The Value of Advocacy in Rural Health: A CFO’s Perspective

Phil Sobol: 

Welcome to the CereCore Podcast, where we focus on the intersection of healthcare and IT. From practical conversations to strategic thought leadership, let's unpack the decisions, challenges, and journey of those whose purpose it is to deliver technology that improves healthcare in their communities. Well, today, we are pleased to welcome to the CereCore Podcast Tim Powers. Tim is the Chief Financial Officer for the Idaho Hospital Association and has witnessed tremendous change in healthcare during his 35-year career.  

He has served as CEO at hospitals in Nevada and Idaho and before moving to the Pacific Northwest, lived in Nashville. Passionate about rural healthcare, Tim joined the Idaho Hospital Association in 2021 and began growing Healthcare Business Ventures, which is a wholly-owned subsidiary of the Idaho Hospital Association that provides products and services that benefit IHA members. Tim, welcome to the CereCore Podcast.  

Tim Powers: 

Thanks so much, Phil. Happy to be here.  

Phil Sobol: 

So Tim, you've worn both hats, both CEO and CFO. We see a lot of multiple hat-wearing when it comes to rural health. So, if you wouldn't mind, take us on a journey to where you got to today. Were there any pivotal moments in your career that you really stick in your mind that said, "You know what? Rural health is where I belong"? 

Tim Powers: 

People use the word passion about it that are serious about rural healthcare and I fall into that category, but I'll more of it happily bring you through that journey to where I've developed that feeling and where I am today with it.  

Phil Sobol: 

We'd love to hear the story.  

Tim Powers: 

Just to give you some background, and Phil, you nailed it. Nashville is our hometown. All of our family continues to live there. I came out my background prior to getting into hospital care, I had a healthcare background, but I was a fix-it guy. I was a turnaround guy. I love needy organizations and I was living in Nashville. I had been unfortunately caught in a right-sizing at a manufacturer there. The first real nibble I got was from IT services company out here in Boise that if you remember back about 20 years, offshoring IT services became vogue.  

Phil Sobol: 

Oh, yes.  

Tim Powers: 

And their primary business models had customers, Boise Cascade, Albertsons, Hewlett Packard, Micron. So, they were unfortunately right in the bullseye of those services going away, and I was brought out to help them reshape and re-engineer that company, a really cool transition and a really great success story. The chief financial officer of St. Luke's Health System, which is largest health system in Idaho, was at a cocktail party one night with one of the guys that I worked with, and he was talking about a little hospital that they were managing, just opened up its doors in Gooding, Idaho. They had to terminate all of their C-suite and did he know anybody that had healthcare experience like this came out of the blue. The next day I get a phone call from a controller. We got this hospital.  

We're in trouble. Would this be something that might interest you from a senior financial level to go down there and take a look at it and give us your thoughts? That week, that Friday, they were having ad hoc finance committee meeting, met a couple of community members who were really concerned about it. But when I drove in the parking lot of this little Southern Idaho town, I see this unbelievable, beautiful, brand new, architected constructed hospital that it was like a spaceship that sat down in the desert there in Gooding. I was blown away by this place. So, I met up with the regional representation from Luke's while I was down there and we were talking. Like I said, I met some of the community members and I don't know.  

You had this big, beautiful asset sitting there and it's a rudderless asset because it's got no leadership. I heard what went down. It was a brand new HUD construction loan that they were completing. They had not reconciled cash in a year. They had no idea how much money they had. So, I decided to take the job and I was fortunate in one sense, St. Luke's had brought in a forensic accountant because they were concerned that there was some shenanigans going on down there. Her name was Sarah. She and I dove into the operations of that facility in a big way. The first eight months I went through three interim CEOs that kept coming in, going out. So, no continuity of leadership. Sarah was a contractor. I convinced her to stay on and help me get through this work.  

They finally brought in who absolutely became one of my best friends, a CEO, who had experience with HCA, who had been with Adventist Health back in Tennessee. He was in East Tennessee. So, during the interviewing process, they brought him in and he and I were talking and I said, "Let me tell you one thing, David. I know you're the guy for the job. You've got exactly what this hospital needs, but if you're a UT fan, you and I are going to have problems because I grew up a Vanderbilt fan." He goes, "Oh, my gosh, no way. I went to LSU. I hate Tennessee."  

So anyway, he and I got off on the right foot and he was probably in my professional career, if not the best mentor I ever had, he was a close second. He absolutely helped me through that entire process of becoming a successful critical access hospital CFO in a rural setting.  

Phil Sobol: 

That's fantastic.  

Tim Powers: 

It took us about two and a half years to turn that place around and we were adding service lines, changing the complexion of that hospital. When I first got there and David got there, there were no employed doctors. There were all traveling specialists. We made our first acquisition with one of the clinics in Gooding, brought them on board, and decided we were sick and tired of having our patients in our community leave with a specialist from St. Luke's and disappear. We needed to go down that route and hire specialists ourselves. So, one thing led to another. Four years later, David came to me and out of the blue goes, "By the way, I got some good news and I got some really good news." I go, "So what's the good news?" He says, "I'm leaving. I'm taking a job with Adventist Health and [inaudible 00:07:49]." 

I go, "That's the good news? What's the really good news?" He says, "I'm going to ask the board to make you CEO." I was stunned. I had never looked at myself from an ambition point of view, really be that guy or that gal in that seat wearing that hat. One thing led to another. I went through the interviewing process with the board and they said, "Yeah, you're the right person for this role at this time." I will tell you this, the first day that I was actively... At the time, I was wearing both hats, CEO and CFO. That first day I'm walking, I get to the hospital. We've got a 7:00 AM med staff meeting, and I'm walking in there going, "Do I have the chops to pull this off?" It's a pretty daunting thing. Now I know what David and all the other CEOs, they've got on their plate and what goes on in their brain.  

I've got all of these employees. I have this community that I'm serving. I have all of these providers and the interdependency between all of that winds its way back to me and the board and me and the board and our strategic planning process decided we need to go toe to toe with the big dog that's 85 miles in any radius that effectively allowed us to go into other communities, build clinics. Where that particular hospital system centralized their operation, we took that as an advantage to go into these underserved communities and be that healthcare resource that our employees and our providers had a passion about it as well was really fulfilling. So, being able to provide that type of growth and access to services, I mean, was a huge accomplishment down there.  

To this day, I really feel proud of that. So, you fast forward those 10 years, Phil, National Healthcare Recruiting Organization said, "Look, dude, we got an interim CFO position open in Winnemucca, Nevada. All of the C-suite were gone. They just had been through an EMR conversion and it was a full-blown disaster." I don't know- 

Phil Sobol: 

Oh, my. 

Tim Powers: 

... about Winnemucca. It's an island community, right on the interstate, two and a half hours from Elko and Reno. So, your community, you want to provide as many services as you possibly can there. It was a full service, critical access hospital, seven-bed labor delivery service, had three ICU beds, owned its own EMS service. They were more than first responders. They were search and rescue because of the area that Winnemucca was in, Northern Nevada, tons of mountains, rocky terrain. That was my second experience in rural healthcare, completely different type of environment, and coming into an organization that had no continuity of leadership. It was a beautiful place.  

I mean the facility was unbelievable, but as you could tell, if you looked at my CV, I began there right before COVID began. During that time, the interim CEO had been there for two years and she had had enough. At the time, it was about twice the size of North Canyon. So, it was a bigger boat to navigate, but took the job and began to do some things down there they had never done. One is do your own rev cycle on campus as opposed to outsourcing. Phil, I'll tell you this, they had used the service that had quite frankly bankrupted the population down there from their healthcare services that they had essentially not been able to pay for. It was certainly easy to go and say, "This is the type of process we need to get away from."  

We need to get our community more involved in the processes here at the hospital and slowly but surely began to build a rev cycle team that came from that community there. The experience of really trying to help a small hospital, independent hospital through trying times like this, it can either be the biggest burden that you've got in your life or you can look at it as that challenge that you need to deliver on. I had a team down there that I relied upon that was really instrumental in helping us change the culture, change the environment, and really change the scope.  

It was also a very good thing that I had really good relationships with St. Alfonso's and St. Luke's back here in Idaho because to try to get a lot of our critically ill patients during COVID, transferred out to higher level of services, it was nearly impossible in Nevada. So, I had those transferred agreements with St. Luke's and St. Al's in place. So, we were able to take care of those. So, there's a lot of things you have to think about when you're leading these types of organizations. Having developed good relationships with other higher end providers regionally is one of those things that I learned really, really well.  

Phil Sobol: 

Well, there's no doubt, Tim, that your experiences have just been certainly transformational. I think you mentioned of it when you said you can look at it as a burden or you can look at it as that calling and that mission. I think it's very evident which direction you chose. Then I would think that that's also then been what's kept you in the game with the Idaho Hospital Association. So, tell me a little bit more about that and the members and how Healthcare Business Ventures is helping the IHA membership.  

Tim Powers: 

Coming to IHA, prior to that leading hospitals, you were serving your community. Now I'm serving my members that serve that community. So, there was that adjustment, but the good news is we've got 51 member hospitals in our association. More than half of those are critical access hospitals. Coming in here, I think I had a leg up on somebody from the outside because I know most of the CEOs, I know most of the CFOs. I've got that broader network, thank goodness, that really helped me transition smoothly. Idaho has gone through exchanges as well over the last few years. COVID has been the link to a lot of bad legislation that's gone on with the political environment in our state right here. This fast session was just a little worse than the previous one last year.  

Thank goodness they only last for four months. No telling what harm they could do to the rest of us if they were here for the entire year. But understanding the advocacy side here, both from an Idaho perspective and a national perspective, that is really the biggest force working against us. I'll just give you for instance, actually Brian Whitlock, my boss, and we were talking today about this. As a citizen of any state, there's a certain expectation that you have for government support and government service. One is you turn on your drinking water, you expect your drinking water to be clean. You expect the highways to be in some serviceable type of environment so that you can travel, right?  

You expect public education to have qualified teachers and access for students for learning developments. Now, wouldn't you expect if you're sick or you need emergency care that you have access to a physician to providers to provide that care? Well, I will tell you this. If healthcare isn't... I guess you could call it like the bedrock of living in a particular state, it sure ought to be, because the types of things that are going on both from a federal point of view and a state point of view right now are not voting well for healthcare and quite frankly are trying to erode the infrastructure of healthcare if you look at it from my eyes.  

Phil Sobol: 

Yeah, I mean it's certainly interesting perspective and I would say that Idaho is not necessarily an exception to the rule when it comes to the challenges that particularly rural healthcare is facing across the nation. Specifically to Idaho, maybe, what are some of the most significant impacts on those hospitals that you're seeing that impacts their financial resiliency? How are the leaders navigating those challenges? Are there things that your association is doing to support the members to help either with preparation or in many cases pivoting to either take advantage of things that weren't there or perhaps hedge off something that is?  

Tim Powers: 

Well, I'll tell you this. We expanded Medicaid back in 2018 and one of the first bills that came up this year was to have Medicaid expansion reversed. So, in a nutshell, that's the environment that we're operating in. I will tell you this in Idaho, and I'm sure in other states, you could see the same thing. But once Medicaid expanded in Idaho, you could see a reduction of bad debt at the hospitals because previously those patients were coming in with no insurance. You also saw an improvement in your net patient revenue percentage of total patient revenue because now you had a payer that was paying for these people. It ultimately ended up being about 4% benefit to the hospitals.  

Now the threat of that going away, we're operating on really thin margins here as it is in most places and most critical access hospitals are really operating that way. A reduction of 4% could be devastating for some of these rural providers in our state. I'm sure that can be said across the country as well. So, that's just a for instance of what powers are in process out there that could really have consequential damage to our provider base.  

Phil Sobol: 

No, that's very true. There's challenges that cross state lines too that are industry-wide regardless of whether it's rural or even urban. Just thinking of a couple of those off the top of my head, labor costs and workforce shortages too, we're seeing those all over the place. Any perhaps unique approaches or strategies to either supporting talent retention or labor cost management that you all are helping your association with?  

Tim Powers: 

I think one of the main things, we started doing it in North Canyon. You have to have a bedrock culture. I mean positive culture, not negative though. You got to have positive energy. At one point, Phil, I mean our competition was going after all of our caregivers and they had deeper pockets than we did. So, I couldn't outspend them, but I can certainly make the environment more enjoyable for them.  

Phil Sobol: 

Exactly.  

Tim Powers: 

I think that's what we ended up doing in North Canyon. Any hospital that I visit, and I'd make it a point, two or three times a year, I head east and north and visit all of our members and primarily our critical access hospitals because I personally know the hardships and the things that you just spoke about, workforce issues and retention, and really try to reinforce what has worked for me and impart that back to them. A small hospital in Los Rivers, Idaho, to retain talent, you're going to have to have something unique there that brings the talent there and keeps the talent there.  

I think our hospital CEOs and senior leadership in a lot of cases, they've just done great jobs of creating environments that nurture that aspect, that keeps that employee content and happy in those marketplaces. We talked about advocating. These small, little independent critical access hospitals can't afford lobbyists to go and lobby on their behalf. I think that's the expectation they have of the hospital association.  

Phil Sobol: 

Exactly.  

Tim Powers: 

We have a great group of people that are well-entrenched and well-connected in the political arena. So, these bad bills that we get, we clean them up and make them as least offensive as possible or get rid of them as best we do. At the end of every legislative session, we create a scorecard and it's colored green, amber red. I'm happy to say again this year, most of it's green.  

Phil Sobol: 

Oh, that's great.  

Tim Powers: 

It means that the efforts of those that are in that arena on a day-to-day basis, it's just getting more difficult and more difficult to sustain that good color balance on that scorecard.  

Phil Sobol: 

Well, I love that you mention about building culture, and you talked about it even when you took that first role, right? You saw a community that was really wanting to rally behind the hospital and bought into that. I think I've had the privilege in speaking on this podcast with some of our other clients, whether they be physicians or whether it be chief nursing officers that have come up through the ranks and they just have a passion for their community. We see that time and time again. You're right, it's building that culture that feeds off of that passion. I think that's something that a large corporation or something like that they struggle with and it truly is an advantage, but you made mention of it, right?  

I mean, the end of the day, you've got to have good financials at the hospital. So, in revenue cycle management, you were touching on it. It's a really a critical component of that and it could really make the difference between having the ability to provide healthcare services to the community or not. So, I'm just wondering what seems to be working for the Idaho hospitals there to improve cash flow and financial stability?  

Tim Powers: 

I will tell you this, that one of the things that Healthcare Business Ventures does bring to the table are those organizational relationships with companies like your own that have an expertise that can be drawn upon by our members. I mean, whatever gaps that they might have on the rev cycle side or the liquidity side, I'm able to bring resources to them that can fill some of those gaps. I think being able to develop some of these relationships, actually, I'm not going to throw you under the bus, Taylor, but I'm going to mention to you, Taylor White cold called on me when I was in Winnemucca. I didn't know what I didn't know down there about the sorry situation that our managed care contracts were in.  

I am happy to report that through his previous organization, they've been able to do a number of different things down there and it all came about from that relationship. I've expanded that network of organizations here. So, they have access if they so desire and so wish to leading people in the healthcare industry that do the types of things that they need to do to be successful. In a lot of cases, they've done that. A lot of these operators at a lot of these hospitals, they don't take those jobs lightheartedly when they're offered to them.  

They know it's going to be a struggle. They know that they've got to collect every dollar possible on every plane that's dropped. I really feel that if your CEO and CFO and CNO and chief operating officer aren't visible, aren't part of the process, aren't assisting in that process, you've got a failure on your hands possibly. So, I think they need to immerse themselves in those processes as much as the rank and file.  

Phil Sobol: 

No, understood. I'm curious. So, we deal with a lot of CIOs. In fact, one of the associations that we do a lot with is called CHIME. It has a lot of CIOs associated with it. We recently did a survey. Of those CIOs that responded, cybersecurity was really top of mind for them as it relates to one priority anxiety, but then also budget, trying to find budget to really elevate their cybersecurity posture for the need to mitigate the financial risk associated with the cyber threats and the data breaches. From your seat as a CFO or a CEO of rural health, what does that cybersecurity issue look like from that senior leadership seat?  

Tim Powers: 

So I'll start with a quick story, Phil, if that's okay. 

Phil Sobol: 

Please.  

Tim Powers: 

So in Winnemucca, I had the trifecta. I had an EMR conversion and I had COVID. Then number three, I had a ransomware attack. That was a hospital that was well-healed. Their tax revenue from the mines down there, that hospital, when I started with them, that hospital had a war chest of money. When I found out what had happened over the last four years, our CIO down there had tried to update and create a better infrastructure of network security.  

Every year when it came to the budget, board had passed, board had passed, board had passed. So, we had this ransomware attack. Thank the good lord, we brought in the resources to help us through it. None of our data got dumped on the dark web. Our CIO was quick enough to withdraw that he started pulling network cables and power cords and closets around the hospital.  

Phil Sobol: 

Sure. 

Tim Powers: 

So when I found out all of those stories about the board, I brought in a group out of Washington. I brought in a group out of Reno to put a 24/7 monitoring service in place. That million dollar expenditure passed so fast it was on your head. So, a couple of things, what that story lends itself to, you've got to be able to articulate the risks involved with reaches on the type of data you're storing on people to your board. If it takes jumping on top of a table and jumping up and down, they've got to be as invested in the security of your network as you and the rest of your team are. I'll tell you this, nowadays, the amount of money that's being spent on cyber at these hospitals is unbelievable and everybody is doing as best they can to minimize the risk. It's not a matter of if, it's a matter of when.  

It could be a huge data breach. It could be an isolated data breach. We've got a relationship with a cybersecurity company. Actually, we use them here at IHA to defend our network. We've had several other hospitals utilize that particular vendor. But I think it's really articulating the risks involved with not putting your best defense available to your board and making certain that they understand how vulnerable you are as an organization at the hands of some of these bad actors out there.  

Phil Sobol: 

Well, unfortunately, it seems that they're getting more and more, but I think you make a great point and there's a lot of very, very smart IT people out there. But at the same point, it's an art form in putting together a board presentation and understanding the board, understanding where they're coming from, and then being able to clearly get that message across in a way that's respectful, meaningful, but meets them where they are from that standpoint. So, I think I appreciate you calling that out because it is something that I think we all sometimes tend to forget, right? It's like, "Oh, I'm smart from an IT perspective. Here's what it is. You should just automatically listen." It's just not how it works.  

Tim Powers: 

No, it's not quite how it works. I will tell you on that story, at Winnemucca, our entire PAC system was encrypted and we had an on-site radiologist. So, that poor guy- 

Phil Sobol: 

Oh, my. 

Tim Powers: 

... was at the hospital 60 days in a row 24/7 because he could only do one modality at a time and he had to go to that particular piece of machine to do it. We could have a whole conversation on the negative impacts of a cyber-attack on a healthcare provider.  

Phil Sobol: 

You know what? I do wish that more organizations who've gone through events like that would share their stories because I do think there tends to be either a public sense of sweep it under the rug or whatever it might be, but at the end of the day, people are searching. They're looking for help, they're looking for guidance, they're looking for assistance. When folks share those stories, when they share the impacts, it can only help others. I think that's what you guys are doing from an IHA perspective across the board, and certainly appreciate all of those efforts and getting that information out there to folks.  

Tim Powers: 

Right.  

Phil Sobol: 

That's great. So, chances are there's some healthcare leaders listening right now that feel overwhelmed, stressed, probably a few of them that go, "Oh, my. I've stepped into a situation just like Tim." Maybe there's any advice that you could give them based on those experiences, your perspectives.  

Tim Powers: 

You can't operate in a silo. A lot of these hospitals are 40, 50, 60, 100 miles from one another, but it should never limit their ability to pick a phone up and go, "What are you seeing over there? What's going on in your world in this particular service?" They've absolutely got the opportunity to do that with me. I've sat in their seat. I can share some of my life experiences with them. I think in a lot of cases, some people have. I think they look at that as that old, seasoned guy at IHA probably somewhere through his career has seen something like that.  

Phil Sobol: 

That's right.  

Tim Powers: 

I really implore them or call your neighbor CEO down the road and have a conversation. The more collaborative we can be on things, I think the better solutions we can come up with.  

Phil Sobol: 

I agree. Again, your passion shines through, Tim, on all of this. I think that's what I like about healthcare so much, and that is that willingness to partner, the willingness to share. I certainly appreciate everything that you've said as part of this podcast because I do think that there's a lot of folks out there that can glean something from those, particularly ones that maybe it's their first CEO role or they've just walked into a situation and they don't know what to do. 

So, certainly appreciate that. So, I'm curious, as one who's not spent a lot of time out in Idaho, maybe what's one of the biggest misconceptions of living in Idaho that you can just share with our listening audience? Healthcare, as you mentioned, can be stressful. Are there things that you do out there to try to relax, maybe any outdoor hobbies?  

Tim Powers: 

Just walking outdoor in Idaho is a trip and a benefit in itself. I'll tell you one of the misconceptions that definitely comes to mind. The state is not made up of a bunch of Napoleon Dynamites out here. There are some really classy people out here, and I think we get painted into a bad light with a lot of things in the past. But this is quite frankly one of the most beautiful states I have been in. I have seen all of it. I took a couple of business partners with me on a road trip in January, and the first night we spent was in McCall. We got up the next morning. It was 19 below zero, and you only had to walk about 20 paces between where the hotel was and the coffee shop. By the time you got there, exposed skin was hurting.  

Phil Sobol: 

That's right.  

Tim Powers: 

That's when I asked my business partners, I said, "When we get hospitals that are willing to see you, you need to be willing to commit to come with me." I'm not afraid of any of them, whether out in this crazy state. I'll go at any time. It's taken probably, and I will tell you this, you got to do the retina test with our hospitals here. If you're a business partner trying to do business on the phone does not work. It does not work. They're proud of their hospital. They're proud of their community. You need to get in a car with me and drive and see them.  

That to me is probably the biggest learning curve that I had to overcome with my business, with my organizations that were partnering with Ventures is you guys can't sell it like you think you can. The state is a little unique like that. I think if you were to canvas my business partners, they'd go, "Idaho's probably one of the toughest places to sell. They have experience." It is just the nature of these independent minded communities. So, I'm glad I've developed good relationships with people that are willing to come out here and experience the whole Idaho experience. That happens when you hop in a car and go in any time of the year.  

Phil Sobol: 

Well, that's excellent. I appreciate it. Well, Tim, as we draw this to a close, I always like to just make the last question an open-ended one. Any last words of wisdom that we didn't ask you about specifically that you wish we would've, that you would like to leave our listening audience with?  

Tim Powers: 

Nothing at all, but I'll try to put a wraparound everything, Phil, if that's okay. 

Phil Sobol: 

That's great.  

Tim Powers: 

When I first started in hospital-based work and started seeing community members that really had positive experiences at our hospital with our providers, I would have our employee meetings. Whether they were in full-blown employee meetings or just impromptu department meetings, I go, "There is not a better job on the face of this earth than to take care of people and specifically people in the community that you live. If you think there is a better job, you're fooling yourself."  

So one fellow who had been at St. Luke's forever put it in the proper perspective. He said, "We do God's work here." He's absolutely right. We do. That sums up my feeling about healthcare, Phil, is I can't imagine another venue that brings such positive feedback and positive feelings than taking care of people.  

Phil Sobol: 

Well, I cannot think of a better wrapper than that, Tim. It truly is why I know you do what you do, why the people in the hospitals do what they do, and quite frankly, why we do what we do in support of that as well. So, Tim, thank you very much for your time. Thank you for sharing your story. I'm hopeful that somebody listening takes that and says, "You know what? What I'm doing is worth it," and maybe encourages them to reach out. You mentioned finding a mentor, and maybe that's all it takes, to find that mentor, to get them through that tough situation, to really be able to deliver the quality care service to the community that's so rightly deserved. So, Tim, again-  

Tim Powers: 

I appreciate you all reaching out to me. This has been a lot of fun and there's nothing better to talk about experiences that have been meaningful to you. But thanks again, Phil. I really do appreciate it.  

Phil Sobol: 

Well, thank you. Thanks for listening to the CereCore Podcast. We hope you enjoyed this conversation. Follow us on your favorite podcast platform for more episodes. Connect with us on LinkedIn. Visit our US website at cerecore.net, and for those abroad, visit cerecoreinternational.net. Learn more about our services and find resources. At CereCore, we are healthcare operators at heart and know the difference that the right IT partner can make in delivering quality patient care 24/7. Let's help make IT better. Here's to the journey.