working together in the ICP world was how quickly you guys developed a shared vision and went to kind of a seamless level of collaboration and we just kind of drew us in into that and it wasn’t like I don’t know Jason come in too, like I don’t know Jason coming too. It didn’t feel like that. We went through this kind of learning to work together phase like y’all just immediately kind of vibed together and had a shared vision. What about your backgrounds or what about your kind of working history kind of led to that. You think Both of y’all.

Kelly: 7:14

You know, I think it’s interesting, I reflect back on occasion about when I first met Sherry and I feel like it was in our very first breakfast, I remember it so well we just were aligned like right from day one and I think and Sherry, passion came from different directions but for the place of independent physicians in healthcare today and what we both saw happening, that was threatening that. And again, I think our experiences were different in how we got to that place, but it created a passion for both of us. And I hadn’t.

Kelly: 8:02

Honestly, when I met Sherry I had been out of supporting independent physicians for seven years maybe. I mean I you know, but I started my career there and so it never left, you know. And so all my years as I caution myself using these words hospital administrator I guess I am one again, by the way I always leaned towards supporting independence because I knew the value and I knew the value they could bring to the hospital, because they were lower cost and I didn’t have to employ them and I didn’t have to employ them. To me it was a great partnership. So I really feel like, again, we kind of came to where we were at in different ways, but we just shared that mutual sort of passion for preserving independent physician practice.

Shery: 8:49

I think that’s true, and when we met it was almost as though we had known and worked together for years because we were so aligned. There was such energy that came out of that meeting and I think, mike, what a lot of what our personal background gave us, with the personal experiences and dealing with the challenges, the losses and those sorts of things from our personal experience. It gives us the perspective of focusing on those things that are the possibilities of what can be done, versus those things that are the obstacles that are going to prevent us from doing what could be done. So I think it’s just really um, I don’t think that everyone has to experience what Kelly and I have experienced to to have that. I think what we have to do in in general is have an openness to say what can be and and as Kelly and I, both at our core, we start with yes and then figure out how to make that yes work.

Kelly: 10:05

There’s a chapter in the book called Delusional Optimism and it comes from that right when you have challenges that are just awful and feel insurmountable at the time and not everybody does, but I think we both left those experiences with really anything’s possible.

Mike: 10:27

So what would you say were the roadblocks you did encounter in kind of learning to not work together but develop that shared vision together as y’all went forth?

Shery: 10:37

You know, our roadblocks really were external to Kelly and to me. They were external to our organizations. Actually, you know, you certainly had those people who were afraid and change is always hard, or the possibility of change is always hard and change is always hard, or the possibility of change is always hard. Our roadblocks came from the people that we were attempting to partner with and those that felt like that we were creating competition, even though we were there saying, as Kelly and I did in our first meeting, saying let’s do this together, let’s create something that will benefit the community, that will raise the quality of care in our community, the access to care in our community, and, at the same time, really could lower costs. So let’s do this together. And we went to the hospitals, we went to the facilities and we went to the networks of those facilities, the payer networks of those facilities. That would be probably the first roadblock that we hit along the way, and there certainly were others and plenty of them, but those became some of our most creative roadblocks.

Jason: 11:52

I see Kelly smiling and yeah, as you guys encountered those particular barriers, the other provider-type networks. Looking back, what would you say was sort of your approach, going in that maybe now that you’re looking back on how those stories unfolded or didn’t unfold like you anticipated what would have been a different approach, do you think if a difference could have been made with a different approach that maybe at the time did not resonate with those particular provider networks?

Kelly: 12:24

Well, you know, we’ve had a lot of time to reflect now and I think about it a lot because I’m in a situation now, from the other perspective, where I’m just watching the same thing play out in a different market, essentially, just watching the same thing play out in a different market, essentially and I think we were trying very hard to be collaborative and to be respectful and to try to bring the existing networks along and not be intimidating or, you know, aggressive.

Kelly: 12:58

I think that was fine, because I think that’s who Sherry and I are, that’s how we approach the work that we do. If we had to do it over again, we could have been more aggressive, and what I mean by that is we weren’t going to change their positions. Right, we had some big players with a lot of money in different situations you know, different situations than what we were in but we had a really strong hand to play. I think we probably could have gone into the market in a more aggressive way. I don’t think the reaction could have been any stronger than what it was. So, yeah, that’s my thought.

Shery: 13:42

Yeah, I agree with that, Kelly, and I think with how we approached the hospitals and how we approached the networks. We were very open. We started very early on in the process to tell them here’s what we’re planning to do. We want you to be a part of this. I don’t know that I would do that a whole lot differently, because we did make every attempt to try to include them and bring them in. There are some other places within our partnerships that we did do. Then I would probably choose different partners or, you know, look for different collaborators than what we had. But from the kickoff of what we did, I’m not sure it would have changed a whole lot. I think we did that well, kelly, I did too. Yeah.

Mike: 14:40

So can we go? Kelly made the comment a minute ago about independent practices, independent providers in the market and sort of a passion for that. How has that environment changed over time? What are the kind of key threats that have come at that and what do you think is the you know? What are the solutions? What’s the future look like for that?

Kelly: 15:01

Yeah, it’s a great question. You know, as I said, I started my career in supporting independent physician groups and, you know, grew up in my dad’s practice, which was an independent group, and then spent 27 years in corporate health care. And what I see happening, and I remember the decision to leave a private practice environment and take a role in a health system for the first time and it was very intentional because even 30 years ago the physician practices were being purchased there were 30 years ago. There were very few left already at that point in the area that I lived in in Southwest Michigan, so it was very intentional to try to understand this other healthcare sector that I really hadn’t been very involved in. And what I’ve seen just continue to grow is the financial drivers around payer contracting and reimbursement just getting harder and harder. It was there 30 years ago and it’s harder. It’s even harder today. The financial investments that it takes for independent physicians to stay in practice with purchasing electronic medical records and you know, having that whole infrastructure to support their practice is is difficult for many to be able to sustain and the margins are so narrow for them that it you know, the return on investment just is not there for them. And so what I see happening is that just continuing to get harder and harder and harder.

Kelly: 16:49

A few years ago in Indiana, you know, and it’s still this way today across the country, the size of the organization and the number of physicians you have is how you get leverage in payer contracting. There is no, they say, value, value-based contracting. But your cost of care, your quality of care, delivery, is not included in the payer contracting process. It doesn’t matter. And so you know, insurance companies today are still 100% tailoring contracting to meet the big systems, even if they’re, you know, paying them 300% or 400% of Medicare and they’re willing to do that really at and will pay an independent group, like the ones that Sherry and I supported there, below Medicare rates. And when you bring that to their attention, it doesn’t matter, it doesn’t matter.

Kelly: 17:53

So you know what I, what I hear a lot, is. You know, value based care is grown. It’s, I think, it’s somewhat stagnating right now. It’s still there. There’s a lot of value-based care opportunities contracting-wise, but it is not yet the driver and until that happens, you know, I think it’s the system itself, the reimbursement system and the payer contracting system is. It disincentivizes independent physicians and that is just getting harder and harder.

Mike: 18:24

So would your answer to that question be the same for independent primary care versus independent specialty? It seems to be a bit different in our world Like it’s a good time to be primary care where we are, you know, farther in the southeast it’s more of an emerging market than it is maybe a fully developed one. Be primary care when we are. Farther in the Southeast it’s more of an emerging market than it is maybe a fully developed one like you are. So it feels like it’s drifting into its heyday, whereas there’s a lot of cobwebs on the surgical specialty with an ASC hunk of the world very stuck in fee-for-service kind of spiral. Fast forward me and y’all’s market to what that looks like. Is it still, you know? Is it a good day to be a primary care in a more mature market like that?

Kelly: 19:11

I mean the incentives for primary care physicians today, this whole emerging and rapidly growing Medicare Advantage. You know, insurance population is where they have opportunities. It’s where primary care has opportunities to generate additional income. So it is making a big difference and that’s why you see all kinds of startups getting into that business and partnering with independent primary care groups to help them build the infrastructure to be successful in that environment.

Kelly: 19:45

You are disincentivized in that model having specialists. They only hurt you, right? They add cost and that kind of thing. So, yes, I think so it is, but I’m not sure it’s enough, quite frankly, because without, without, you know, the startup companies that you know will provide the population health infrastructure and you know, can do the aggressive, you know, pair contracting side of it. They take the majority of the income. The clinicians still, you know, benefit from that, but it’s, yeah, it’s, it’s tough. And then on the specialty side, benefit from that, but it’s, yeah, it’s tough. And then on the specialty side and I don’t think it’s changed a lot in the last couple of years you know the hospitals are replacing the specialists with their own employed, and so that’s, you know, that’s, that is the challenge on that side of it. But, yes, there is some incentive for primary care Currently. I’m just not sure it’s enough.

Julia: 20:43

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Jason: 21:16

I kind of want to pivot. I know we’ve talked about payer mechanisms, payer reimbursement all day and the impact it’s got Kind of shifting to more recent headlines, I guess you could say and disruptors that you see not just on the retail side, but AI. Everybody’s reading everything about the impact of AI. We’ve interviewed some in the care management space as well and it’s pretty interesting to hear where they see things going. What do you guys see in particular in the independent practice side, where maybe something like AI or any form of automation and technology could have an impact on the practice for an independent practice?

Shery: 21:56

AI covers. It’s such a broad category. It’s such a broad topic and the first thing that I think of when I think of AI in a medical practice is a patient showing up with their AI generated. Here’s what I learned about my diagnosis. So, doctor, here’s how you’re supposed to treat me. I think there is certainly going to be more of that kind of thing because as it gets easier to access that information and come in with it. But certainly a caution to all of us healthcare consumers be careful. We know that those mistakes exist within AI and that’s not something that we’re going to want to go in and tell the physician how to practice medicine.

Shery: 22:45

I think the practices have some opportunity with AI and how they use it and can capture perhaps certainly spitting out information about a patient’s diagnosis and treatment and those sorts of things and what they can do with it. It could be very beneficial for the treatment of patients and the aftercare and those sorts of things with the patients In terms of how to manage within the practice itself. Are there ways that we could use AI to determine how the payers are paying us? Are we getting paid what we’re supposed to get paid? What are the clawbacks doing that are happening from the payers and can AI help us to be more efficient and better at determining that sort of thing, which could generate millions of dollars for a practice of what the health plans actually underpay them. So I think that’s a really opportunity in that arena to gather data and information and help to benefit the practices through AI.

Kelly: 24:06

Yeah, I agree, sherry and I had a chance to listen to a radiologist speak to some of the AI functionality in that particular specialty and it’s phenomenal. And there are some specialties that I don’t know. I mean they’re getting really really hard to recruit. You know any of the internal medicine subspecialties rheumatology, endocrinology, really any of them. And so if there’s any portions of that that, can you know? Ai can make a difference just reading images. You know that’s helpful, that for radiology specifically, that’s becoming pretty advanced. It’ll never take the place of a person. They were careful to you know, call that out.

Kelly: 25:02

But I think there’s lots of opportunities on the non-clinical side. So much opportunity for expense reduction. You know what I’m hearing right now, like in the space of health information management automating. There’s a lot of it that’s already been automated, but with AI even more. And so there are a lot of healthcare companies looking at how they may be able to completely eliminate or outsource HIM. Eliminate or outsource HIM, that’s one area. Revenue cycle there’s a lot of automation and payment posting and things like that already. But Epic, for example, is working on building in more AI into its software. So there’s going to be a lot of efficiencies gained and may help reduce overhead in a lot of the administrative areas.

Mike: 25:53

Can I go back, kelly? You know as a lot of these sort of the wave of change as it relates to physicians in general, independent physicians and the alternatives that they have in markets have come at you now sitting back in the seat of hospital administration. How does that make you think differently now? Because you go back several years ago there was either employment or there was independence. Now there is value-based, enabler-tied independence. There’s corporate medicine quote-unquote independence there’s so many other flavors of that. Now. Medicine in quote unquote independence, there’s so many other flavors of that. Now. How does that make you have to think differently now as you look at your not employed but in the morass around you market?

Kelly: 26:40

Yeah, I mean I think the addition of private equity into supporting independent physicians does bring a different dynamic, but not necessarily a negative one, and I think that’s unfortunately. I think there’s a belief that with that evolution the focus on the cost of care will go up for those clinicians, and I don’t. I haven’t seen that as I haven’t read evidence of that, and I do look for that because I hear it a lot. Cms actually did some work on that and there is no evidence that that’s really the case. But now that I’ve been removed from the market that Sherry and I were in and I’m in where I’m at, I feel like it’s not any different, right, it’s the same. It is the same as it was there and really is in lots of places, most places across the country is it really is still health systems versus independent, whether the independents are by private equity.

Kelly: 27:51

The Minnesota market has a lot of very large independent specialist groups that are private equity backed and they pose quite a challenge for the health systems. They do and in the market I’m in right now there’s actually a fair number of independents left, one in particular in right in my immediate market. That is a challenge for the health systems and you know, I feel really compelled to support them. So, yeah, I think back 30 years and I think about where things are at today and, sadly, not a lot has changed. I mean, you still really have the choice of independent and if you’re independent, you’ve got a few other levers to pull, like private equity and Medicare Advantage. You know contracting opportunities, which is a great way to bring in some, you know, additional income but I’m not sure that.

Shery: 29:02

Sadly, you know, a lot’s changed that way and Kelly’s view of independence, of being able to lower the cost of health care overall for the health system by using what already exists in the market with these high-quality providers and you don’t, as the health plan, have the cost of hiring them yourselves but then partner and collaborate with them.

Shery: 29:29

In our market in Indiana that’s not the case.

Shery: 29:35

The hospitals view it that as if you are not working for us, then you’re working against us, and if you do not become employed by us, we will employ physicians, no matter how much this duplicates what already exists in the market, because we want to control that entire system and throughput of the services, whereas these physicians had historically or since the beginning of healthcare time in South Bend, had these two hospital systems that were the same physician groups that serviced both, and as the competition at the hospital levels grew, the hospitals felt like they had to own everything and so it’s a different.

Shery: 30:33

I think it’s still market by market as to what that looks like, and the collaboration that Kelly is talking about is absolutely right on target. There’s a place at the table for all of us place at the table for all of us. But the health system needs that vision and those eyes to see how much they can save by using some of that existing. And then they fill in the gaps in the areas where some of those harder to recruit services say, you know, urology might be a difficult one to recruit, for it is across the nation. Perhaps they would look there that kind of thing where the groups themselves, the independent groups themselves, are struggling more. So we’d like to see that more of what Kelly’s talking about go in through the rest of the US. I think that’s missing somewhat, certainly in our north central Indiana area.

Mike: 31:37

Sherry blunt, assessment of the previous market. The freedom of retirement right you get to just say it the way you feel it.

Shery: 31:47

Beautiful thing.

Mike: 31:50

But let me flip that discussion around through the eyes of the employer. How have you seen that evolve over time, sherry, like what you know? Obviously, the availability of good utilization data and the kind of interactivity of that is much more available. But go back for both of y’all, go back 15, 20 years ago. How have their requests, needs, models changed and how you wanted to interact with them from a provider perspective?

Shery: 32:19

I think the employer’s perspective has not changed all that much and they’re looking for low cost, high quality care.

Shery: 32:31

They want to make sure, they want to ensure that their employees are well cared for, and what we are seeing and experiencing now in many markets is the insurer, the payer, is now saying yes, of course, this practice is in network and your employees have access to this broad network of providers.

Shery: 32:59

However, when the employee goes to access those services, a physician within a larger group may not be included in that they may not be covered in that network, and then, or a location of that same practice may not be covered in that payer’s network. And so the employers are being sold these broad networks that can service their employees throughout a region and yet when it becomes operational within those patients seeking care, it’s not available. It’s not available and it’s becoming more and more difficult. It’s starting to look to me like much like the HMO market looked like in the 1990s and where you really had to be very involved with your healthcare to understand what it was that you were getting. You can’t just pick up your provider book and say I’m going to go over here to see whether it’s this primary care or this cardiologist, because that particular one may not be, even though their entire practice is in.

Mike: 34:18

Kelly thoughts.

Kelly: 34:19

Yeah, no, I was just laughing inside thinking about how much back to the HMO sort of feel as we were in the 90s. I mean it is very much that market today. I feel like you know it happens regularly that a group is in but one or two doctors are out, and so it’s complicated for patients to manage. But yeah, nothing other to add.

Jason: 34:49

All right, like Mike mentioned, we tend to ping pong our questioning back and forth, so I’m once again going to pivot left, this time Kind of backing up. You both have held numerous CEO roles, very successful, different markets, different settings. How, in the past, have you measured yourself as a CEO and or the organization? While as CEO, how did you measure yourself in the organization, on you know as you were moving along to your success? Were there certain metrics, certain you know, as you were moving along, how did you measure yourself?

Shery: 35:25

Yeah, go ahead, sherry. Well, you know, I think they’re the standards. You know you have your financial viability and all the factors that go along with that. You have your physician retention, your employee retention. All of those are those pieces that we all measure, whether it’s in healthcare or in manufacturing, in retail. Those are the basis, those are the standards.

Shery: 36:00

I think where we really get into it and where the fun is is when we break a few eggs.

Shery: 36:10

I think the most successful organizations are those that really step into innovation and they really embrace the idea of change or to try new things, or to perform the old things in a new way, and to take those risks, to step out and say let’s try this innovation. Some of it’s going to work, some of it is absolutely not going to work, but these are the things that really help to move an organization forward. And I’ve had the fortune, I’ve had the opportunity to do some of those things in my career here in the South Bend area and they were exciting and they were fun. Some worked, some didn’t, but at the end of the day, more worked than those that did not and you see it in the result of those typical metrics that you look, you have the financial viability, you have the employee satisfaction and the physician satisfaction and the retention of those things that come along with doing the things that are exciting. But again you have to break a few eggs.

Kelly: 37:28

I love the way you described that, sherry, breaking eggs. That’s good, I agree. I mean there are some standard measures right that we all look at and I’m accountable to a board for, you know, to be successful, the typical sort of financial measures and patient experience measures and things like that I’m also a big believer in. For me, the most important measure for me is around how my employees feel. So if they, you know, if you have a team that feels valued and engaged, everything else just gets better. Right, your financials are better, and there’s lots of studies that have been done to kind of show that. So I spend a lot of time on that and on culture, and if you know I’m successful there. To me that’s a huge win.

Kelly: 38:12

But so much of the work today is to remain viable.

Kelly: 38:17

You know we live in a world where big health systems are losing money and struggling to stay financially viable, and so you know, a large part of the work is what Sherry did is said so well is about how do we be innovative, how do we do something different to help keep the organization viable and, you know, be a value to the community and to your patients. So it’s, you know, you’ve got to be willing to think a little bit different and you know I’m not one to get caught up in market share and sort of fighting over that kind of thing. So I keep my team really focused around what is our value proposition. You know what can we bring to the community that not only will take care of their sort of, you know, basic primary care needs and emergency needs and things like that, but you know what can we also do in terms of service and support that will help us ensure we’re going to be here in 10 years or 15 years. So so much of the work is around that.

Kelly: 39:26

So I do feel a fair amount of you know my role today and my energy and time is the strategic lens of you know what is the marketplace need? What are we providing today? What do we need to do different to ensure that financial viability and, you know, most importantly, be a value right to the community?

Jason: 39:48

So I think that’s a fair amount of the work Fantastic. That kind of dovetails nicely into our conversation I know that we’ll have tomorrow. We kind of dive deep into y’all’s perspective in terms of leadership. It was a great conversation. I appreciate you guys giving us some perspective from the CEO seat. I know we’re going to have another deep dive conversation into the book Two Rivers that you guys released just last year, right March or April of 23,. Is that right Fantastic? And we’ll have a couple of new SHPers well, not new to SHP, but new interviewers on for that podcast and we’ll record that tomorrow. But appreciate you guys doing our podcast today. Thanks again.

Kelly: 40:28

Thank you.

Aaron: 40:29

Thank you so much you guys doing our podcast today. Thanks again, Thank you. Thank you so much. This has been an episode of Beyond the Stethoscope Vital Conversations with SHP. If you enjoyed this podcast, please be sure to rate and share it with your friends. It sure helps the show.

Jason: 40:43

Production and editing by Nayla Wiebe. Social media by Jeremy Miller.

Aaron: 40:48

And our co-hosts are me, aaron C Higgins and Jason Crosby. Our show producers are Mike Scribner and John Crew.

Jason: 40:56

Thank you for listening and we’ll see you next time. So our most important question I need you to really focus, get ready. When Mike and I first met you guys, we had a lot of fun of the you know two southern guys coming up north. We were scared how much snow and all that. So I gotta ask you’re thirsty? You’re going into a restaurant. All they have are soft drinks. Are you ordering soda or pop? I’m ordering coke southerner right there okay pop michigan.

Kelly: 41:32

That’s all we called it in Detroit, yeah for sure.

Jason: 41:37

Yeah, Aaron is our resident Northerner, since Trina is not with us, who are Minnesota and so yeah, yeah. Minnesota.