Episode 88 – 20 Years of Fulcrum Strategies

Recap of Episode 88 of the FLATLINING Podcast

This week Ron and Matthew share in the celebration of Fulcrum Strategies’ twenty years of advocating for providers. They discussed why Ron left the health insurance industry after nearly two decades and started Fulcrum. They also talked about what changes he has seen and the challenges he experienced running his own medical consulting business.

This week was the launch of the FLATLINING podcast on video, you can now watch our co-hosts on our YouTube channel and enjoy this new aspect that is sure to add a new dynamic to the show.

Matthew asked Ron how and why he started Fulcrum. Ron explained that it was two things that spurred him on. He said the first thing was the frustration of working for somebody else, having someone above you make decisions that he did not agree with, or thought were not the right thing to do but had to go along with.  He said he would complain to a close friend about his challenges at work and this friend finally said that I needed to either stop complaining or start my own business. He said to me, “You’re not going to be happy unless you’re the one sort of calling the shots so either do it or stop complaining.” Ron shared that he really took that counsel to heart.

The other thing, he said, was his deep-seated concern about what the insurance industry was doing to the independent practice of medicine.  Ron said there are plenty of things wrong with the U.S. Healthcare delivery system, things like medical debt, the uninsured, or the cost, but he said we forget the incredible things we do well in our system. The quality of our health care is second to none, he said, and our innovation leads the world in new technologies, new drugs, therapies, and more. Most importantly he said, “To a large degree [the fact] that your doctor is working for you and what’s in your best interest” is the hallmark of the independent practice of medicine.  He explained that the combination of wanting to be his own boss and do his part to help independent physicians succeed became the impetus to start Fulcrum Strategies.

Fulcrum has one employee that has been with him for over fifteen years with others who have been with Ron for about a decade or so. Getting started in North Carolina, the company has worked in about 30 different states and currently is operating in twenty states. Ron has spoken at countless trade shows and medical associations. His unique perspective has helped thousands of physicians, and their practices succeed.

Matthew asked Ron what the biggest challenge was when he left the payer world. He said getting started as a business owner was the challenge, “I worked for large corporations my whole life and you take for granted things like somebody is going to do accounting, somebody is going to run payroll and you got to get benefits, all the things small businesses have to do, that was the most challenging.” He concluded that finding clients and conducting negotiations was not too difficult, it was learning how to run a business, something he never had to do before was the primary challenge.

Matthew asked Ron what the top three events or issues were in the last twenty years of leading Fulcrum Strategies. He said the Affordable Care Act (ACA), payer backlash to Fulcrum’s professional representation of providers, and the No Surprises Act (NSA).  The ACA posed a lot of unknowns as to what it was going to do to physicians, he said. Fulcrum had been established for about six years when the ACA became law, he explained, so the challenge was just trying to adjust to what it was going to do. The second challenge came when two payers tried to blackball Fulcrum by not talking to them, he said. The payers did not like the fact that Fulcrum was representing providers in contract negotiations. Cigna still does not talk to Fulcrum, but, he said, United Healthcare determined after one year that it wasn’t in their best interest to continue this tactic. More recently, trying to navigate the NSA has been the latest challenge.

Matthew circled back to ask Ron to expand on the ACA and asked if he thought it was a good or bad thing. Ron said it’s a bit of a mix, explaining that it depends on who you talk to and where they are in the healthcare delivery system. For some patient populations it is a huge benefit, he said. He shared a story of someone he knew who could not afford coverage and received a bad diagnosis, but due to the pre-existing condition exemption language in the ACA, she was able to get coverage. “For a lot of physicians, it’s been a positive because it reduced the number of people they would see without insurance or increased the number of people that could come to see them,” he said. Ron further explained that the ACA did not lower the cost of healthcare, it added to the federal deficit, and he said, we have not seen the long-term impact of it on the economy.

The NSA has been good for patients Matthew said since they don’t get surprise billing when visiting an in-network facility with out-of-network physicians.  But not every entity within the law is following all the rules he said. Ron expanded and said that he is not a big fan of a lot of government involvement in solving issues, mainly due to the government’s inefficiencies. But in this case, he thinks the NSA is a good law as written, and pointed to the implementation of the law as the problem because it is not being executed as written. The result could affect provider groups that support the things you need in a hospital, like radiologists, emergency room medical personnel, or anesthesiologists he explained. To stay viable, these practices may need to reduce staff, if that happens it directly impacts patients by increasing wait times for scheduled surgeries or emergency room wait times, he said.

Matthew asked Ron for a quick update on what is going on with the NSA lawsuit and the Texas Medical Association. Ron provided his take on the current waiting game but said he hopes that since the Centers for Medicare and Medicaid Services indicated that the payers had a role in not following the NSA procedures, someone might decide to take on the payers in a lawsuit. That he said might get their attention and convince them to follow the law as written. Ron and Matthew speculated on the impact of the November election, agreeing that if Trump ends up in the White House, you may see some positive results from the NSA. The NSA was passed during the Trump administration.

Our team continued the legal discussion with Ron bringing up the U.S. Dept. of Justice’s investigation into United Healthcare (UHC) for antitrust violations. Explaining that insurance companies were exempt from federal anti-trust laws for many years under the McCarran-Ferguson Act, but that has now been watered down some he said. He explained that insurance is often highly concentrated in a market, so when your practice gets over 50% of its patients from one insurance company, you are not able to leave that carrier. If, Ron said, instead of only four big insurance companies in your market, there were 20 smaller ones, then you would have more competition. The result of this could benefit providers with payers competing for their business, but it might also increase the quality of services to enrollees, much like the introduction of streaming services did to the cable companies, he said. We won’t know what the market will do exactly until this takes place, he said.

Matthew asked Ron what he was hopeful for or what did he expect to see in the next twenty years. Ron said that he is hopeful that the people in healthcare, and he meant caregivers and administrators alike, will be able to solve some of the problems we are facing. These are dedicated and caring people he said. He fears that the system will have to break before it gets better.  The reason for this he said, is that the consumer, i.e. the patient, hasn’t felt what the doctors and providers have felt. The medical community, he said, has been “covering” for the shortfalls in the system. It’s going to take large numbers of physicians saying they can’t take Medicaid or Medicare anymore, or staff shortages creating long wait times for surgery or in emergency rooms that will get people up in arms, he said. When the consumer feels that, then we are likely to see changes in the system he said.  

Next week, the Flatlining Podcast team will talk with Lou Tharpe, Executive Director of the Global Healthy Living Foundation, a non-profit dedicated to improving the quality of life for those with chronic illnesses.