Latest / The Operator | Healthcare Business / Who Gets the First Vote? Clinical Judgment, Coverage, and Learned Helplessness

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Who Gets the First Vote? Clinical Judgment, Coverage, and Learned Helplessness · The Operator | Healthcare Business

• 0:05
  All right,
• 0:06
  we spend years training clinicians to make
• 0:08
  good clinical decisions.
• 0:11
  Then they get into practice and another
• 0:13
  voice enters the room.
• 0:15
  What will insurance cover?
• 0:16
  And somewhere along the way,
• 0:17
  that question can start getting asked
• 0:20
  before,
• 0:21
  what does this patient actually need?
• 0:23
  Larry's latest article said that this
• 0:26
  isn't just a payer problem.
• 0:28
  Operators maybe have their hands dirty.
• 0:30
  Maybe they helped build it.
• 0:32
  So let's start by asking this.
• 0:34
  Larry, you start by saying, you know,
• 0:36
  new clinicians are arriving less
• 0:37
  clinically ready than they used to.
• 0:39
  You're careful to say it's not an
• 0:40
  indictment on dental education.
• 0:43
  So then what's sort of changed?
• 0:46
  Yeah, I think, you know,
• 0:48
  Jimmy,
• 0:49
  this is a little bit of a hangover
• 0:51
  from COVID or that actually occurred
• 0:53
  during COVID,
• 0:54
  but fundamentally two things changed and
• 0:56
  only really one of them ever gets talked
• 0:58
  about.
• 1:00
  The structure changed, you know,
• 1:01
  fewer patient volume hours,
• 1:05
  were necessary to graduate.
• 1:06
  So that means you get less procedural
• 1:08
  diversity and you get maybe a little bit
• 1:11
  of earlier specialization is the other
• 1:14
  factor.
• 1:15
  So less reps effectively.
• 1:17
  So they come out,
• 1:18
  the new grad and this traverses
• 1:20
  everything, right?
• 1:21
  They come out technically capable,
• 1:23
  but short on repetition.
• 1:25
  And when you have short on repetition,
• 1:27
  you have short on confidence.
• 1:29
  And really confidence you can only get
• 1:31
  through volume.
• 1:32
  So it becomes a cycle.
• 1:34
  So you can't blame the student.
• 1:37
  Blaming the student is like blaming the
• 1:38
  teenager, you know,
• 1:40
  for being a shaky parallel parker.
• 1:42
  If you had a parallel park when you
• 1:44
  were driving, right?
• 1:45
  Yeah.
• 1:46
  The second thing that changed is nothing.
• 1:48
  And that's the problem.
• 1:49
  We didn't change.
• 1:50
  We still hire like it's nineteen ninety
• 1:52
  five.
• 1:52
  Right.
• 1:53
  Week one.
• 1:53
  Here's your schedule.
• 1:55
  Here's the production target.
• 1:57
  We built our expectations around a
• 1:59
  graduate graduation.
• 2:01
  effectively stopped existing years ago.
• 2:03
  And so, as I said,
• 2:05
  I've seen the same thing happen in
• 2:07
  physical therapy for four years.
• 2:08
  Every clinical profession that compresses
• 2:11
  hands-on hours produces the same graduate,
• 2:15
  smart, credentialed, but under repetition,
• 2:18
  therefore lack of clinical confidence.
• 2:21
  Dentistry isn't anything special.
• 2:23
  It's just sort of late to admitting it.
• 2:26
  Yeah, yeah.
• 2:28
  You've said these clinicians enter
• 2:29
  organizations that want them to also do
• 2:32
  this, be productive quickly.
• 2:34
  This feels like putting dysfunction on
• 2:36
  instability.
• 2:37
  How are most platforms trying to close
• 2:39
  that gap?
• 2:40
  Like, you know,
• 2:41
  what's wrong besides the obvious on that
• 2:42
  approach?
• 2:43
  Yeah,
• 2:44
  so the implications of high clinical
• 2:46
  shortages, less therapists, less dentists,
• 2:49
  less doctors,
• 2:50
  is that you become very efficient in
• 2:52
  onboarding.
• 2:53
  You give them a checklist and a production
• 2:55
  target.
• 2:55
  That's sort of the industry's answer.
• 2:58
  And I wish I was exaggerating.
• 3:02
  You get orientation,
• 3:03
  maybe a tour of the break room,
• 3:04
  maybe some shadowing,
• 3:06
  but the idea is go produce.
• 3:08
  You've got a salary.
• 3:09
  We're paying you higher than we ever have.
• 3:12
  Go produce.
• 3:12
  That's not development.
• 3:14
  That's hope with a paperwork, right?
• 3:17
  What's wrong with it is that it treats
• 3:19
  clinical readiness, which is a problem.
• 3:22
  It treats it as a scheduling problem.
• 3:25
  And so the dental company of the future,
• 3:26
  the physical therapy company of the future
• 3:28
  builds an actual infrastructure.
• 3:31
  Mentorship,
• 3:32
  simulation was real common in dentistry
• 3:36
  now, structured case review,
• 3:37
  deliberate practice.
• 3:39
  That's the big buzzword.
• 3:40
  And yes,
• 3:41
  overhead does rise before productivity
• 3:44
  shows up.
• 3:44
  So you have to think of human capital
• 3:48
  as an investment,
• 3:49
  like you were buying a piece of equipment
• 3:51
  or a modality in physical therapy
• 3:53
  language.
• 3:55
  you know, I won't pretend it's otherwise.
• 3:57
  And so human capital is an investment and
• 4:00
  it's cap X.
• 4:02
  And you have to understand that you're
• 4:04
  going to get less productivity and you
• 4:06
  have to model it that way.
• 4:08
  But the multiplier on the other side of
• 4:10
  this retention engagement,
• 4:12
  better procedure mix, better referrals,
• 4:14
  you know, that's unambiguous.
• 4:16
  It's very objective.
• 4:18
  And the benefit is to the company
• 4:20
  downstream.
• 4:21
  Yeah.
• 4:21
  Yeah.
• 4:22
  Well, you've done something about this.
• 4:23
  At DCA,
• 4:24
  you've actually built something called
• 4:26
  Ascend,
• 4:26
  which you described as almost like a
• 4:29
  residency for general dentists,
• 4:31
  for general practitioners.
• 4:33
  What are you trying to create that maybe
• 4:35
  an ordinary onboarding or mentorship
• 4:38
  doesn't?
• 4:39
  Yeah.
• 4:39
  So I did this same playbook in physical
• 4:42
  therapy where we had the initial
• 4:43
  certification programs.
• 4:45
  These are best thought of as not short
• 4:47
  term weekend courses, but longer term.
• 4:50
  Then those became residencies.
• 4:51
  Physical therapy became accredited
• 4:53
  residencies.
• 4:53
  We have those in dentistry as well,
• 4:56
  but they're a lot more profound and a
• 4:58
  lot more accreditation risk.
• 5:00
  And so what we do now is develop
• 5:02
  a curriculum.
• 5:03
  And if you think about it,
• 5:05
  ordinary mentorship depends on entirely
• 5:08
  where the dentist or the therapist lands,
• 5:11
  right?
• 5:11
  Maybe there's a great senior therapist or
• 5:13
  doctor there.
• 5:14
  And if that happens, you flourish.
• 5:16
  So what Ascend is,
• 5:17
  is really a certification pathway.
• 5:19
  It's advanced training for a general
• 5:21
  dentist
• 5:22
  to get upskilled in endodontics,
• 5:25
  orthodontics, restorative.
• 5:28
  Medicine decided a century ago that a
• 5:31
  residency is how you turn a graduate into
• 5:33
  a physician.
• 5:35
  And dentistry sort of is winging it,
• 5:37
  for lack of a better term.
• 5:41
  It's interesting.
• 5:43
  The Army taught me this well before
• 5:45
  dentistry did.
• 5:46
  Nobody in the military hands you a mission
• 5:48
  without a training pipeline behind it.
• 5:51
  But in dentistry, we have a mission.
• 5:53
  But we basically say to the dentist,
• 5:56
  figure it out.
• 5:58
  And getting upskilled is expensive.
• 6:01
  And you've already got somebody who's got
• 6:03
  a lot of student debt.
• 6:05
  The good news is like in a general
• 6:07
  GP, a general practitioner in dentistry,
• 6:08
  a general dentist has a very liberal
• 6:11
  practice act.
• 6:13
  In healthcare,
• 6:13
  I can never get my primary care docs
• 6:16
  to deliver a baby or to do orthopedic
• 6:18
  surgery.
• 6:19
  But in dentistry,
• 6:20
  a general dentist can do orthodontics,
• 6:22
  oral surgery, endodontics, periodontics,
• 6:25
  and can do it rather well.
• 6:27
  Now,
• 6:27
  there's a defined line of what they can't
• 6:30
  do.
• 6:31
  But they can be upskilled.
• 6:32
  And so in order to do that, though,
• 6:33
  you have to have training.
• 6:34
  What is training?
• 6:35
  Training takes investment,
• 6:36
  investment in human capital.
• 6:39
  Again,
• 6:39
  we think of de novos and equipment and
• 6:41
  space and build outs.
• 6:43
  We have to start thinking of our human
• 6:44
  beings under those same investment thesis.
• 6:47
  Yeah.
• 6:48
  Well,
• 6:48
  here comes a sentence that brings somebody
• 6:49
  else back into the room.
• 6:51
  We're training a clinician to let a payer
• 6:53
  make clinical decisions.
• 6:55
  That's serious.
• 6:55
  That's some hot take, right?
• 6:57
  So how does a clinician get trained to
• 6:59
  do that without anyone ever explicitly
• 7:02
  teaching them to do that?
• 7:04
  Yeah,
• 7:04
  so all these things sort of happen by
• 7:06
  default.
• 7:07
  We send a default to what the payer
• 7:09
  does.
• 7:11
  But if you think about it in dentistry,
• 7:13
  it's a little bit worse because the
• 7:16
  dentist will say to a patient, OK,
• 7:18
  go now talk to our treatment coordinator
• 7:21
  who will talk to you about our insurance.
• 7:23
  So we outsource the decision making to
• 7:27
  somebody who's not even a clinician.
• 7:30
  And that's just absolutely wrong,
• 7:32
  you know.
• 7:33
  A plan gets, think about it,
• 7:35
  a plan gets denied in dental or
• 7:37
  healthcare.
• 7:39
  A code gets downgraded.
• 7:41
  Something happens with a write-off.
• 7:43
  And all we tend to do then is
• 7:47
  just kind of default and we train this
• 7:49
  into our system rather than just
• 7:51
  fundamentally understanding that the
• 7:54
  clinician should be having the discussion
• 7:56
  with the patient.
• 7:57
  The payer should be secondary to all that.
• 8:00
  I refer to all this as learned
• 8:02
  helplessness.
• 8:04
  As you remember,
• 8:06
  I've got a degree and master's of applied
• 8:09
  positive psychology from University of
• 8:10
  Pennsylvania where Marty Seligman,
• 8:12
  you know, Angela Duckworth,
• 8:16
  all those luminaries teach.
• 8:18
  And Marty Seligman really was the
• 8:20
  researcher who in the nineteen sixties,
• 8:22
  well before there was optimism,
• 8:25
  defined learn helplessness,
• 8:27
  which is the idea that no matter what
• 8:29
  I do, what I respond to,
• 8:31
  it doesn't impact the outcome.
• 8:34
  And when you can't impact the outcome,
• 8:37
  you learn to be helpless.
• 8:39
  And that's what's effectively happened in
• 8:41
  healthcare.
• 8:41
  A clinician whose judgment keeps getting
• 8:44
  overruled by a portal,
• 8:47
  an insurance portal,
• 8:48
  stop exercising the judgment.
• 8:50
  And so the portal doesn't have to win
• 8:53
  the argument anymore.
• 8:54
  There is no argument.
• 8:56
  In physical therapy,
• 8:56
  this happens a bit as well.
• 8:58
  It's just that our codes are more
• 9:00
  scrunched in.
• 9:02
  They're fewer.
• 9:03
  They're not as diverse and there's not as
• 9:04
  many procedural-driven expensive codes.
• 9:09
  And what happens in dentistry, again,
• 9:11
  is we just sort of outsource all this
• 9:13
  because we learn we shouldn't be doing
• 9:15
  that.
• 9:15
  The reality is those conversations should
• 9:18
  absolutely be happening between the
• 9:20
  clinician and the patient.
• 9:23
  You painted this recognizable scene that I
• 9:26
  think many people in healthcare have
• 9:28
  walked through,
• 9:28
  and maybe you never named it,
• 9:29
  but the clinician knows what the patient
• 9:32
  needs.
• 9:33
  They then open the benefits portal,
• 9:35
  and then all of a sudden,
• 9:35
  without anybody telling them to,
• 9:37
  the treatment plan then bends.
• 9:39
  It shifts.
• 9:40
  What's sort of happening in that moment?
• 9:42
  You've touched on it a little bit,
• 9:43
  but what's going on there?
• 9:45
  Yeah, so the judgment comes first,
• 9:46
  and it's very real, right?
• 9:47
  They see the right answer.
• 9:49
  Years of training are pointing at it.
• 9:52
  Then the portal opens up and the plan
• 9:53
  reshapes itself around the coverage.
• 9:56
  And what does it cover and what does
• 9:57
  it not cover?
• 9:58
  Nobody orders it.
• 9:59
  And here's what makes it dangerous from
• 10:01
  the inside.
• 10:02
  It never feels like surrender.
• 10:03
  It feels like being realistic,
• 10:05
  being practical, being a team player,
• 10:07
  trying to be patient centric,
• 10:09
  understanding what they have and what they
• 10:11
  don't.
• 10:12
  Well, in dental,
• 10:12
  there's not true underwriting and
• 10:14
  insurance.
• 10:15
  And really the conversation has to sort of
• 10:20
  happen between the patient and the
• 10:23
  clinician
• 10:24
  and then you know secondarily to that
• 10:27
  whatever insurance covers whatever
• 10:28
  insurance covers right but it's not just
• 10:30
  generally how it works um and so you
• 10:33
  know no dentist in america has ever
• 10:35
  written surrender to the fee schedule in a
• 10:38
  note the chart says the patient elected
• 10:40
  alternative treatment the language is the
• 10:43
  thing that that that launders the moment
• 10:46
  Now there's a data point in dentistry
• 10:48
  called treatment case acceptance.
• 10:51
  That's the number of patients who accept
• 10:54
  what the treatment case is supposed to do.
• 10:57
  Believe it or not, Jimmy,
• 10:58
  that number hovers between fifty and
• 11:00
  seventy five percent.
• 11:02
  The reason it happens that way is because
• 11:04
  of learned helplessness, in my opinion.
• 11:07
  We never really have the clinician have a
• 11:10
  conversation.
• 11:11
  It goes and it gets outsourced.
• 11:13
  When that conversation gets outsourced,
• 11:16
  that percentage doesn't go up,
• 11:17
  it goes down in my view.
• 11:19
  Now,
• 11:20
  there are a lot of practices that would
• 11:21
  disagree.
• 11:21
  They say,
• 11:22
  I don't want the conversation between the
• 11:23
  dentist and the patient,
• 11:24
  but I don't see it that way because
• 11:26
  I think these are clinical issues and not
• 11:28
  insurance issues.
• 11:30
  Yeah.
• 11:31
  Well,
• 11:31
  from what I know about you is you
• 11:32
  try to not make anything a blame game.
• 11:33
  This is where I think in your article,
• 11:35
  you turn sort of the responsibility or the
• 11:37
  accusation towards ourselves, right?
• 11:39
  This is the only thing we can control.
• 11:40
  You're talking about learned helplessness.
• 11:41
  Well, what can we control?
• 11:43
  In the article, you said, well, listen,
• 11:45
  the operators, you signed off on it.
• 11:48
  Okay, where did we sign?
• 11:49
  So that's probably the big question.
• 11:52
  You know,
• 11:52
  where did we sign on for this?
• 11:54
  When?
• 11:55
  How did that happen?
• 11:58
  Yeah, I would say it's how we train.
• 12:00
  I mean, that's the signature.
• 12:03
  No operator ever wrote a memo handing the
• 12:06
  payer the final word.
• 12:08
  We do something a little bit quieter.
• 12:10
  You know,
• 12:10
  we built a development program to teach
• 12:12
  everything except judgment under coverage
• 12:14
  pressure, right?
• 12:16
  Think about it.
• 12:16
  We should be teaching clinicians judgment
• 12:19
  under cover pressure.
• 12:20
  We don't.
• 12:21
  And then the clinician,
• 12:22
  we accept the bent treatment plan as
• 12:24
  normal because it's, you know,
• 12:26
  very straightforward.
• 12:27
  That's where the billing code that we
• 12:29
  should have.
• 12:30
  You know,
• 12:30
  every cohort we onboard without teaching
• 12:32
  that separation is another, you know,
• 12:35
  is another class where you're learning the
• 12:38
  portal doesn't have the final word.
• 12:42
  And that's what happens.
• 12:43
  So we didn't sign with a pen.
• 12:44
  We signed with an onboarding calendar and
• 12:47
  silence repeated at scale is signature.
• 12:50
  It's called acceptance.
• 12:52
  It's called learned helplessness.
• 12:54
  what we should be teaching is a
• 12:55
  conversation.
• 12:57
  So people say, well,
• 12:58
  it might take a little longer.
• 12:59
  Okay,
• 12:59
  but if it takes you a little longer,
• 13:00
  your treatment case acceptance can go from
• 13:02
  fifty to seventy to one hundred percent or
• 13:04
  ninety percent.
• 13:07
  And, you know,
• 13:07
  patients generally like listening to their
• 13:09
  doctor, you know, generally.
• 13:13
  And it's why we let an intermediary like
• 13:16
  a fee schedule or an insurance portal get
• 13:18
  in the way.
• 13:19
  And we have to fundamentally reverse that,
• 13:22
  in my opinion.
• 13:23
  right well what i also know about you
• 13:25
  is you don't just sort of drop a
• 13:26
  question and say i guess you'll figure it
• 13:27
  out so you your fix is really three
• 13:29
  questions also in the order the order of
• 13:31
  questions does in fact matter and here's
• 13:33
  your three what does the patient need what
• 13:36
  will coverage support how do i have that
• 13:38
  conversation so why those questions why
• 13:42
  does the order matter so much yeah i
• 13:45
  mean the order is the intervention
• 13:48
  Think about that.
• 13:49
  That's the intervention is those three
• 13:50
  things in order.
• 13:51
  What does the patient actually need?
• 13:54
  Unfiltered clinical judgment before
• 13:56
  anybody opens a benefit portal.
• 13:57
  What do they need?
• 13:59
  That's the whole program.
• 14:01
  Sort of then the second question,
• 14:03
  what will coverage support?
• 14:04
  That's a data point.
• 14:06
  I run a business.
• 14:07
  I don't get to pretend that coverage
• 14:08
  doesn't exist.
• 14:09
  I understand that.
• 14:11
  But a data point is not the answer.
• 14:13
  In most groups trained patients,
• 14:15
  those two questions it really only that
• 14:18
  question only which is how the data point
• 14:20
  got promoted to a ceo right so what
• 14:23
  does a clinician need or what the patient
• 14:25
  need what's what does it covers and that
• 14:26
  is has become the data point but where
• 14:28
  to take number three is the third question
• 14:31
  how do i have this conversation so it
• 14:33
  builds trust
• 14:35
  That's not a clinical skill.
• 14:37
  That's a communication skill.
• 14:39
  It's an empathy skill.
• 14:40
  It's positive psychology in the operatory,
• 14:43
  in dentistry anyhow.
• 14:44
  And it's the delivery mechanism for the
• 14:46
  first two.
• 14:47
  The best clinical judgment in the world
• 14:50
  dies in a bad conversation.
• 14:52
  It just does.
• 14:53
  A dentist who can do all three isn't
• 14:56
  selling, they're treating.
• 14:57
  And that's why I say the order is
• 14:59
  the intervention.
• 15:00
  Patients can feel the difference.
• 15:03
  And so can the clinician,
• 15:04
  which is only half of why the ones
• 15:07
  who really learn this really have such
• 15:09
  high clinical acceptance rate.
• 15:12
  And by the way,
• 15:12
  the higher the clinical acceptance rate,
• 15:14
  the correlation is the proxy efficacy or
• 15:17
  the trust or the thought,
• 15:19
  I have the best provider and a validated
• 15:21
  instrument to patients.
• 15:23
  So patients who get talked to
• 15:26
  as though that was the medicine and the
• 15:29
  intervention,
• 15:30
  as opposed to that's the insurance
• 15:33
  transfer here, really view it as medicine,
• 15:37
  really view it as the intervention.
• 15:39
  It's interesting.
• 15:40
  All right, well, you have to pretend now.
• 15:42
  All right, I'm the CFO.
• 15:45
  Let me see if I got this right.
• 15:47
  You want me to spend more money on
• 15:48
  training and mentorship and case review
• 15:51
  and communication skills before
• 15:53
  productivity shows up.
• 15:55
  How do you show the CFO where I
• 15:57
  get my money back?
• 16:00
  Yeah, those are the right questions.
• 16:04
  And the reality is, you know,
• 16:06
  it's this combination of clinical
• 16:08
  confidence plus communication skills.
• 16:11
  What happens?
• 16:12
  Case acceptance improves.
• 16:14
  That's number one.
• 16:15
  Procedure mixing strengthens, right?
• 16:17
  So more expensive upskilled procedures.
• 16:20
  What decreases?
• 16:21
  Marketing costs per new patient drops
• 16:24
  because patients treated with that kind of
• 16:26
  respect refer.
• 16:27
  And that's why you need this sort of,
• 16:29
  you know, friends,
• 16:30
  family referral statistic.
• 16:32
  That last link is the one CFO is
• 16:34
  under price.
• 16:36
  A referred patient arrives essentially for
• 16:39
  free, no customer acquisition costs,
• 16:42
  trusting you and more so ready to accept
• 16:45
  treatment case and accepting you.
• 16:47
  While marketing, you pay retail for,
• 16:50
  right?
• 16:50
  You call in the air,
• 16:51
  you have lead generation, you have,
• 16:53
  I call those things the leaky bucket.
• 16:55
  You may pay, you know,
• 16:56
  the math runs something like this.
• 16:57
  You may pay eighty one dollars a lead.
• 17:00
  or a hundred and fifty to two hundred
• 17:02
  dollar acquisition cost.
• 17:03
  Are you familiar with Zocdoc and these
• 17:04
  kind of companies?
• 17:05
  Sure.
• 17:06
  Yeah.
• 17:06
  Well,
• 17:06
  those are transactional relationships.
• 17:09
  You pay more for them than you're going
• 17:10
  to get that first visit.
• 17:11
  And guess what?
• 17:12
  You pay whether they show up or not.
• 17:15
  One eight hundred dentists is another one.
• 17:17
  And so all of this,
• 17:20
  you're using your relationships to fuel
• 17:22
  everything from treatment case acceptance,
• 17:24
  better payer mix, to referrals,
• 17:27
  and then marketing savings.
• 17:29
  And the five-year button,
• 17:30
  in five years from now,
• 17:33
  my competitor is still renting patients
• 17:35
  from Google, Jarvis, ZocDoc,
• 17:38
  one eight hundred dentists.
• 17:40
  renting confidence,
• 17:41
  which from whatever office their
• 17:43
  associates are in, paying retail for both.
• 17:46
  And every January,
• 17:47
  the meter resets to zero.
• 17:49
  Now,
• 17:50
  if I own a training pipeline for dentists
• 17:52
  to choose on purpose and a patient base
• 17:54
  that recruits for us,
• 17:55
  that's the difference between compounding
• 17:57
  and rent,
• 17:58
  human capital and expense and marketing
• 18:01
  and lead generation.
• 18:02
  Does that make sense?
• 18:03
  It's a fundamental difference.
• 18:05
  Yeah.
• 18:05
  All right.
• 18:05
  So bottom line,
• 18:06
  the payer isn't going away.
• 18:08
  There are benefits or fee schedules or
• 18:10
  coverage limitations.
• 18:12
  Your argument,
• 18:13
  your article is about who gets the first
• 18:15
  vote, need first, coverage second,
• 18:19
  conversation, then third in that order.
• 18:23
  Because really,
• 18:23
  it sounds like you're saying a treatment
• 18:24
  plan quietly filtered through someone
• 18:26
  else's actuarial model isn't really a
• 18:28
  treatment plan.
• 18:29
  It's surrender.
• 18:30
  It's learned helplessness.
• 18:32
  That's right.
• 18:33
  Part three of your Inside a Platform drops
• 18:35
  next week on the operator on Substack.
• 18:38
  And if you're thinking about these
• 18:40
  questions today,
• 18:41
  make sure you stick around for the next
• 18:43
  one.
• 18:44
  Until then, keep operating.