The Last Word (for now . . .)

Wednesday, December 20, 2017 | Larry Sobal

The Last Word (for now . . .)

This represents my 109th blog post for MedAxiom, a number which is significant only to illustrate that this crazy health care industry does not lack for content to write about. For those of you who are not networked as part of the MedAxiom cardiovascular community, I announced last week that I am leaving MedAxiom to be the new Vice President of Service Lines for the 23 hospitals of Ascension Wisconsin. Thus, this is my last MedAxiom blog posting, although you can expect me to show up from time to time in cyberspace to share my perspective.

For starters, I want to thank MedAxiom for allowing me to rant, refute, reflect and any other “r” verbs that are relevant—you get the point—on a weekly basis. And of course I want to thank all of you who have read and responded, both positively and negatively, to these posts. Your feedback and comments were very much appreciated. And, though this blog is obviously public, I have sometimes thought of it as a way to express my “private” thoughts on the health care industry; it humbles me that some of you liked what I had to say and are honored that you may have found some of my thoughts helpful.

Anyway, I spent the weekend going back and reading all my blog posts, and years of newspaper columns on health care I wrote prior to joining MedAxiom. I arrived at four pieces of closing advice I would like to share, if you’ll allow me one last opportunity.

#1 – Get your leadership team in alignment. I think the best way to do that, and one that we use for our own strategic planning at MedAxiom, is to answer the Six Critical Questions defined by Patrick Lencioni in his book The Advantage. I can’t think of any leadership team I have been a part of, or have consulted with, that would not benefit from this exercise. To give you an “easy button” to do this, simply watch this short video of Mr. Lencioni explaining the process. Some practical advice: the first time your leadership team does this exercise, I recommend you plan for about eight hours over two days.

I have no vested interest in promoting his books, but if you want to really improve your team and organization, I suggest you read the following Lencioni books, in this particular order:

You can probably read all these in a weekend and may also want to consider adding Death by Meeting somewhere down the road as we have all spent too many hours in ineffective meetings.

This may be health care heresy, but I want to start a national movement to stop using the phrase “volume to value.”

#2 – This may be health care heresy, but I want to start a national movement to stop using the phrase “volume to value.” I admit I am guilty of using it myself, but feel that it is at best, vague, and at worst, wrong—it should be erased from our dialogue for a number of reasons that include:

  • Can anyone tell me what “value” is in health care? Exactly. If we can’t agree on a definition and measurement, why are we so anxious to go there?
  • Do we really agree that volume is bad? Not if it represents the right treatment for a patient, and that is what happens most of the time. Perhaps the best we can say about volume is that sometimes less is more, and sometimes more is more.

I think a better rallying cry would be something that moves us from an era of unwarranted variation to proven validity. As a patient I want treatment that is valid, not just from a clinical perspective, but also a financial one. I also want my caregiver to engage me in a thorough discussion of my options, including the risks and benefits, so that I personally validate what is going to be done to me.

We could change the industry rallying cry from “volume to value” to “variation to validity.” It may not sound as sexy, but I want us to all to align on something that is clearer and more accurate. If not variation to validity, how about “inefficiency to efficacy” . . . ? If you can come up with something better, I would love to hear from you.

#3 – It’s been percolating for a while and it’s starting to boil over. What I’m referring to is physician frustration, particularly with administrative leadership. I’ve written a lot about physician alignment (plus burnout and administrative burdens) and am concerned that “alignment” (or lack of) may be too passive to describe the current situation. And to be fair, administrators are often just as frustrated with their physicians in many organizations.

While every organization has its own unique circumstances, the misalignment is often rooted in a lack of candid and respectful conversations about what each expects of the other and, sometimes, maintains a silo structure that seemingly guarantees turf battles and no feeling of interdependence. Too often I have come into an organization where people have allowed an issue (or set of issues) to fester to the point where I’m not certain it’s repairable, and that’s really unfortunate. The saddest part is that sometimes the other side doesn’t even know how fractured the relationship has become.

What advice do I have? There needs to be a mutual willingness to sit down, have honest conversations, and build a relationship. Leave the physician compensation and incentive plans at home. You’ll have to spend the time together to earn trust, reach consensus, and have the grit to make some hard decisions with each side reflecting on what must be changed to move forward. What if you undertook answering the six critical questions noted in #1 above? What do you think the outcome would be?

#4 – Consider this one a rant, but an impassioned one. I’ve been onsite at a lot of health care organizations and there is one problem that is consistent for all of them. Can you guess what it is? I’ve covered the topic no less than 15 times in one way or another in my MedAxiom blog posts.

My plea is to fix the financial issues you already know you have.

Whether it is cleaning up your dysfunctional revenue cycle, optimizing your cath lab and getting onboard with the movement to transradial access and same-day discharge, utilizing your clinical team to the top of their licenses (especially your Advanced Practice Providers), finally addressing your poor access and clinic flow, or any number of opportunities I’ve implored you to resolve, there has never been a better time to clean up your financial act. Margins are only going to get tighter, and you can’t afford to pass on what can be some significant cost reduction or revenue enhancement.

So, that’s what’s on my mind, at least at this point in time. Have a great holiday season, thank you for reading, and when the health care industry starts to get you down, consider doing what I do: THINK SNOW!


llustration: Lee Sauer


Larry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and  health systems. His weekly blog post comes out on Thursdays and can be accessed at


Larry on the frozen Wisconsin lake that is his backyard 

About the Author
Larry Sobal

Larry Sobal, MBA, MHA, is CEO of a yet-to-be-named cardiology practice which is transitioning from employment to an independent physician group effective January 1, 2019. He has a 37-year background as a senior executive in physician practices, consulting, medical group leadership, hospital leadership and health insurance.

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