
I have a master’s degree in negotiations (technically, “Psychology, Religion and Conflict Negotiations,”) so I’ve studied the gamut from the neuropsychology of fear to the Nash Equilibrium, to global conflicts over land and faith. Anyone who purports to summarize negotiation strategies in one article is obviously lying—there are countless variables to accommodate.
But one constant source of strife that any married couple can attest to is the need for resources to finance one’s ambitions. The same applies to raising kids at a standard that gives them the freedom to pursue their dreams. Or to a country seeking manifest destiny. Or to having cash to build a Community Paramedicine program that will make one’s community healthier while easing the burden on transporting ambulance services. After all, there aren’t enough medics to go around, and hospital wall times keep getting longer.
Even though negotiations training is great preparation for engage with insurance companies and other stakeholders in Mobile Integrated Health, I can make no blanket overarching statements about the strategies that will enable a community to sustain its Mobile Integrated Health program.
Indeed, I’d argue that past efforts to do just that—“Tell us, sir, how do you get someone to pay for our program?”—have been insufficiently nuanced and led to the current crisis of imploding CP/MIH programs. There may be specific things not to do, or at least some methods that should be at the bottom of the go-to list. (Hello, readmission avoidance!)
Data Are Ultimately the Key
Let the numbers do the talking, and at least one of those numbers is likely to have a dollar sign (or other local currency) in front of it. It’s not rocket surgery—it’s delivering on promised value. You can either measure it, or you can’t, as Peter Drucker is famous for saying: “What gets measured, gets managed.” Part of management is, of course, ensuring that you have cash to pay your people, so they can keep doing excellent work. I am frequently inspired by the nun Irene Kraus, who became CEO of the multi-billion dollar Daughters of Charity National Health System and famously called out: “No margin, no mission.”
It’s also vital to remember that, as an old friend and former business partner—who ran an ambulance service near Philadelphia—taught me: “This too shall pass.” Both the great, and the challenging. Decisions made now resonate into the future. Would you want a choice made during a moment of dire straits to keep you from doing (very) well by doing (very) good when economic conditions improve—and the need for what you do best has only increased?
During a recent gasoline price runup, I found myself holding economic therapy calls for colleagues considering an exit from the ambulance business thanks to the pinch of oil prices. I reminded them how hard they had worked to build sprawling and successful services: instead of throwing in the towel for a cost that is ultimately seasonal—even if that seasonality felt particularly painful in light of global events—I suggested that they construct a financial hedge and put money (there are many ways to do this) into oil stocks that would rise with the price of gas.
In short, lose money over here, but gain money over there, and as long as one remembers to sell—such decisions should be modeled out in advance—the two balance out, ideally with an upside slant.
Big Bucks
Jeremy Irons, the growly actor who portrays a fictional version of former Lehman Brothers CEO Dick Fuld in “Margin Call,” describes the job of a chief executive as follows: “Do you care to know why I’m in this chair with you all? I mean, why I earn the big bucks…I’m here for one reason and one reason alone. I’m here to guess what the music might do a week, a month, a year from now. That’s it. Nothing more.”
In truth, one’s title doesn’t matter—it could be CEO, chief, director, owner-operator, pick it. At the end of the day, a leader’s job is to bet on the future…but that bet isn’t willy-nilly. In business, one is playing chess, not checkers (as I explain my job to my kids): three, four, five, ten moves ahead. What could go right? What could go wrong? How might something going right impact the things that could go wrong next, and vice versa? Strategy isn’t reactive; tactics are reactive. Strategy is the plan; tactics bear out the plan. Strategic is whether to do a thing; tactics are how to pay for it.
Mobile Medical agencies are rallying behind the promise of Community Paramedicine but largely without plans to fund it. The question of whether funding exists is unrelated to whether or not the need exists—there’s no real chicken-egg quandary here. If the need doesn’t exist, there won’t be funding for it; if there is funding before documented need, there will be (a) moral hazard, like people lying just to get the money; or (b) the funds will go unawarded.
Whose Problem?
Yet the recognition of a need certainly impacts whether funding exists: Are you sure there’s really a need if you cannot find someone who is willing to pay to solve it? This is Silicon Valley’s problem: subsidizing artificial demand is not the same as discovering willing to pay then offering customers a venture capitalist-based subsidy.
I recently encountered a pair of homeowners who committed the cardinal sin of negotiations: They panicked, bluffed and got called out. Things took longer than they planned, and they had neither a contingency plan nor a buffer.
They should have stepped back, breathed, surveyed, and adjusted—what Reddit co-founder Alexis Ohanian calls “the surfer’s mindset: “the proper mix of patience, focus and calm to properly judge which waves are best to catch and ride, and which ones will result in a wipeout.” Instead, serious judgement errors compounded their struggles, costing them the chance to sell their house quickly and lucratively.
I have spoken with Mobile Medical colleagues who faced a similar challenge as property value drops and population migration out of town hit their tax levies, which in turn hit their ability to hire. Consequently, they “take who they could get.”
At least one a paramedic has gone rogue, with the chief acknowledging that this crew member was not following even basic protocols. But what could he do? He lamented having to keep his service operating without the funds to be choosey. He said, “I’m afraid that it’s going to take someone dying in an ambulance to make things better, and I just hope it’s not in one of my rigs.”
Better than Nothing?
Does the ambulance service have to keep operating—is something better than nothing, if the crew on the truck feels like they do not have to follow protocols? Or is the solution to getting more reliable resources letting ambulance and fire services to go dark rather than prop them with one-off stimulus—the economic equivalent of a cortisone shot?
If some shut down, assuming demand stays constant, those that remain will make more money and thrive; this is a fundamental truth of economics since Adam Smith. But telling patients that they cannot have their ambulance service because it ran out of money is hard for emotional beings—so ambulance services keep running on coffee, ethics and smiles…which of course just perpetuates their risk of running out of money.
Early in the entrepreneurial journey, I learned from David Thrower, a successful biomedical tech executive, that an organization’s financial plan must stay distinct from its financing plan. That is, how you pay for things is unrelated to what you plan to do for your customer and the world.
The financial plan is defined by what you bring to market, your skills, passions, and—critically—the market’s willingness to pay (“WTP”). WTP, is, everything: if a community won’t pay for ambulance services, perhaps it doesn’t think it needs them. When it realizes that it needs them, it’ll pay extra for them—and hopefully it isn’t too late. The ambulance service may be vindicated along the way—and that is tragic, yet it is also the way markets are supposed to work.
How and Why
For a profession like Mobile Medicine, where folks quote Simon Sinek all the time, the financial plan is intertwined with the why. The financing plan is how, but how is distinct from why. Why remains, even if the how fails to materialize.
The difference is that if the how succeeds—if you figure out how to pay for it—then you have the privilege of addressing the why.
Good people operating the ambulance service want to keep people from getting hurt: their mission is sacred and sweet. People don’t pay for sacred and sweet. They pay for value delivered. Business leaders in pain rarely say, “Well, I guess it’s my company’s/agency’s/technology’s time to die off.” No…businesses, like life itself, fight to survive.
Look at the pain in the market right now—rampant inflation, employees being furloughed from overbuilt firms with business models that are fuzzy at best—and see what happens when markets get manipulated.
Bumping from grant to grant, instead of creating a sustainable line of business, acts like a special form of market manipulation: it postpones the need to stand on one’s own. Seeking more government subsidies is the opposite of showcasing such a compelling ROI that the community can’t wait to pay its bill.
More from the Author
If Mobile Medical Money Did Grow on Trees, Would Agencies Realize They Can Reach It?
What Happens When We Can No Longer Tell the Difference?
A ‘Thank You’ to Governments (On Behalf of CP/MIH Programs That Deserve to Get Paid)