Featured In This Issue
At any point in time, 25 to 37 percent, or more than one in four people in the United States are dealing with mental illness, according to the federal Substance Abuse and Mental Health Services Administration.
“It can—and likely will—happen to anyone during the course of their life,” says Peggy Terhune, Ph.D., CEO of Albemarle-based Monarch, which offers behavioral health services.
This statistic totally disrespects any category of wealth, poverty, race, ethnicity, gender, or economic level. Yet Terhune says that what she does not find within the population of people who turn to Monarch for help are clients and patients.
“They are no such things,” says Terhune. “We call them people. If we call them clients and patients, we’re calling them ‘other.’ You’re saying they are different from you.” Terhune is adamant that they are not. “You’re a human being—I’m a human being—with all the hopes, desires and dreams that come along with that.”
Monarch provides services for adults and children with intellectual and developmental disabilities, mental illness and substance abuse challenges. Services, treatments and resource assistance in Mecklenburg County are administered through open access centers, outpatient clinics, intensive in-home services, community support teams, assertive community treatment teams, and transitional housing for people with mental illness.
Helping People Feel Better
Terhune is especially proud of Monarch’s open access centers.
“Somewhere, someone in need is walking into an agency. It’s like urgent care for mental health. We help them on the spot,” says Terhune. Most agencies will agree to see a person immediately only if they are presenting as suicidal or of harm to others. Terhune’s response is, “Why wait? Each person should get what they need when they need it.”
People exit from Monarch’s open access centers with an assessment, a prescription if needed, and an appointment or referrals for recommended therapies. “It’s so awesome to be with an agency that can do the right thing,” says Terhune.
“Peer support services also play an important role. Relating to someone who has walked in their shoes can really help another person along,” says Terhune. She also touts the Assertive Community Treatment Team. “They even go find people in need under bridges. If you are so depressed you can’t leave your home, we can come to you.”
Additionally, other services, such as those provided by group homes, employment services, day programs, and community services for adults and children, are available in various counties across the state. Services vary from one area to the next because providers such as Monarch are not approved to provide all services utilized by any one local management entity (LME) or managed care organization (MCO).
The MCO responsible for managing Medicaid funding for mental health, intellectual and developmental disabilities and substance use/addiction services in Mecklenburg County is Cardinal Innovations Healthcare Solutions, the largest MCO in the state.
“We’re very creative and innovative,” says Terhune, citing pilot programs across the state designed to further integrative care and safely keep people out of the hospital, as well as medical consultation and teleconferencing. Monarch is responsible for bringing Mental Health First Aid, developed on a similar concept to CPR, to get the individual out of danger to North Carolina. Training is available to individuals and professionals. Monarch is also looking for new ways to provide services to veterans.
A not-for-profit, non-governmental entity, Monarch has grown into an $80 million budget aimed at providing services across much of the state of North Carolina. Thirty-thousand people were treated or assisted last year through Monarch services. The organization operates over a 100 group homes. Still, these numbers aren’t Terhune’s focus: “I don’t care about the numbers. My priority is the individual person.”
“We have lots of programs, but we try to allow people to tell us what they need versus fitting them into a program,” says Terhune. “We want to meet individual needs; craft something around what those specific needs are.”
Terhune offers up a few words that she believes describe the organization: cutting edge, mindful, holistic, proactive, and evidence-based.
Monarch, mantra “Helping Dreams Take Flight,” refuses to define people by their diagnoses. “Instead, we recognize each individual as a person of worth and value. We teach and remind people, some of whom have often been marginalized, devalued, maltreated or stigmatized, how to dream—how to live self-determined lives.”
“Individual goals vary widely, develop over time, and often have to do with some aspect of mainstream desires for a home, job or relationship,” says Terhune. “But most people seeking help, initially, just want to feel better. People who are hurting want to be able to get up in the morning, put their clothes on and have a nice day.”
Meeting the Need
Monarch operates under a volunteer board of directors. Three-fourths of the members either have, or are recovering from, a disability or mental health issue or have a family member who does. Additionally, each member brings some expertise to the board, such as finance, legal, marketing, human resources, or a specific experience, all which add up to a diversity of skills.
Members who cannot read or are otherwise unable are assigned a board buddy who helps them navigate material and discussion. “We especially want to hear from these folks; they are the ones most affected by the decisions the board makes,” emphasizes Terhune.
Monarch’s origins date back to 1958, when Albemarle was a relatively isolated locale with Charlotte a distance away. The post-WWII baby boom increased the number of children with disabilities. At that time, it was illegal for children with disabilities to attend school. They could sit in Sunday school classes, where it was witnessed that they could learn. According to Terhune, this led a group of Albemarle parents to get together and form The Association of Retarded Children.
They established the first group home. Their work led to the organization of The Arc of Stanly County, which is one of many chapters across the state and country. The organization evolved, changing its name to The Association of Retarded Citizens, then Arc Services and later Arc of Stanly County, all before becoming Monarch. The Arc of Stanly County remains as the local advocacy chapter now operated by Monarch.
During the 1960s, with states beginning to realize that they needed to take care of people with disabilities, area programs started to develop. These programs were self-managed, often with little accountability of funding and costs.
North Carolina responded by establishing local management entities which were financially responsible, but contracted out all services. They act more like insurance companies, approving services and expenses, and are referred to as MCOs. These groups have continued to be reduced in number for greater efficiency.
Today, the legislative debate is over Accountable Care Organizations (ACO) in which health care providers come together to simultaneously lower costs and raise the quality of care. This model puts a premium on integrative care which allows doctors to communicate with each other and reduces the duplicity of services, particularly diagnostic testing versus more general managed care.
These several decades have seen enormous strides in mental health care. “One of the things we know today is that one can recover from mental illness,” says Terhune. “We’ve gone from warehousing people that we thought would never get better to thinking that people can get better with appropriate services and medical intervention.”
Causes and Costs
Although much has been learned about mental illness, its exact causes still largely elude the medical research community. It is generally accepted that some mental illness can be hereditary, or genetically acquired, or caused by chemical imbalances in the brain.
Also, many medical issues carry a psychiatric component. People with chronic disease, such as diabetes or heart conditions, are more likely to have mental illness, as well. Circumstances, especially loss or trauma, can trigger mental illness. It is also believed that greater rates of diagnosis are behind the increased number of people with mental illness.
The social impact of mental illness and the stigma around it is often measured in losses—of homes, family structure, jobs, self-esteem, and overall health.
“Sufferers, if not treated, can lose everything,” says Terhune. There is also a great cost to productivity and the economy with losses of wages and tax dollars, and increased cost of services and systems—fire, police, EMS, prisons, hospitals, and schools—which are burdensome to society.
“The cost is huge,” laments Terhune. “We could so contain that cost if we had adequate, sufficient services.
Monarch obtains funds from Medicare, Medicaid, private insurances, Social Security and individual payments. Funding also comes in the form of grants, donations and in-kind contributions.
“We lose money on some services—people with no insurance—and balance that with other services,” says Terhune. “We also have to spend money on buildings, furniture and fixtures. The square foot rental cost of the restored warehouse where Monarch’s state headquarters is located is discounted by tax credits, but we can’t find that everywhere.”
Terhune’s frustrations are apparent when the discussion turns political. “Do I seriously hope that North Carolina legislature’s agrees at this point to accept the federal Medicaid expansion signed into law with the Affordable Care Act?
“Because behavioral health services are capitated, predictable and cost-effective, North Carolina needs to accept Medicaid expansion,” says Terhune, who sits on the five-member Medicaid Reform Advisory Group appointed by N.C. Gov. Pat McCrory.
“Can you imagine how many people could be helped? People express concern over Medicaid but we keep voting the same people into office. Why don’t we vote in people who get it?”
Monarch has experienced significant growth since its name change in 2008 and its expanded service offerings (beyond those for people with developmental disabilities) to include mental health programs. “People keep calling us and inviting us in. We’re in all of North Carolina’s MCOs in some way. We have the value they want,” says Terhune.
Another way Monarch has grown is by acquiring services from other organizations. “We are happy to merge with other providers; we do it all the time,” says Terhune. “We’re mostly looking for shared values, but we have taken on groups that are inept or are about to go under.”
Terhune explains that these expansions can be expensive. “Our board of directors says that we have to break even.”
One at a Time
One of Terhune’s first experiences with mental illness took place growing up in Brookfield, Ill., in the 1950s when her father, who worked in medical supplies, took her along to an orphanage of sorts that provided her with some ugly truths about how America treated people with mental illness and developmental disabilities.
The children were very sick, expected to die. Babies were housed in cribs lining the walls. Older children, ages four or five, were in cages and had not been taught any language skills. There was no visible staff. Terhune tried in vain to persuade her father to take one of the children home.
She remembers his words: “Peggy, you can’t save everyone, but when you grow up you can do whatever you want to do.”
And Terhune is doing just that. As horrific as it was, the experience solidified her desire to do something for the people represented there.
Having earned her bachelor’s degree in occupational therapy in 1974 and an M.B.A. in 1984, Terhune accepted her current post in 1995, after being second in command with a similar organization in Rochester. She has since earned her Ph.D. from The University of North Carolina at Greensboro. She has been married to “the love of her life” for the past 22 years.
Terhune loves kids. Her husband loves kids. Together, they have raised a combined family of seven children and have fostered over 100 children. They are currently serving as therapeutic foster parents.
“It’s who we are,” says Terhune. “When you do what I do, it’s your whole life; it’s your value.”
“I have the best job in the world. I am so privileged,” says Terhune. “Every day I get to come to work and save the world and do God’s work. You save the world one person at a time. Every single day one of my 1,800 staff is touching someone in need; helping dreams take flight.”
Most people don’t think about the possibility of needing home health care, but for one entrepreneur, the thought of assisting others became his passion.
In 1975, Mark Baiada, alongside one nurse, created BAYADA Home Health Care in order to meet the rising need for home health services in Philadelphia, Pa. Today, the company has expanded across the globe with nearly 300 locations, including five right here in Charlotte.
As a BAYADA Division Director Melinda Phillips says, “Our company was founded on the principles of compassionate care and understanding for those in need. Mark Baiada realized that medical technology advancements didn’t need to keep people confined to hospitals for long periods of time, so he set out to create a company that would allow individuals the chance to receive care at home.”
Today, BAYADA Home Health Care operates offices in 22 states and in India, providing a range of home health solutions for clients facing a variety of needs, including wound care, light housework and habilitation.
Responding to the Need
Phillips describes Baiada’s model for growth as allowing people who had proven themselves to go where they wanted and open offices to expand the business and offer compassionate care. In 1989, one of his trusted employees, Tom Mylet, decided to come to North Carolina and open an office in Winston-Salem.
“In fact,” says Phillips, “I started working with BAYADA Home Health Care as an associate at that location in 1994, allowing me to engage in my passion for service to others.”
“After some time as an associate, I became a client services manager and had my own case load. Once that grew large enough, in 1998, I presented Mark Baiada with the idea of opening a Charlotte location. I saw how we were able to help people in Winston-Salem, and I knew there were needs elsewhere in the state. He agreed and the first BAYADA Home Health Care office in Charlotte opened in the University Park Executive Drive area.”
The new office was a success from the start. Under Phillips’ leadership, the company opened more office locations in Charlotte, designating Charlotte as a division with multiple offices.
By 2009, Phillips observed that each office handling all lines of service, including pediatric home care and home health aide care, put a strain on resources and personnel. She had a logical suggestion.
“It seemed logical with multiple offices to start specializing. So now, each office in the Charlotte region specializes in a specific type of care. This allows BAYADA Home Health Care to better manage our client’s needs,” she affirms.
There are over 50 BAYADA offices across the Southeast, including North Carolina, South Carolina, Georgia, and Florida. And, as per the company’s decision to offer specialty care, each office offers a different specialty. These specialties are adult nursing care, adult personal care, pediatrics, and habilitation, which offers care for people with developmental and intellectual disabilities.
“We saw that BAYADA Home Health Care could provide a greater number of services and a better quality of care if the company were more focused,” attests Phillips.
“All of the locations I oversee each have a director, client services managers, and clinical managers who are registered nurses. The client services managers handle interviewing staff and scheduling case shifts, and the clinical managers handle oversight of the clinicians. So, across all service lines, we ensure that each base is covered.
“We’re one of the few home health companies in Charlotte that does it all,” Phillips adds. We don’t do it all from one office, but we can handle anything. If you need home care, we can get it to you.”
Phillips stresses that BAYADA Home Health Care is committed to not just providing care, but also seeing patients get better. She notes that, 30 years ago, a child who underwent a tracheostomy (a surgical procedure to create an airway into the trachea when the usual route for breathing is somehow obstructed or impaired) would be in the hospital for months, but today, through BAYADA Home Health Care, that same child can recover at home under the supervision of trained specialists.
In fact, Phillips notes, “BAYADA Home Health Care is the largest provider of pediatric home health services in Charlotte.”
Aside from traditional at-home care, BAYADA Home Health Care also offers its services to assisted living communities, and it often receives referrals from doctors and hospitals. Additionally, the company has a dedicated staffing office in Charlotte that provides medical assistance to physicians’ offices, hospitals, and other medical businesses throughout the region.
Speaking globally, Phillips says, “We’ve recently begun services in India through India Home Health Care. They wanted to adopt our model, so last year, Mark Baiada asked me to go to India and support them, give consulting, do some training. It was a great experience, and I can’t wait to see that division grow. We’re also currently working to gain an acquisition in Germany.”
Making a Difference
When asked what makes BAYADA Home Health Care different from other providers, Phillips says, “A lot of companies simply write their mission statement down. The difference is the BAYADA team is expected to live by ours. Our core values are compassion, excellence, and reliability, and our team is dedicated to living these values out in our personal and professional lives.”
Phillips recounts with some passion, “In 2004, Mark Baiada started thinking about articulating his legacy. Teaming up with Dr. Al Freedman, a teacher and psychologist, Mark described his emotions relating to client care. Dr. Freedman helped him craft The BAYADA Way, the defining set of values that we, as a company, live by today.
“Then, Mark wanted to ensure that the company’s values were uniformly supported, so he embarked on a nationwide tour of every single BAYADA Home Health Care location to speak with not only employees, but also clients.
“During this tour, Mark received feedback regarding everything from workplace happiness to client satisfaction. As a result, The BAYADA Way was finalized and distributed across all company locations. It provides a guide path to all employees regarding the dispensation of total care and compassion for clients, excellence in all that they do, and reliability in delivering professional medical services.”
Phillips emphasizes, “There are three essential things that separate us from the competition, and chief amongst them is The BAYADA Way. Our people live our core values. We truly mean it when we ascribe to compassion, excellence, and reliability.
“Second, we’re privately held, meaning we have a lot of flexibility when it comes to providing care. Mark’s heart and my heart are in this…all of our employees’ hearts are in this. While other home health care companies are bought and sold every few years, we’re not. They cater to shareholders, we cater to our clients’ needs.
“Third, is that we offer continuity of care. When you need multiple home health services, you’re going to be dealing with multiple companies, but with BAYADA Home Health Care, we have our clients covered across a range of services.”
This third point is ultimately what has made BAYADA Home Health Care as successful as it is in Charlotte and beyond. Phillips points out that the vast majority of the company’s marketing strategy has relied on word-of-mouth advertising and client referrals as well as repeat business. In addition, the company has continued to add more specialty services to its roster in order to drive business.
“In the beginning, we had basic home health care services, then we added pediatrics, and then more services were added as we saw needs grow. In fact, I remember starting out in Winston-Salem and receiving calls from Carolinas Medical Center and Baptist Hospital asking, ‘Who is going to care for these babies?’” recalls Phillips.
Phillips says that the people of Charlotte are what first drew her to the area; aside from the need in the city and its surrounding area, she says she observed the strong work ethic and the overflowing compassion that Charlotteans have.
“The people are what have made us successful in Charlotte. We’re tough on each other and hold each other accountable, but we’re all committed to the same goal: We put The BAYADA Way first. It’s not about us, it’s about the client,” smiles Phillips.
“We’ve evolved through The BAYADA Way,” Phillips continues, “but also through offering specialties. We encourage our people to find their niche, whether that be home health, pediatrics, or something else. When you put someone in a field they love, they’ll do all kinds of amazing things.”
Exceptional People; Exceptional Standards
Because home health care is such a personal industry, BAYADA Home Health Care goes out of its way to attract and work with the best. The company typically brings in new hires through recruiters and targeted ads, followed by a phone interview to assess qualifications. If they meet requirements, candidates are then brought in for an interview with office staff and a skills test. Only candidates who have at least one year of supervised experience are considered.
After that comes a thorough background check, a drug screening, and a clearance from the Office of Inspector General to ensure that candidates don’t have governmental violations. From there, successful applicants are brought in for an orientation and then spend another 30 to 48 hours in home and lab tests to further assess skills. After completion, a specialist may spend as much as 30 days with a supervising mentor in a client’s home to ensure a good fit.
Phillips explains, “Integrity is one of the most important things we look for in our employees. Because they are expected to live The BAYADA Way, we don’t cut corners in our hiring process.
“Success is measured by client satisfaction. We use a nationally-recognized outside vendor for surveys to gather satisfaction ratings. We have three key questions out of many that must be marked as 100 percent satisfactory in order to determine where we stand. If those three questions aren’t 100 percent, we investigate the problem completely.”
Phillips says that the goal is not just to manage a client, but to improve his or her health. If that isn’t happening, BAYADA Home Health Care is not doing its job.
BAYADA Home Health Care has also taken advantage of developing technology, using tablets for keeping track of patient and employee records as well as offering a physician portal on its website to allow doctors the ability to see patient chart information 24 hours a day.
In addition, the company has a simulation lab at its Charlotte office for training purposes. They use a mannequin that can simulate a variety of medical conditions. For example, anaphylactic shock—in such a case, the mannequin’s tongue actually swells to simulate a real-life reaction to an allergy. The simulation lab is also outfitted with cameras so that training staff can not only monitor trainees, but also play back video to demonstrate what went right and what went wrong.
BAYADA Home Health Care also uses technology to scour sources for government funding to cover Medicare and Medicaid patients, and in this tight economy, to find new ideas to provide more and better care at a lower cost.
“We’re committed to patient care and employee satisfaction,” says Phillips. “That’s The BAYADA Way, and it always will be.”
The Centers for Disease Control and Prevention cites nearly 130 million visits to U.S. emergency rooms (ERs) in 2010. Statistically, that is around 43 visits per 100 people annually. As often the first and sometimes the last defense against medical crisis, emergency departments (EDs) are the melting pots of their communities, seeing all walks of society and adapting to technological, cultural, economic and legislative change.
Hospital EDs perform a vital and complex role for the communities they serve, and for the last 38 years, Mid-Atlantic Medical Associates, P.A. (MEMA) has played a pivotal role in emergency medicine in Charlotte and the surrounding region.
Founded in 1976, MEMA is an independent, physician-owned emergency medicine practice that provides emergency and acute medical care through its longstanding relationships with several area hospitals.
With corporate leadership including a chief operating officer, chief financial officer and a professional recruiter, and governed by an elected board of directors, MEMA currently consists of 48 physicians who are board-certified/board-eligible in emergency medicine and pediatric emergency medicine, with several physicians double-boarded. MEMA also has 24 advanced practice providers, including both physician assistants and nurse practitioners.
Partners in Health Care
MEMA President and CEO Timothy Lietz, M.D., FACEP, explains the practice’s origins.
“We’ve been at Presby [Presbyterian Hospital] 38 years,” Lietz says. “We were the first emergency department group to staff that hospital. Before that, the emergency department was staffed by community physicians who would take turns.
“MEMA was originally a group of doctors who did the majority of shifts. Then they were hired by the hospital and eventually they became an independent group of emergency medicine specialized staff that provided the service to the hospital.”
Lietz joined MEMA in 1994 to staff the then newly opened Presbyterian Matthews hospital and was medical director there for 17 years.
Since 1976, MEMA has provided the 24/7 staffing for the Novant Health Presbyterian Medical Center (formerly Presbyterian Hospital Charlotte) ED and currently also provides 24/7 ED staffing for Novant Health Matthews Medical Center and Novant Health Huntersville Medical Center.
The ED of the new Novant Mint Hill Medical Center, slated for completion in 2017, will also be staffed by MEMA when it opens.
Lietz describes the practice’s relationship with the hospitals they staff as a strong partnership involving common goals.
“We walk hand in hand with Novant Health in their goal of a remarkable patient experience,” Lietz says. “It’s our vision as well. We’re dedicated and committed to it. We had staffed other hospitals in the area but when their vision became different from ours, we went separate ways.
“Our goal is a patient-centered experience where we provide the best, highest quality emergency care. Physicians aren’t the only factor in accomplishing that. The hospital, the nursing staff, the administration and the tools available to us are all factors in making that happen.”
MEMA’s close relationship with partner hospitals is reflected in their joint work. All three Novant Health Medical Centers are certified stroke centers and accredited chest pain centers and Novant Health Presbyterian was the first hospital in the Charlotte area to open a dedicated Pediatric Emergency Department in 2003. The department was expanded in 2011 and is staffed by MEMA physicians that are board-certified in pediatric emergency medicine.
MEMA physicians are also involved in key hospital committees such as the Medical Executive Committee, Emergency Services Council and the ED Hospital Steering Committee, among others. “Innovation is collaborative between us and the hospital,” says Lietz.
One such innovation implemented last year was the Safe Sign Out Project. “One of the times most vulnerable to mistakes is when patients are turned over at the end of a shift,” Lietz explains. “If a patient is in the middle of a work up and is waiting on results from an X-ray or a CT scan, things can be miscommunicated or not properly followed up.
“To prevent these issues, we decided to institute a formal process to ensure that all information was provided to the oncoming physician. In this way, the physician taking over care of the patient has the patient’s anticipated diagnosis, pending tests and a tentative action plan. It enhances patient care at our partner hospitals and makes our practice safer.”
Commitment to Leading
The relationship between MEMA and its partner hospitals is bucking a trend. Lietz notes that MEMA is the last independent emergency group in Charlotte. “When I first came to Charlotte in 1994 there were three or four private practice emergency groups that staffed area EDs,” he explains. “Now some of the hospitals use national contract groups to provide their physician services.”
Integration, where hospitals buy private practices and physicians become employees of the hospitals, is also a long-term trend in Charlotte and nationwide. “Maintaining our independent practice status is a challenge,” says Lietz, “but we believe it is the best way for MEMA to remain a high quality practice.
“Our independent, physician-owned status allows us to hire physicians who eventually become owners of the practice and who are committed to making the practice a success,” he says. “We hire people who want to be in the Charlotte area and establish a long-term career here. National contract groups often have doctors who will work here for a few years and then move onto other regions.
“We try to develop a core group of physicians at each one of our hospitals who will spend their careers there. That way we get to know the medical staff and hospital administration and become integrated into the medical community of the Charlotte area.
“What makes us stand out is that our physicians are committed to our group, they’re committed to their hospital and they’re committed to their community.”
Leadership also makes MEMA physicians stand out. Of their current physician members, 19 are former chief residents; 11 are former attending physicians from teaching hospitals; three are past presidents of the North Carolina College of Emergency Physicians; two are current councilors of the North Carolina College of Emergency Physicians; two are current board members of the North Carolina College of Emergency Physicians; one is a current representative to the American College of Emergency Physicians, Reimbursement Committee; and Lietz currently holds the prestigious position of a member of the North Carolina Medical Board.
“It’s important for us to hire leaders in emergency medicine,” he says. “We hire people who are leaders among their peers as medical students and residents so that during their career with us they become leaders within emergency medicine in our state.”
The Charlotte community appears to also think that MEMA physicians stand out. In 2007, a MEMA doctor was named Presbyterian Healthcare Physician of the Year. In the 2013 Charlotte Business Journal list of Top ER Doctors, three of the five doctors named were MEMA members and in the 2014 Charlotte Magazine Top Emergency Doctors, five of the eight top doctors were MEMA physicians, including Lietz.
Lietz says he chose emergency medicine because he likes the high volume and high intensity of the specialty. “Every day, every shift is a new adventure,” he says. “We’re diagnosticians. We see a patient fresh. We see a set of vital signs and their chief complaint and we make a diagnosis. Other than that, it’s about trauma care, stabilization and resuscitation. Everything under the sun comes into the emergency department and we take care of it all.”
With life and death stakes as a regular part of a work day, you might think emergency medicine doctors would become emotionally detached from the crisis situations they routinely encounter and efficiently handle, but when asked about a memorable work experience, Lietz has trouble beginning—still emotionally impacted by the case years ago.
“About five years ago, I took care of an 18-year-old girl. She’d had a stroke. She was 18 years old.,” Lietz emphasizes. “She was in the emergency department all day—critical care, life support—all that stuff the whole time. We thought she was going to die.” Lietz pauses briefly to compose himself.
“About four years later, a young woman comes up to me in the ER and asks me if I remember her and tells me that I took care of her when she had a stroke. Today she works in our ER as an administration person.”
Real World Medicine
While the very nature of emergency medicine is a difficult one fraught with inherent challenges, emergency medicine today faces complex issues that can significantly impact its practice.
“Our practice mirrors what goes on in the real world,” affirms MEMA Chief Operating Officer Michael W. Icenhour. “When I started with MEMA 15 years, ago our Medicaid population was 16 percent. Now I’d estimate it to be around 25 percent.
“After the economic downturn, we saw a difference in our payer mix. Medicaid went up, self-pay went up and commercial (insurance provided by employers) went down. Our ER physicians treat patients based on acuity only, not on whether they have or don’t have insurance. But if 25 percent of our patient population is self-pay, that’s a huge issue for us from a business standpoint.”
The Congressional Budget Office estimates that through the implementation of the Patient Protection and Affordable Care Act of 2010 (PPACA) an additional 32 million Americans will have health insurance by 2019.
To date, Lietz and Icenhour say they have not seen an improvement in coverage. “The North Carolina Republican-controlled general assembly has elected not to expand Medicaid in the state so there’s a gap of people between those who can get subsidies to pay for their health insurance and those who are eligible for Medicaid,” explains Icenhour. “Those in the gap are our self-pay patients.”
“A huge challenge is taking care of all the folks who don’t have the resources to get health care,” Lietz adds. “Part of the practice of emergency medicine is taking care of the people who can’t get health care anywhere else but there’s a misconception out there.
“People don’t use hospital emergency departments as primary care because they need routine care for their diabetes or hypertension. They show up for an acute part of that illness. So a diabetic will show up in the emergency department because their sugars are out of control or in the case of hypertension, because their blood pressure is sky high. We take care of the acute phases of a chronic illness but we don’t function like a primary care physician.”
The cost of caring for the uninsured, which is absorbed by EDs, has serious financial consequences. According to the American College of Emergency Physicians (ACEP), the annual number of ED visits has increased by 23 percent from 1997 to 2007. Contemporaneously, 535 hospitals closed, 381 EDs folded operations, and available inpatient beds shrank by 134,000, exacerbating a nationwide problem of ED crowding.
“It’s a complex problem,” says Icenhour. “Even if everybody gets insurance, we don’t have enough primary care physicians to take care of all these people. I was talking to my primary care physician about this and he said he can’t find any internists to hire. They’re not out there, so people who can’t get in to see a primary care physician will still have to come our way until the crisis in primary care physicians is resolved.”
In fact, the ACEP points out, “In sum the PPACA, by increasing insurance coverage to individuals who in the past had none, and by not addressing the PCP [primary care physician] shortage, will exacerbate the problem of ED overcrowding by an influx of 13 million newly publicly insured patients.”
“For the Affordable Care Act to really work it’s going to take a culture change,” says Lietz. “It’s not just about how we pay for health care. People are going to have to change the way they think about getting their health care.
“They can choose to maintain their health instead of just using the emergency department for an acute medical crisis. That could change the role of EDs in health care, but unfortunately people are still going to have heart attacks and strokes and get into car accidents. They’re still going to need us and we’ll be here to help them.”
When you think of renovation, you likely think of upgrading a few fixtures in a kitchen or bathroom, but for the Crowne Plaza Charlotte Executive Park located at 5700 Westpark Drive, renovation has meant a year-long process to change not just the look of the hotel, but also the feel, both inside and out. From the new open lobby/restaurant/bar concept to the guest rooms and even the hotel’s green spaces, virtually everything has received an upgrade that calls to mind beautiful European influences.
Of the renovations, General Manager Bill Bennett says, “When you look at the scope of the renovations that we’ve done at this hotel over the past year and how dramatically they have changed the look and feel—to take a building that’s served this market for over 30 years and completely change it—it’s just exciting to be a part of that.”
Although the Crowne Plaza brand is new, “The hotel itself was built in 1983, so it’s been serving the Charlotte market for quite some time,” acknowledges Bennett. “It originally operated as a Marriott hotel. At that time, Marriott was in the middle of a very large growth span, so you saw a lot of these hotels open in the early to mid-’80s.
“One of the main attractions here was a high-energy nightclub, which is now our lobby/restaurant/bar concept, ‘Food for Thought.’ This was one of the first true luxury hotels outside of the city center area, and a lot of people we talk to have fond memories of coming here for meetings or to the nightclub during that era.
“It operated under the Marriott franchise agreement until June 2013. The prior November, Marathon Asset Management, located out of New York, bought the hotel. At that time, they were reevaluating the direction they wanted to take things and they questioned whether Marriott was the right brand. Even though it had been operating under Marriott for 30 years, was it truly reflective of what today’s business traveler is looking for?”
Marathon Asset Management decided to convert the hotel to the Crowne Plaza brand. Crowne Plaza is part of the InterContinental Hotel Group, the largest hotel chain in the world. Currently, the company is in the process of completing a full re-launch, and the Charlotte location is conceptually the face of the new Crowne Plaza brand.
Bennett continues, “June of 2013 we came under new management by Valor Hospitality Partners, based out of Atlanta, Ga. I’ve been at this hotel since April 2010. I come out of a sales and marketing background, but I do have a history of running hotels as well with the Peabody Hotel Group under the Hilton brand. When we converted to the Crowne Plaza hotel, I was honored to be appointed to general manager.”
Renovating and Reinventing
It has been a challenge over the course of the last year for the hotel’s staff to contend with providing guests with excellent service in the midst of renovations at the Crowne Plaza Charlotte Executive Park, acknowledges Bennett, yet rewarding he says as he’s watched his team handle the process with skill and ease. In fact, he acknowledges, “The team is the heart of the hotel.”
He explains, “24/7…that’s an operation that takes a team in order to be successful. Our management philosophy is that we believe our relationship with our associates is cultural. We have to develop the culture where our associates can excel. Our relationship with our guests is emotional. Knowing and understanding that travel today is much different than it was five years ago, 10 years ago, we want to make that emotional connection with our guests, and it’s only through our associates that we can do that.”
“A hotel is nothing more than brick and mortar,” Bennett adds. “No matter how much money you invest into a property, it’s your hotel team that gives it its personality. The culture within a hotel is what plays a major role in delivering a memorable guest experience. So, in order to take care of a 24/7 operation, you have to surround yourself with stellar team members, and you have to develop a culture where those team members can excel.”
Finding the right team members, however, is only one piece of the puzzle. In a city full of lodging accommodations, it can be easy to get lost in the crowd as more and more hotels are vying for the business of travelers in the Queen City. In fact, near Crowne Plaza alone, there are at least six hotels within walking distance.
As companies like Bank of America, Wells Fargo and Duke Energy have expanded over the last decade, they have brought with them more workers traveling in and out of the region, meaning it takes more than just a comfy bed to attract guests.
In order to stand out, Bennett says, “First, we have to start with the facility itself. There’s no other facility in the city of Charlotte that can offer what we do in terms of proximity. We’re three blocks from the Lynx light rail. And if you want to go to uptown, go to South Park and do some shopping or enjoy dining at some of the bistros there, if you want to go to the White Water Center or to Carowinds, literally everything is within about a 15-minute reach of this location.”
“On top of that,” he continues, “we offer 300 guest rooms and, 16,000 square feet of meeting space. But we also sit on almost seven acres of land, so we have a park-like feel to the hotel. Our pool deck area is very expansive, contains dual fire pits, and is able to accommodate receptions for up to 200 people. Simply put, our outdoor area is second to none. Additionally, there’s only a handful of full-service hotels that offer complimentary airport transportation, and we’re proud to be one of them.”
Crowne Plaza Charlotte Executive Park is also meticulous in how it organizes its team as the facility caters to thousands of guests each month. Using a leadership team comprised of Bennett, a sales and marketing force, food and beverage director, a chief engineer, a director of financing, an executive chef, and several other experts, Crowne Plaza Charlotte covers every detail to deliver a memorable guest experience.
“Everything that we’ve done with our restaurant ‘Food for Thought’—in fact, everything that we’ve done with our entire kitchen’s makeup—has been scrutinized by our leadership team,” Bennett remarks. “When searching for an executive chef, we spent nine months, reviewed 180 resumes, and flew in 10 candidates just to find the right individual to fit into this team.
“This hotel, even under the dramatic, invasive renovation that we’ve experienced over the last year, is currently rated number four for meeting satisfaction tracking surveys,” Bennett continues. “Out of 400 hotels, we’re number four, which is something that wouldn’t be possible without our leadership team and all of our associates.”
Keep Guests Coming Back
Speaking to changes and growth at Crowne Plaza Charlotte Executive Park, Bennett says, “Right now, we have about 140 employees, but we anticipate seeing that grow. Over the course of the last year, we’ve had on average 74 rooms out of service at a time, and as we continue to rebound out of this renovation, we anticipate adding about 30 new associates.
“Charlotte is such a dynamic market, and we’ve had unprecedented occupancy growth. I want to say something like 36 months of continued occupancy growth within the city itself. As a result, it’s our duty to our guests to keep up with this growth.”
Attracting and retaining guests also requires the right marketing, the right loyalty rewards, and the right feedback mechanisms. Currently, Crowne Plaza Charlotte uses a variety of marketing channels, including digital and print, but it also relies on its strategic partnerships with BMW Motorsports and the PGA Crowne Plaza Invitational at Colonial to get the word out.
In terms of building guest loyalty, Bennett points out that the hotel targets a demographic referred to as “strivers.” These individuals are highly motivated and work in a fast-paced environment, but they are also in need of a hotel environment where they can transition from work to leisure to socialization, all in the same area.
“Take a look at how this hotel is now designed to accommodate today’s traveler,” says Bennett. “They can sit in our lobby and enjoy complimentary WiFi, which is also available in all guest rooms, and that’s something that’s rare in today’s hotel environment. They can return their emails, watch sports on TV, get a bite to eat, share a plate or cocktails with friends, all from the comfort of our lobby. This is just one small part of what keeps our guests coming back.”
He continues, “We also offer IHG Rewards, the largest hotel rewards system in the world, but brand consistency is key as well. What you receive in Charlotte is what you’ll receive at the Crowne Plaza in Greenville, S.C., or at any one of our 400 locations.”
What Bennett truly attributes to Crowne Plaza’s success in keeping guests coming back, however, is the passion with which its management team serves each hotel.
“Every management company has their own mantra or value system, but how many really believe in their passion and develop an entire company around it? At Valor Hospitality Partners, our managing partner, Euan McGlashan, has operated the Cape Grace Hotel in South Africa, the number one hotel in the world as recognized by Condé Nast.
“After this experience, he decided that he was going to start his own management company. He wanted to work with people that have that passion for excellent service, people that want to be successful. In a short amount of time, Valor Hospitality Partners is up to 22 hotels in the United States and in Europe, which is why you’ll see the European influence in our recent renovation.”
Keeping Up With Change
Bennett keeps abreast of technology as it impacts the hotel industry as a whole and specifically Crowne Plaza Charlotte Executive Park. “Technology is a major player shaping the future of our industry, and I think it’s great—but it can also be a hindrance,” he remarks. “Nowadays we need to be connected, but at the same time, we need to be able to just unplug.
“We offer free WiFi and a strong bandwidth and things like programmable voicemail for our guests, but we’ve also designed our pool, fitness and green spaces to be inviting to help our guests get away for a little bit.”
Indeed, technology is changing the face of the hotel industry. Many hotels are toying with the concept of doing away with check-in and check-out times, allowing customers to remotely check-in online, and some have begun instituting the ability to use smart phones to unlock doors. This may speed up the check-in process, but it can also lead to a “self-service” experience.
Bennett says, “At the end of the day, the hotel business is still about the art of hospitality, and in order to be hospitable, you have to have a staff that is trained in guiding towards that. People still want to be pampered, recognized, they still want to sit down and share a plate with friends. Whoever can provide that along with the technology side is going to win the race.
“I feel like, as an industry, we’ve done a great job at greying those lines of delineation. Today’s business traveler knows that they need convenience. They need something that’s clean. They need to have something—how they want it—at the time they want it.
“It still goes back to the fact that we’re in a people business and you have to provide that level of care and understanding.”
Last October, all anyone seemed to be talking about was the Affordable Care Act (ACA). The first open enrollment period had just begun, and nothing seemed to be going right.
Millions of Americans were receiving cancellation notices from their health insurance providers because their existing health insurance policies didn’t meet the minimum coverage requirements. On top of that, the website for the federally operated insurance exchange repeatedly crashed, unable to handle the volume from a crush of consumers shopping for new coverage.
ACA implementation certainly got off to a rocky start, but one year later, the program seems to have regained momentum. Despite rollout problems, over 8 million Americans signed up for health insurance coverage on the state and federal marketplaces and another 8 million or so consumers gained coverage through other provisions of the new law.
Now, as the start of the second enrollment period looms on November 15, what changes can we expect nationally, and more specifically, in North Carolina? Will the website work this time, and what else will change for 2015?
Success But Challenges Remain
According to the Department of Health and Human Services (HHS), between October 1, 2013, and April 19, 2014, nearly 2.6 million people signed up for health insurance coverage on State-based Marketplaces and over 5.4 million signed up in the Federally-facilitated Marketplace. An additional 4.8 million people gained coverage through Medicaid expansion, and HHS estimates another 3 million young people under the age of 26 gained coverage under their parents’ plan, bringing the total Americans securing new health care coverage to over 16 million.
Health care advocacy group The Commonwealth Fund conducted a national survey of 19- to 64-year-old adults this spring to compare to a similar survey conducted in the summer of 2013, prior to the first enrollment period. The survey found that the uninsured rate for the 19-to-64 age group declined from 20 percent in 2013 to 15 percent in 2014. The uninsured rate for young adults 19 to 34 declined the most of any adult age group, falling from 28 percent to 18 percent.
In North Carolina, 357,584 people enrolled through the Federally-facilitated Marketplace. Of those, 91 percent qualified for federal premium subsidies. Most popular were the mid-tier Silver plans, chosen by 74 percent of enrollees. North Carolina was in the top five nationally in ACA enrollment.
As the only insurer to offer products on the exchange for all 100 North Carolina counties, Blue Cross and Blue Shield of North Carolina (BCBSNC) signed up over 230,000 customers through the Federal Marketplace. (Aetna’s Coventry subsidiary, which offered coverage in 39 counties, accounted for the rest of the NC total.) But with an estimated 1.3 million marketplace-eligible consumers in the state, BCBSNC President and CEO J. Bradley Wilson says there is still a huge opportunity to tap.
“There’s great opportunity out there for 2015 and beyond,” says Wilson. “There are plenty of people who did not choose to purchase for 2014. It was a strong start, but there are many more people who can come into the system beginning this fall.”
With the success of the 2014 enrollment, one additional competitor will enter the North Carolina marketplace for 2015. United Healthcare will become the third company on the N.C. exchange, but may not offer products in every county.
Despite the strong start, Wilson says there are reasons for concern moving into 2015. A massive effort is underway to get the Federal Marketplace website functioning properly, but he says technology concerns remain for the second enrollment period, which runs from November 15, 2014, through February 15, 2015.
“As we all know, the technological capability of the federal exchange fell far short of anyone’s expectation,” says Wilson. “I know they have been working diligently since the close of open enrollment in April to get ready for reenrollment in November. But while great strides have been made, our concern is that it is still going to fall short.
“People who are looking for the Amazon-type experience this fall will not have that. It is still going to be challenging and complicated, but we are all committed to working together to make it as seamless and as painless as possible.”
The renewal process for 2015 plans is intended to make it easier for customers to keep the plan they selected last year. However, it is important for customers to update their information for 2015 subsidy eligibility. There is a new calculation, so even if customers do not have any changes to their personal information, they will want to make sure they receive the amount they are qualified to receive in 2015. If no updates are made, the system will automatically renew with 2014 information.
But the technical challenges are not the only issue for 2015. As it turns out, the health demographics of the 2014 enrollees were somewhat different than expected.
“We’re also concerned because the pool of new customers was generally less healthy than what we had anticipated,” says Wilson. “The pool was also older than what we anticipated. Not surprisingly, those folks who needed insurance most desperately probably stayed with it longer, worked through the technical challenges, and procured their insurance. But that means the cost pressure will continue to be there as we go forward. So we clearly need more young people to enroll and purchase through this program.”
Wilson says that while the health and age of the marketplace pool will put upward pressure on premiums, the primary reason rates continue to increase is that overall medical costs keep rising. Whether it’s a new drug like Sovaldi that can cure Hepatitis C, but costs over $84,000 for a 12-dose regimen, or the increased use of medical services caused by aging baby boomers, or whether it’s the obesity epidemic, uncompensated care for the uninsured, or rampant waste and inefficiency in hospitals, overall health care costs continue to rise.
“Insurance premiums reflect the underlying cost of care,” explains Wilson. “If you really want to think about it simplistically, insurance premiums basically reflect the average cost of care in the particular geography where they are charged, plus an administrative cost for product construction, maintenance, and customer service.”
BCBSNC will announce rates for individual under 65 plans this month.
Uncompensated Care and Medicaid Expansion
One component of rising health care costs has always been uncompensated care, which is defined as care that is delivered, but for which the health care provider does not receive any or sufficient compensation—usually because the patient is uninsured. A hospital must try to recoup that loss through other mechanisms, which include looking to commercial insurers to pay more for the services their customers are receiving. The cost of uncompensated care gets calculated into the premium paid by people who buy insurance in the commercial and public marketplaces.
One of the primary goals of the ACA was to increase access to health insurance, thus decreasing the amount of uncompensated care. The act expanded Medicaid eligibility for Americans living at or below the poverty level, and the subsidized plans offered on the federal or state marketplaces were designed to cover those families living above the poverty level.
But in 2012, the U.S. Supreme Court ruled that the federal government could not mandate that the states accept Medicaid expansion, thus turning it into a state option. About half the states opted out of Medicaid expansion—including North Carolina—leaving many of those below the poverty line ineligible for either Medicaid or the subsidized exchanges.
According to The Commonwealth Fund survey, in the 25 states that, along with the District of Columbia, expanded their Medicaid programs, the uninsured rate for adults with incomes under 100 percent of the federal poverty level declined from 28 percent to 17 percent. In the states that did not expand their programs, the uninsured rate remained almost unchanged at 36 percent, compared to 38 percent in 2013.
A study done by the Kaiser Family Foundation showed 319,000 North Carolinians are in the coverage gap created by the state’s decision to opt out of Medicaid expansion. The North Carolina Institute of Medicine estimates 500,000 state residents in total—both those in and slightly above the coverage gap—would qualify for Medicaid under an expansion. The federal government would have funded the entire cost of the expansion for the first three years, with North Carolina’s contribution never rising above 10 percent.
“In my view, it is unfortunate that North Carolina did not expand Medicaid,” say BCBSNC’s Wilson. “Those North Carolinians who would be eligible for that coverage are still accessing care today. When they need medical services they are going to the emergency room, and our hospitals are delivering that care. But there is no mechanism for those hospitals to get paid. Medicaid provides a rational way to get some of that care paid for.
“There is plenty of opportunity to improve the way we do Medicaid, but while we are working to improve it, not covering these people does not add to the solution, in my opinion. The federal money is available, so turning it down does not do anything to balance the federal budget. The money is simply going elsewhere.”
The burden of uncompensated care is particularly acute for many of North Carolina’s rural hospitals, a number of which are highly dependent on Medicaid payments for their revenue model. Wilson says these hospitals are among a growing chorus urging the state legislature to reverse course and opt to expand Medicaid in North Carolina. Only time will tell whether that actually happens.
Impacts on Employers
The ACA “employer mandate” requires that all businesses with over 50 full-time-equivalent employees provide health insurance or pay a per-employee penalty. Originally set to begin in 2014, the mandate was delayed until 2015 for companies with more than 100 full-time employees and to 2016 for those with 50 to 99 full-time employees.
“Employers are evaluating what their options are, whether they are going to be able to afford it, and if not, what the alternative is,” explains Wilson. “Most employers would like to be able to continue to provide the benefits, but for small employers there is high anxiety about the value proposition and whether they are simply going to be able to afford it.
“We will provide the best products and services we can, at the best price, and will help employers make the right decision for themselves and their employees. I also think there will be an ever-growing place for private exchanges as companies try to control costs.”
Private exchanges are similar to the public marketplaces operated under the ACA, but are offered by employers to their own employees. While there are many variations of private exchanges, companies will generally contribute a specific amount for employees to spend on insurance, with the workers choosing from a menu of options.
“According to some estimates, there could be as many as 40 million people—about 10 percent of the population of the country—enrolled in private exchanges by 2018,” says Patrick Brady, Blue Cross’ Charlotte-based director of major and national accounts. “National research shows that a lot of the exchange activity is taking place in mid-sized companies with up to 1,000 employees, but any company with over 50 employees will be able to purchase coverage on BlueBenefits Center, Blue Cross and Blue Shield of North Carolina’s private exchange.”
Most large companies are not directly impacted by the employer mandate since they already offer coverage to their employees. But the ACA also mandated minimum coverage levels, out-of-pocket maximums, and other plan elements that went into effect for 2014. Large employers had several years to prepare, so they should already be in compliance.
“Enrollment by employees of larger employers has actually ticked up some this year,” offers Brady. “I think it is an awareness by employees that the individual mandate requires that they have health insurance, so they need to either look at their employer’s plan or look at the public exchange to see if that is better than what they can get from their employer.”
“Employers are offering more choice, and more choice for the consumer is a good thing,” Brady continues. “It allows them to self-direct what they want to accomplish in health care, much like they would in any financial environment. We’re now in an era when the consumer is being asked to make good decisions, and in order to make good decisions the consumer needs good tools. So we have focused and will continue to focus on providing those tools.”
With greater choice comes the need for the consumer to understand health insurance and the options and tradeoffs they will be faced with in choosing the right plan for their own family and their own situation. Gone are the days when their employer made all of the decisions with a “one-size-fits-all strategy.”
“I believe that having informed and empowered consumers will be the key to improving and transforming our health care system,” concludes Wilson. “Being informed and empowered starts with education and engagement, so I think that is where this country is headed with health insurance.”
Most, if not all, business owners have been approached by at least one of their advisors with the ever-popular question, “What would happen to your business if you got run over by a truck?” Few business owners fail to recognize this question for the thinly-veiled pitch to buy insurance that it is.
Our goal is not to discourage you from buying life or disability insurance. Far from it. Purchased in the proper amounts and for the correct reasons, life and disability insurance proceeds will, indeed, help your business to survive your sudden absence.
Insurance alone, however, cannot resolve all of the three primary issues that face every business when owners go AWOL. In this series of articles, we’ll identify the three primary continuity issues that face your company and examine possible solutions.
Issue 1(a): Continuity of Ownership for Co-Owners
The most obvious business continuity issue is: Who will succeed you in ownership? If you co-own your company, an up-to-date, adequately funded, buy/sell agreement that completely addresses all of the possible transfer issues can solve this problem. Please pay careful attention to all of the qualifiers in that last sentence.
First, “up-to-date” means that the agreement reflects the current value and structure of your business. It also means that you and your co-owners don’t sit down once, discuss continuity, and shove the resulting agreement in a bottom drawer, never to be removed again.
Second, “adequately funded” means that one of your advisors has analyzed what the company’s financial needs would be in your absence and has made sure that adequate funding is in place.
Third, your agreement must fully address a list of “possible transfer issues.” The list includes:
• Transfer to a Third Party
• Termination of Employment
• Involuntary Transfer Due to Bankruptcy or Divorce
• Business Dispute among Owners
Issue 1(b): Continuity of Ownership for Sole Owners
If you have no co-owner, your ability to ensure continuity of ownership in the future depends on your ability to create and to implement a continuity plan today. Vital to that plan is the involvement of your key employees. You must create a plan that motivates your important employees to stay with your company even though you do not. One of the best ways to accomplish this goal is to create a “stay bonus” plan.
A stay bonus is a written, funded plan providing monthly or quarterly bonuses and salary guarantees, usually over a 12 or 18-month period, for employees who remain with the company during its transition from your ownership to new ownership. (New ownership may be a third party, a transfer to employees, or a continuation by family members.) The stay bonus provides a cash incentive for your important employees (perhaps 20 to 50 percent of your workforce) to stay, hence its name.
The stay bonus is typically funded with life insurance in an amount sufficient to pay the employee bonuses over the specified timeframe. The life insurance may be owned by the company or outside the company in an estate tax-sensitive trust. You must tell your important employees that you’ve put a stay bonus plan in place so that they know you’ve put thought, planning and money to pay salaries into ensuring the survival of the company upon your unexpected departure.
Your ability to ensure the continuity of your company also depends on your willingness and ability to communicate your continuity wishes to those who will be affected. We typically suggest that business owners complete a “Business Continuity Instruction Form” as a great way to organize and to communicate your thoughts about continuity of your business to your key employees and advisors.
The instruction form includes suggestions from the owner (in the event of his death or disability) as to a number of issues including which key employee(s) should have responsibility for business operations, financial licenses, internal administrations, etc., as well as the owner’s suggestion of specific professional advisors, and to whom the company should be sold or transferred (along with his suggested price range).
This instruction sheet helps answer the many questions about “What would Sam (the business owner) do?” Of course, the instruction form should be regularly updated by the owner.
In our next article, we will tackle the second continuity issue that faces your company should you unexpectedly leave: the company’s loss of financial resources.
Today’s presidents and C-suite executives are faced with a harsh reality: They must decide whether to participate in social media or be left behind. Their competitors are more forward-thinking and are controlling their own messages while being viewed regularly on the Web. In addition, the competition recognizes the importance of presenting themselves in the most positive light via platforms designed to enhance their personal brands.
LinkedIn is dedicated to executives seeking to conduct business with other businesses and individuals. It’s a marketing tool, a branding tool, a content-rich tool, a talent acquisition tool and a prospecting tool.
With over 310 million members and growing (two new members join per second), LinkedIn currently houses over 3 million company pages and 2 million groups. It’s currently the go-to tool for 95 percent of all recruiters. According to Hubspot, as a lead generator it is 277 percent more effective than Facebook or Twitter.
So why should presidents and C-suite executives be actively immersed in LinkedIn?
Your Professional Digital Profile and Portfolio
Every president and C-suite executive should Google his or her name. With a LinkedIn account, their profile page will likely be in the top three search results. Companies and individuals seeking to conduct business with your company routinely seek to gain insight into the person at the top of the organization. Your profile should be optimized and creatively written to depict you in the most positive manner, while providing insight into you as an individual and businessperson. Make yourself approachable.
Add valuable content to your profile in the form of presentations, videos, documents, articles and photos. This enhances your opportunities for being discovered for collaborative opportunities, speaking engagements or talent acquisition.
Establish Yourself as a Thought Leader and Industry Expert
LinkedIn Publisher provides you with the opportunity to present yourself as a knowledgeable expert in your industry by allowing you to post articles and original stories. Pulse is the LinkedIn portal that permits you to see what’s trending among professionals worldwide. By personalizing your feed from a variety of channels and influencers, you are able to select from news and professional content that you can easily share with everyone in your network and groups.
Your Presence Encourages Your Employees to Participate
By virtue of you setting the example, you are stating that your employees should be actively promoting your company on LinkedIn. Whether they see you posting content, participating in strategic groups, following companies or simply “being there” your actions are speaking volumes.
You should connect with your team, key customers, strategic partners and industry influencers. Encourage them to cross-connect. Collectively, their networks will easily range into the millions. Think of it as one large networking event within your organization where everyone has access to each other’s connections for new business development.
You Will Find A-List Prospective Employees
If you are looking for new talent LinkedIn allows you to find A-list ‘passive’ candidates. Top contenders are not always looking; it is likely that they are currently employed. Some of your finest potential employees can be found on LinkedIn through referrals from the connections that you and your current employees trust. Once you have identified the specific skills and experience needed for the position you have available, you have the ability to conduct a free search to narrow down the possibilities.
After you have found several top candidates, you are able to check their references and recommendations before you decide to invest the time to interview them. Then you can contact them and engage these ‘warm leads’ by asking them if they are interested in a possible career move.
You Will Gather Competitive Intelligence
Two key areas to stay current with your competition and gain industry insight are groups and company pages. Both can be invaluable resources to uncover up-to-the-minute company announcements.
Monitoring or participating in groups will expose you to trending subjects and developing strategic partnerships. Join groups related to your industry, geography, alumni or personal interests.
Following companies will provide you with competitive intelligence as it is posted. Engage with companies of interest both competitively and for future collaborations.
Whether you conduct business locally, regionally, nationally or globally, it is imperative that presidents and C-suite executives in general participate in the largest professional networking site in the world.
Many books have been written about business improvements focusing on growing sales, improving customer service, lowering costs, developing better managers, etc. These books include strategies and techniques to help business owners and managers make changes that will result in higher sales and greater profits. Unfortunately, little emphasis is placed on the importance of improving a company’s accounting system—usually financial processes and procedures are considered “good enough” to meet the business’s needs.
However, as companies mature and become more sophisticated, the accounting system can be “outgrown,” leaving managers with insufficient financial information to make good business decisions. To avoid this, here are six steps to help both new and existing companies enhance their accounting capabilities in order to mature financially.
Step 1. Implement an internal accounting system and generate monthly financial statements. With accounting software from QuickBooks, Sage and many others, it is relatively inexpensive and simple for even start-up businesses to purchase a robust, computerized, accounting system that can grow with the company. Setting up the system does take time, and the first challenge is often getting owners to understand that preparing a timely balance sheet and income statement each month is important. The second challenge is getting managers to review the statements to see how the business performed financially.
Step 2. Compare monthly financial statements to prior periods. Think of financial statements as a scorecard for the business. Since most companies are unable to compare themselves financially to their competitors, companies can compare last month’s scorecard against prior periods. This allows managers to determine where the company has improved and where it has suffered.
Step 3. Learn how cash flow differs from sales and income. Sales, net income and cash flow are different. The balance sheet and income statement can be used to calculate a company’s monthly cash flow. Ask your accountant or banker to help you understand how cash flow is generated. A company can have strong sales and positive net income and still run out of cash and be forced to close. It is critical to manage your business so it consistently generates a positive cash flow.
Step 4. Identify and track a small number of key performance indicators. Identify five to 10 critical sales, financial and production factors that make your business successful, and then develop a way to measure and view these key performance indicators (KPIs) every day or week. Examples of some daily indicators may be the number of customer orders received, pieces produced or shipped, or total regular employee hours and overtime hours worked.
Step 5. Make business decisions that positively influence your KPIs. Management decisions should focus on improving the key performance indicators. For example, overtime increases a company’s labor costs by 50 percent. A company could measure overtime hours as one of its key performance indicators, because its profits might be significantly higher when overtime is low. As a result, managers should then make decisions that limit overtime: reject orders that create overtime or redesign production steps to prevent overtime or price overtime orders higher to recover this additional cost, etc.
Step 6. Build an annual income budget and track monthly performance against the budget. Developing a monthly income budget requires managers to look forward and estimate where they should be or where they want to be in the future. Future sales revenue and costs are estimated and a financial plan is created. Managers then “work the plan” and track actual monthly performance against the budget. When actual performance is different from the budget, managers can immediately take steps to correct. While budgets are not exact, they are useful tools to help businesses plan to be financially successful.
As companies grow, their financial capabilities should also expand to support the growing needs of the business. Accounting tools should be developed that allow managers to look forward instead of backwards.
The monthly financial statements, Steps 1 through 3, provide a financial scorecard for a company, but this shows past performance. When key performance indicators, Steps 4 and 5, are added, management has the ability to see current business conditions. Adding an annual income budget in Step 6 allows managers to look forward and plan for a financially successful future.
Before extending an offer of employment, businesses go to a great deal of trouble to identify the right employee. The process includes defining the job, planning a recruiting strategy, reviewing credentials and applications, prescreening and interviewing candidates, as well as checking backgrounds and references—all in an effort to locate the best possible candidate.
But what if the ideal candidate happens to be a Foreign National requiring visa sponsorship? What then? Adopting certain “best practices” can help an employer determine whether to pursue such a candidate.
First and foremost, an employer should review its employment application to ensure that it includes a question regarding whether the applicant is legally authorized to work in the U.S. without restriction. (Such a question should be carefully worded to ensure it is not discriminatory.) The response to this question will alert the employer as to whether the candidate requires visa sponsorship.
The application form should also include a warning that providing false information is grounds for immediate rejection or for rescission of a potential offer of employment. In the event the candidate indicates s/he does not require sponsorship when in fact s/he does, this provides the employer with an “out” on the basis that the candidate misrepresented critical information on the application.
Further, this should help avoid a potential issue as to whether the candidate was rejected or the offer rescinded on discriminatory grounds. Such termination grounds should be applied uniformly.
Next, an employer will need to consider the candidate’s education, experience and immigration history as these are factors in determining appropriate visa options. When extending an offer, an employer should make it contingent on the candidate securing appropriate work authorization. In the event a visa application is unsuccessful, the employer is thereby not tied to the offer.
In some cases a candidate will be working for another employer pursuant to that employer’s sponsored temporary visa. The candidate should not resign from the current employment until the new employer has had an opportunity to obtain employment authorization for the candidate. This should help avoid a finding that the candidate violated his/her visa status by failing to continue to work for the authorized employer. An employer will need to (1) be flexible with the anticipated start date of employment due to fluctuating government processing times and (2) track the Foreign National’s visa validity dates to help ensure visa extension requests are timely filed.
Next, if the goal is to employ the candidate full-time and indefinitely, an employer should consider what is involved with obtaining permanent residence (“a green card”) for the employee. An employer should have guidelines as to when it will and won’t sponsor for green cards and whether the company will pay all or part of the sponsorship costs (including costs for dependent family members’ applications).
An employer may also want to consider having a repayment agreement policy if sharing costs for the green card process, with the understanding that by law, fees and costs associated with certain petitions and applications may not be recouped from or paid by the sponsored foreign worker.
Although acquiring a temporary work visa may be a relatively easy process, an employment-based green card application is typically more challenging. In most instances, a test of the U.S. labor market is required and can only be approved if no “able, willing, qualified U.S. applicant” applied for the position.
An employer must be prepared to consider external factors that could affect such a test including recent industry and geographic layoffs. An employer must also consider how much time the candidate may remain on the temporary work permit and whether the business can support renewals of the work permit throughout the green card process.
Despite the intricacies involved with temporary or permanent visa sponsorship, the decision to hire a foreign worker can be rewarding—both for the employer and the worker. Having the right policies and procedures in place can make all the difference.
The information contained in this article is not, nor is it intended to be, legal advice, nor does it create an attorney-client relationship. You should consult an attorney for advice regarding your individual situation.
For the Charlotte region, being situated essentially on the edges of both North Carolina and South Carolina presents a paradox. While we frequently feel like a distant cousin of state government in Raleigh, unempowered to coordinate economic development across the state border, our location central within the Carolinas is logically integral to emerging corridors of commerce and absolutely essential to our region’s economic growth.
While that is an obvious and inevitable truth, unfortunately the Charlotte region is stuck in a state of limbo; we are seemingly unable to help ourselves.
From the perspective of economic development, we are just marginally competitive. We have made some progress in recruiting MetLife, Sealed Air and Spectra Group among others to our fair city, but we can do so much more if we stop standing in our own way.
We have yet to resolve fundamental differences over our most major asset, our airport. And our economic development organizations are at loggerheads, being functionally supplanted at least in part by the reorganization of the state’s economic development unit.
Consider the dispute over who will run Charlotte’s airport, described as “mess” by former mayor and now Secretary of Transportation Anthony Foxx. We have accumulated over $1 million in legal fees already, where the judge has said he needs the FAA to rule before he can, and the FAA has responded that they will not act without a request from the City of Charlotte to move the airport management, and the City of Charlotte is determined to maintain ownership and management control over the airport and is not budging.
Amidst this turmoil, is anyone fretting about the amount of energies not being spent in a forward direction? Is it eerily disturbing that successful economic development seems to be occurring around us—on both local and national/international fronts? What is the real cost of doing nothing??
Land use around the airport and intermodal center is critical to our region’s economic growth and needs to be thoughtfully planned for our collective futures. We have nearly 12,000 acres that is prime for development.
Who should be out in front on this? Our two economic development groups—the Chamber and the Charlotte Regional Partnership (CRP)—are stymied by inevitable coattail snipping of the newly debuted Economic Development Partnership of North Carolina, a public/private entity that can seek corporate and private contributions as well as state funds, but that has just begun operations and is still without legislative support for incentives for new and expanding business opportunities.
As a consequence, the business community, normally the bulwark of support for our economic expansion, is hesitant and perplexed about where to direct their limited resources.
The resulting quagmire has been thrown on the doorstep of the Foundation for the Carolinas, whose Economic Development Task Force has been tasked with “figuring it out,” ironically funded with the balance of Advantage Carolinas monies—the very initiative which brought the Charlotte region to presence on the world stage. This group is expected to report its results in January 2015.
Given increasing competition for global business growth and development, and Charlotte’s location (i) as the commercial center of the Carolinas (ii) along the highly productive I-85 manufacturing corridor, it is incredibly important that Charlotte get organized quickly and aggressively.
With Charlotte’s most valuable assets—our airport and new intermodal center—Charlotte should be leading, or at least facilitating and integrating economic development efforts across the Carolinas.
Economic growth is the result of business planning and decision-making. It is not the result of politics or political boundaries. While taxes and regulations affect business decisions, they may not be the primary driver of those decisions.
uLook at the corridors of commerce—look at the expansive growth that has taken place along the I-85 corridor between Richmond, Va., traveling south through Raleigh, Durham, Greensboro, Winston Salem, Charlotte, Spartanburg, Greenville, Atlanta and all the way to Birmingham, Alabama. Some call this “Char-Lanta.” Others call it the Piedmont Atlantic Megaregion or PAM.
uLook at the competition that has developed among Southeast ports including Norfolk, Wilmington, Charleston, Savannah and Brunswick. Together, the ports and our corridors of commerce operate substantially in tandem in the global marketplace. Together, they define a rapidly growing region that is expecting huge growth by 2060.
uLook at our neighbors in South Carolina whose economic development map includes the Charlotte region, with an I-77 Alliance formed to attract investment and quality jobs to the I-77 corridor from Columbia to Charlotte, as well as the recent proposal to deepen the Port of Charleston shipping channels from 45 feet to 52 feet to accommodate bigger post-Panamax ships.
Others are acting in our void. Charlotte is well-positioned geographically and has the assets to promote and encourage greater cooperation and integration of economic development efforts, but we are stuck in our own state of limbo for now. We cannot compete globally when we are fighting locally.
We need leadership that capitalizes on our location, our assets, our people and our position within these economic regions that offer us endless possibilities. And we need it NOW!