Pillars of Strength

When I finished my first terms as ASNM President, a good friend and colleague sent me an email that said, “Being a leader is not, and never will be, an easy job; in fact, it’s the hardest job in the world, and many times a thankless job. You have to be the pillar of strength even when you feel like you are crumbling to pieces inside.” There is so much truth to that.

This post is the second in a 4-part series in which I’m discussing “What’s happening in IONM.” In a previous post called “The Elephant In The Room” I talked about many of the challenges that people from the various roles in neuromonitoring face today, including executive leaders and the things that concern them. In this episode, I’m going to be talking about what executive leaders need to know.

Before I jump in, I want to say this… my intro for this post was very much one of support, and some of what I have to say today may sound slightly critical in places, but I don’t intend it to be. I’m just trying to share observations, insight, and advice… and, I hope you’ll take this as support… from one leader to another.

I can’t address every possible topic in a single post, I don’t know everything, and I don’t have all the answers. I have been in this field for a long time, though, and I’ve worked at every level. So, I know it well.

Now that that’s out of the way, let’s begin today by talking about employee retention.

This is of burgeoning concern for leaders in IONM, and it’s a problem the extends to all corners of the American workforce. According to a recent article in The Wall Street Journal, “Fifty million Americans quit a job in the last year, and another third of the workforce is renegotiating where, when and how they work. Three-quarters of Americans in a recent survey said that they plan to look for new work this year.” In a post-pandemic world, the nation’s workforce is focused on work-life balance, and “in the balance of power between work and life, life is playing a greater role.”

The article goes on to say, “Today’s workers are focused as much on the quality of their lives as on the quality of their jobs. Gallup found that millennials and members of Gen Z, who now make up half the workforce, place their greatest emphasis on well-being at work. Deloitte heard from the same group that work/life balance was their number one priority. High salary and other financial benefits came in well behind, with only one in four mentioning it.” How interesting is that?!? The take-home here is today’s workforce doesn’t want to live to work, they want to work to live, and there’s really nothing wrong with that.

Before you start your mental tirade about “quiet quitting” and how lazy millennials are, let me stop you right there. Blaming the younger generation is a shiftless and uninspired cop-out that goes back, literally, millennia. There’s a great post on the History Hustle blog called, “The 2,500-Year-Old History of Adults Blaming the Younger Generation.” It’s an interesting read if you find the time. Anyway, blaming the younger generation… boring!

There is nothing wrong with wanting to have a life outside of work, and today’s American workforce (not just millennials) wants to devote more quality time to people and activities outside of work. So, executives need to adapt to employee needs, within reason, but it’s about finding balance. This will take a reimagination of how you allocate resources for case coverage, where you focus your business, and how much you charge for the service you provide (more on that later).

It’s also important to think about burnout…. I think a lot of people don’t know the difference between stress and burnout, so let’s tackle that real quick…

Burnout may be the result of unrelenting stress, but it isn’t the same as too much stress. Stress, by and large, involves too much: too many pressures that demand too much of you physically and mentally. However, stressed people can still imagine that if they can just get everything under control, they’ll feel better.

Burnout, on the other hand, is about not enough. Being burned out means feeling empty and mentally exhausted, devoid of motivation, and beyond caring. People experiencing burnout often don’t see any hope of positive change in their situations. For them, there’s no end in sight.

The leading cause of burnout isn’t overwork, it’s loneliness and isolation. There was an interesting article in Harvard Business Review by Emma Seppälä and Marissa King. They note the burnout problem is pervasive at all levels across all professions. The problem became endemic during COVID-19, and it persists today.

Vivek Murthy, former Surgeon General of the United States, wrote in a separate HBR article that, “Loneliness and weak social connections are associated with a reduction in lifespan similar to that caused by smoking 15 cigarettes a day and even greater than that associated with obesity.” Research by Sarah Pressman, of the UC, Irvine, demonstrated that while obesity reduces longevity by 20%, drinking by 30%, and smoking by 50%, loneliness reduces it by a whopping 70%. While feelings of social connection can strengthen our immune system, lengthen our life, and lower rates of anxiety and depression, loneliness and isolation have the opposite effect.

You may be wondering how this applies to neuromonitoring. What contributes to people feeling lonely and isolated? Well, you probably have some remote employees, whether they are back-office staff or physicians who always work from home. I’ve worked from home before, and it sucks! Sure, there are benefits, but it is a terribly isolating experience. You sit in a room for 8-10 hours a day with no genuine human interaction. You lack that social connection that people get in the office environment. It’s like solitary confinement, and if you don’t find ways to essentially force these folks to actively participate in company social activities and other networking opportunities, these employees will burn out. It’s only a matter of time.

What about neuromonitorists? They can’t possibly experience this isolation because they work in the OR surrounded by people, right? Wrong! If the environment they work in is unwelcoming, or even hostile, if they are not accepted as a member of the team… If they’re forced to dress differently than the rest of the staff, if they’re told to stay in the corner and keep their mouth shut… – all of which happens more often than not in our profession – then they will absolutely feel isolated and lonely. This is not an enriching environment, and it’s not sustainable to continue working in this environment. People get burned out, and they jump ship.

So, what’s the solution? Well, research has shown a very strong link between social support at work, lower rates of burnout, and greater work satisfaction and productivity. After all, the most important factor in work happiness, a UK study showed, is positive social relationships with coworkers. Workplace engagement is associated with positive social relations that involve feeling valued, supported, respected, and secure.

As a leader, the most important things you can do are:

  1. Promote a workplace culture of inclusion and empathy.
  2. Encourage employees throughout the organization to build developmental networks.
  3. Celebrate collective successes.
  4. Help people to maintain a healthy work-life balance, so they can attend to their personal lives in a healthy and productive way.
  5. Defend your employees who are mistreated at your client facilities.

Today’s employees will no longer accept coming to work and being mistreated, and particularly as it happens in IONM. I’m not sure why any of us accepted this in the past, but times have changed and it’s the fastest way to lose your employees. As an employer, maybe you genuinely treat your employees well, but if they spend their days in hospitals where the staff treat them poorly that’s just unacceptable.

I still hear reports about rude and dismissive hospital staff, people yelling or cursing at neuromonitorists. They are made to feel unaccepted and marginalized. Can you imagine going to work every day and being treated like that? The hospital is the neuromonitorist’s workplace, and your policies on employee conduct and treatment should carry over to that environment. Too often, they do not. Probably because executive leaders are unaware this is even happening.

I know you care about your staff, so you must know it’s imperative that you stand up to the hospital staff and let them know these behaviors are unacceptable. Shrugging your shoulders and saying, “the surgeon’s just a jerk” is just a passive form of acceptance. Maybe you risk losing business in standing up to your clients but consider this: it doesn’t matter if you are active or passive in the mistreatment of your employees, you’re still ultimately responsible for their wellbeing. As an executive leader, it’s important that you make time to talk to your front-line workers and ask them about their daily challenges, ask how you can help to improve working conditions, make your assessments, then roll up your sleeves and jump in wherever you can.

The days of thinking about your employees in contractual terms are over. It’s true: you expect them to work, and they expect you to pay them, but today’s workers want more – they want to know you care. So, you also need to think of your employees in relational terms (i.e., we care for and about each other). Leaders need to build a culture that protects employees from toxic circumstances, recognizes their work, and includes them in the organization’s vision.

This is not a progressive idea. It’s a pillar of common sense sitting atop a mountain of evidence from decades of research in psychology. I love it when I see companies recognize their employees routinely on social media, and I’m sure the employees appreciate that as well. But think of all the companies that post little-to-no recognition. Appreciate your employees and they will appreciate you back. Remember: automated periodic bank deposits do not constitute employee appreciation. If people are leaving you, it’s probably because they feel like they’re in a broken relationship.

I think all executive leaders understand that reimbursements have declined in recent years, and money is increasingly tight. But, do your employees understand this in a way that makes sense to them? Have you included them in the conversation, more than just superficially? Try giving your employees more visibility. Maybe you can’t offer them a promotion, but you can still develop them and advance their careers. Offer to bring them into the fold and teach them about management, contracting, revenue cycle, finance, etc. A little bit of development goes a long way.

If you have an employee working as a neuromonitorist for 10 years and their knowledge base is limited to IONM, no one really wins. People who have a better understanding of why things are done feel more like they’re part of a team. If you take people under your wing and mentor them, you’re making great strides on the “relational” side. Also, don’t blame them for not proactively asking for your support and career development. Think about it… you can blame the junior employee for not asking to be included, or you can blame the seasoned leader for not offering to develop and support. Which makes more sense?

The last thing I want to say before I move on to finance is this: you’ve gotta find a way to get your neuromonitorists more training. This is not a job you learn in a few weeks. It is a difficult job that requires extensive training and frequent continuing education. You can’t just put them in the OR and hope for the best, or assume they don’t need the training because they’re online with a neurologist. There has been a massive shift away from high quality IONM in recent years, and I believe one of the primary contributors to this shift is allocation of resources away from education. Your company provides a patient care service, and patients deserve care from highly trained and highly competent clinicians. There are lots of places you can get lean, but clinical education is not one of them. It’s not worth the risk to save a few bucks, and there are plenty of cheap or free continuing education programs out there. Meaningful participation in them should be something you require of all clinical employees.

Moving on to finance… I hate to be the bearer of bad news, but there’s a good chance that you’re at least partially to blame for our current financial situation in IONM. When I say “you,” I mean the collective you… decades of executive leaders in IONM making the same collective mistakes, and the entire IONM profession is now the beneficiary of the consequences.

From the professional reimbursement side, the biggest reason why insurance companies won’t pay for IONM is lack of high-quality evidence to support utilization and reimbursement of IONM services. They call our work experimental and investigational. Sure, the internet is flooded with interesting research in the form of case examples, but insurance companies don’t care about anecdotes. They care about large, multi-center studies incorporating thousands of patients evaluating the utility and efficacy of IONM in systematic ways. These studies are nearly impossible to publish because many of (the collective) you built databases, or participate in the use of databases, that have zero utility for research.

We need to be logging everything that happens in the course of patient care in a format that is easily quarriable. We’re not. Even if we could, most of your employees are not getting detailed clinical exams before and after surgery, they are under-documenting case details, and you are signing contracts with facilities that limit access to this critically-important information. Every ounce of data that your company collects in a quarriable format helps you schedule cases and get reimbursed quickly, and that’s the root of the problem. It’s short-sighted.

There’s limited evidence to support IONM because we monitor 600,000 cases per year and don’t record the information most critical to long-term reimbursement. We’ve been doing it for decades, and now we’re lying in the proverbial beds we made. Research is one of those things that leaders feel is superfluous. People view it as a hobby for nerds, or something, and it’s the first role to get dropped when the proverbial belt tightens. BUT, it’s the most critical piece for securing future revenue on the insurance side.

It will take efforts on behalf of the entire IONM community to develop an evidence base that will support reimbursement in the long-term, and that starts with leaders demanding drastic changes to how we collect and store information. The question to ask yourself is this: are you a collaborative leader who is invested in the long-term success of this profession – someone who will join together with other leaders to drive the necessary change, or are you here to suck IONM dry of every penny and dump it (along with your under-appreciated contractual employees) when there’s nothing left to drain?

Ok… let’s pause here for a word from our sponsor:

The No Surprise Act has been a thorn in everyone’s side. Insurance executives are lying about providers submitting false and unnecessary claims. Arbitration slows down your revenue cycle. I’m sure you know the cost of arbitration has increased 600%, and many executives tell me they must arbitrate each CPT code separately for the same patient encounter. Rather than bare the cost, they drop most codes because the cost to arbitrate exceeds the revenue potential. The whole thing feels like a punishment for being in healthcare. It’s a frustrating and disgusting abuse of power on the part of insurance companies who have significant influence on both state and federal government. As if NSA wasn’t enough, insurance companies won’t let your neurologists into their networks because their “panels are full,” then they reject your claims for being out of network. It feels like you just can’t win.

I think a lot of executive leaders want to blame IONM societies for not providing support. I don’t think that’s fair, and here’s why. Each society has different areas of focus. The ASNM is a 501(c)3 with a mission focused entirely on providing clinical education. If you want the best available continuing education in IONM, you go to the ASNM, but their incorporation status as a not-for-profit doesn’t allow them to lobby. ACNS is also a 501(c)3, but they have a larger scope of function, and they’re able to lobby through their delegates to the American Academy of Neurology (AAN), a 501(c)6 which, by definition, is created for the improvement of business conditions. So, the best place to voice your concern is to the ACNS and/or AAN. It’s really the AAN who has the resources and power to drive the change you’re hoping to see. The same is true for other medical societies like AANS/CNS and NASS.

Let me give you an idea of how some of this stuff plays out behind the scenes…

In 2018, myself and a few others wrote a summary of the literature for Cigna, and gave a great argument for why IONM should be reimbursed. Cigna took the meeting, but balked at the idea of changing their policies for the benefit of so few people who cared enough to work on this project. Not long after that, Cigna updated their coverage policy to exclude IONM in lumbar and cervical spine surgery… the majority of what we monitor. When Cigna implemented this policy a couple years ago, I brought it to NASS where I hold a leadership position as Chair of the Section on IONM, and a member of the Section Development Committee.

Through this connection, NASS was then able to coordinate a strongly worded letter to Cigna from 5 surgical societies representing 34,000 orthopedic surgeons. The gist of the letter was that surgeons should decide when IONM is most beneficial to their patients. Of course, there was no response from Cigna, and the policy remained in effect. Earlier this year, AANS/CNS wrote their own letter to Cigna, and requested a phone call, which was granted, and I was on that phone call just a few weeks ago representing NASS (and also representing all of IONM – Wilent/Doan). On the phone were leaders from other medical societies (AANS/CNS/AAN) and Cigna’s medical directors. It was a good call, and I hope it will catalyze some degree of change. BUT, that’s 5 years’ worth of work with one insurance company. Talk about a Sisyphean task, talk about grinding it out!

My point is this, the only groups who have the power and influence to drive change on the insurance side are the major medical societies, not ASNM or ASET. That’s where you go for great education. I think a lot of leaders sit back and complain that no one is doing anything about these problems. But, if you’re not communicating with these major medical societies, they may not even be aware there’s a problem that needs to be addressed. There’s power in numbers, so everyone should be sharing their concerns. The best approach is probably to draft a letter and ask your neurologist colleagues to push it up the chain in the medical societies. Speaking of which, I believe each state has a dedicated medical association (e.g., Texas Medical Association). You might consider asking your neurologist colleagues to share your letters with those groups as well. 

I feel like driving change on the reimbursement side is one of those hot potato items that everyone asks, “What are you going to do about it?” Let me ask the question a different way: What are you gonna do about it? This is a place where we really need collaborative efforts on the part of all executive leaders.

OK. Enough about insurance.

On the facility side, technical fees have declined significantly in recent years. I believe the main reason why facilities are paying less for IONM is because the market is flooded with undifferentiated competition. What was once an advanced clinical service provided by highly skilled clinicians is now being sold as a fungible commodity, so you’re forced to compete on price alone. It may be difficult to hear that your company’s service isn’t substantially different from any other company’s service, but it’s mostly true from where I sit.

If you sit in these sales pitch meetings between IONM companies and facilities, or if you ask supply chain coordinators on the facility side, you’ll learn quickly that all these IONM companies say the same exact thing.

We are HIPAA-compliant with highly qualified and certified techs using state-of-the-art equipment, we use real-time professional supervision by neurologists, we have 24/7/365 coverage with rapid coverage of emergent cases, we have our own education and QA programs, we’re Joint Commission accredited, and we cover all case types. Did I miss anything? When facilities listen to these sales pitches, everyone sounds like the teacher from the Charlie Brown cartoons.

The facility makes you compete on price because, as far as they see, at the end of the day, they’re getting a tech with a box. On top of that, you have medical device companies offering IONM “for free,” which is essentially a box without the tech. I know a lot of people balk at these medical device companies and their sales methods. You might not like it, but they’re using effective strategies in an unpredictable and evolving marketplace. In the words of Jamie Foxx, “Don’t hate the player, hate the game.”

Hospital supply chain coordinators have no clue what IONM is. It’s a line-item on a spreadsheet that needs to be acquired at the lowest possible cost, and they’re probably incentivized to reduce expenditures. Some facilities outsource to Group Purchasing Organizations (GPOs), which are a thorn in the side of anyone who’s ever completed their nonsensical spreadsheets and gone through the stoplight auction. It’s never been more clear that facilities care only about getting IONM at the lowest cost.

You know, some of these larger facilities have 3, 5, 10 or more different companies providing IONM services… all under the same roof. Some of this is related to the fact that surgeons have a financial stake in a particular company, and some of it is related to the fact that individual surgeons have preferences for specific techs. But, there’s only so much influence surgeons have. Ten years ago, they always got what they wanted, but today, the need to cut costs is outweighing the preferences of individual surgeons. So, we’re seeing facilities consolidating the number of vendors they contract with. At the end of the day, if surgeons can get a consistent service that isn’t terrible, they’ll go with what the hospital tells them to. And, if they really happen to love a particular tech, and the company loses the account, they’ll just go to the company who wins the contract and encourage them to hire the tech. It will be difficult or impossible for you to enforce a non-compete or non-solicitation clause. And, if you don’t have any other business in the region, it may make sense for you to just let the tech go to a different company, rather than terminate the position or move their entire family to a different region.

The sad fact is, even if you genuinely provide an exceptional service with expert clinicians, facilities don’t see the difference until they get hit with a major lawsuit, which is extraordinarily rare, but that’s when they shop around for quality. I think technical reimbursement is a storm that must be weathered, but you can fight it by having a solid understanding of what IONM is, how it works, what constitutes quality, why that’s important… and then educating the right people on the facility side about these things. In my mind, there’s nothing more embarrassing and defeating than watching someone who doesn’t have a deep understanding IONM try to sell it.

Speaking of which, there’s a good chance your business development team, if you have one, is bonused on closing accounts regardless of profitability. They don’t care if the margin is flat, if the payor mix sucks, if the surgeons refuse to use IONM properly, or if the techs have basic accommodations like parking, lockers, badges, unfettered patient access, and appropriate attire to protect them from bloodborne pathogens. They may be closing accounts, but are they closing the right accounts with the right margin, and the right accommodations to support your staff? Some business isn’t worth having. Remember: volume without revenue is not your friend. That’s a quote from my good friend, Melissa Hanley!

The good news for declining prices on the facility side is I think basic economics will prevail. We’ll continue to see integration and consolidation in the marketplace, fewer companies will have more bargaining power, and the market will move toward equilibrium. When it comes to price, I don’t know what equilibrium is. If you’re like most companies, your average direct cost to staff a case is approximately $450 (and that doesn’t include all your indirect costs). It’s difficult to fathom a technical fee price floor much below that.

As companies begin to cut ties with under-performing facilities, and as facilities continue their movement toward consolidating (what they call) vendors, and as workers continue their exodus from the market, the decrease in supply will give way to greater demand and likely to higher prices, at least in an ideal world. Of course, this is an over-simplification of the true economics in the IONM marketplace. Market forces will also influence what you pay employees, how many are available to hire, their level of education, how well you can train them, etc., etc. Again, I think this is a storm that must be weathered. Larger companies benefit from the economy of scale, which puts smaller companies at a significant disadvantage.

For that reason, I honestly wouldn’t be surprised if most of the smaller IONM companies are no longer around in 5 years. It’s a bold prediction that will anger and frustrate some, and maybe evoke fear and anxiety in others. I wouldn’t worry. I don’t think the jobs are disappearing. I just see a lot of consolidation coming in the marketplace. I mean, just this week, Assure Neuromonitoring acquired Dallas-based Innovation Neuromonitoring who covered cases in Texas, South Carolina, and Nevada. Also, Houston-based Peak Neuromonitoring Associates, who did business primarily in Kentucky, just closed up shop quite suddenly last week. There have been multiple other closures, acquisitions, and consolidations this year. I believe there are more to come.

That’s it for today. Please join me next time when I’ll be writing to and about neuromonitorists and their managers working in the neuromonitoring space.

In the meantime, please feel free to leave a comment below, or send your questions and comments to [email protected]. I’d love to hear from you!

I’m Rich Vogel, and that was Stimulating Stuff!

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