From the Gift Shop to the C-Suite

Richard Miller [00:00:00]:

I do think that both the payer and the provider have tremendous opportunity to gain efficiencies through automation. And I think besides the financial impacts of that obviously from those efficiencies is I think the consumer experience could be better as well.

Narrator [00:00:17]:

From Healthcare IT leaders, you’re listening to Leader to Leader with Ben Hilmes. Our guest today is Rich Miller, Executive Vice President and Chief Business Strategy Officer at Northwell Health. In our conversation, Rich discusses the evolving landscape of healthcare, the challenges in revenue cycle management, and the potential of technology and automation to improve efficiencies across the healthcare industry.

Ben Hilmes [00:00:42]:

Rich, thanks so much for joining me on the podcast. I am really excited for this conversation. You’ve spent 25 years in leadership at two of the largest hospitals in New York. You’ve seen a ton of growth. I can’t imagine all the change you’ve seen and now you’re about to head into retirement, but it feels like you’re really still hard at work. You played a big role in the pending merger between Northwell and Nuance. It’s interesting. I was really close to when, when HealthQuest was coming together with Western Connecticut to create Nuance.

Ben Hilmes [00:01:14]:

So I’ll be interested to hear your perspectives on the Northwell Nuvance piece. So we’re going to talk about all that today, get your perspective on where healthcare is going and just learned a lot about you and this incredible career you’ve had. So let’s go back to the early days. You came up through the ranks at NYU and I understand you’re one of the first employees to ever have a computer, a personal computer. Tell us kind of those early days and about your start there at NYU.

Richard Miller [00:01:44]:

Sure, Ben. So I started at NYU actually in 1978, right out of high school. And my first job was as the night and weekend manager of the hospital gift shop. And they said maybe you should join the finance department. And so I wound up doing that. I finished my undergraduate studies at night and started working full time in the finance department at about 21 years old. And I was the first non research scientist to get a personal computer so that I could begin to automate processes that involved our banking and investments. So every morning up until that point I would come in and I would take the handset of a phone and stick it into something most of your listeners probably have never heard of this an acoustic coupler which basically was two rubber cups and served as a modem.

Richard Miller [00:02:34]:

I would use that thing, what the touch tone phone to dial up the bank and all the banking information would download onto a Gigantic dot matrix printer. And I would take that information and transcribe it then onto a columnar pad with a pencil and I have a matting machine and everything was manual. I got this personal computer and mostly self taught in terms of how to program and began to use a spreadsheet program that was pre-Lotus 1, 2, 3 called VisiCalc. Later came to learn a couple years later learned that I could get data downloads from our IT department and I created relational databases and programmed how to produce and our financial statements and create all the analytics around that. Which led to a tremendous amount of efficiencies in the organization. And really was a big step taking us from what was almost entirely manual processes to moving into a world where there was basically all automation. And it did eliminate some roles in the organization. Folks were able to be retrained and redeployed to other types of roles.

Richard Miller [00:03:42]:

But it did create a lot of efficiencies in the organization. Really was a kind of a springboard for me in my career in terms of moving forward. About 20 years after that I was appointed as the chief Financial officer at nyu. But I always look back to those early days as my opportunity to kind of shine and be able to take a real transformational change again going from mostly manual processes to a lot of automation as really, really great opportunity for me to do so. And I think we’re at kind of the precipice of another big transformational change now with AI and things like RPA Robotics. I mean I think there’s a real opportunity now to have another leap forward to use automation to gain more efficiencies and Lord knows in the healthcare industry that’s well needed.

Ben Hilmes [00:04:31]:

Oh for sure. And we’re going to get into a little bit of that and a little bit around just the revenue cycle space. Just I believe that’s even beyond all the clinical aspirations, et cetera. I think the revenue cycle space is maybe the most ripe area for innovation and I’d love your perspective on that in a bit. But self taught you kind of created this ecosystem of automation that drove tremendous efficiency. You grew your career to the CFO spot and you were at NYU and 911 happens you guys were one of the closest hospitals to ground zero. Just share from your perspective and just memories of that time because I think it’s very interesting when you’re literally in that space at that time just how things came about.

Richard Miller [00:05:26]:

I would say the definitely the most difficult time in my career. We had our data center right across from the World Trade Center on Rector Street. So for a number of weeks, we had difficulty getting any bills out the door, so we were not able to do any. You mentioned the revenue cycle before. We were not able to do any of our billings for a number of weeks. Obviously that created tremendous interruption to cash flow. You know, eventually we were able to, obviously to get back up and running and get, you know, all the, all the bills retroactively out the door. But it was a very, very challenging time.

Richard Miller [00:06:00]:

And in addition, you know, we were incurring a lot of expenses, obviously related to the event. And so it was a very, very challenging time, both from standpoint of expenses, you know, a loss of revenue or I’ll say delay in revenue for a period of time. And then, of course, not having the data center operable for a number of weeks just created a lot of chaos during that period of time. And obviously the loss of life, the involvement of our clinical staff down at the site, it really, really was a very challenging time. And that’ll be with me for the rest of my life.

Ben Hilmes [00:06:34]:

I can only imagine, you know, through your leadership and just how much your team had to rally. So if you think about it from a management leadership perspective and the overall just leaning in on something that is kind of bigger than any of us and figuring out ways to get it done, I mean, you probably pulled a lot from your early days of if there’s not an automated way to do it, or if we don’t have our systems up, how do we think critically and, and put a solution together that. That keeps us moving forward. So I’m assuming you pulled on a lot of that early entrepreneurial mindset.

Richard Miller [00:07:10]:

And you know, a lot of it too was, was engaging with, with partners, you know, for example, with the cash flow issues. We engaged with our banking partners and they were able to help us in terms of cash flow, you know, during that period. And a lot of it was internal, you know, colleagues, but also working closely with partners was really, really important.

Ben Hilmes [00:07:30]:

So let’s pivot here a little bit. So seven years later, you decided it’s, I’m leaving NYU and I’m going to this big place called Northwell. So in 2008, you went over there and, and so what drove that and kind of what was your overall mandate when you joined?

Richard Miller [00:07:47]:

Yeah, I had the opportunity to meet with Michael Dowling and a number of the other executives at Northwell at the time called North Shore LIJ Health System. I really liked what they were doing. I was at a point in my career where either I was going to be at NYU for my. My entire career or going to make a pivot. I really like what I heard from Michael and his senior leadership team. And I decided to make the move. And, you know, it was definitely the best move of my career.

Ben Hilmes [00:08:15]:

Well, Michael is a legend. Any unique stories you want to tell about Michael that our listeners would be probably interested in hearing?

Richard Miller [00:08:24]:

There were a few things, but one that really stood out was he had a binder on his desk, which was titled High Potential Program. I had seen another organization’s attempts to do those kinds of programs. And so I was just curious about what North Charlie, at the time that Northwell was doing in that regard. And Michael told me he was closely following the careers of about 150 people across the organization, identified as potential future leaders the organization. And these were folks at all different levels of the organization. And he had their resumes, their performance reviews, and so forth. And I was just kind of amazed that he had this binder right on the top of his desk, and he was following it so closely. I took it a little bit with a grain of salt because, again, I had worked at other organizations that had attempted to do this. And Michael said to me, it was in its first year of operation, but as I came on board at Northwell, I got to see that this was a real program. There were people actually moving around the organization into different stretch assignments and different roles. And so, for example, when I joined in 2008, I was leading up the financial planning and analytics function of the organization. And I had several people that over the following couple of years, moved into operations roles. So these were people who went to business school, had MBAs, and they got opportunities to run hospitals, run clinical as an administrative role in a clinical department. And some of those people now are in very senior leadership roles in the organization. So it wasn’t just talk, you know, that Michael was saying to me, it was really walking the talk. We developed a corporate university, and there’s a lot of internal development.

Richard Miller [00:10:09]:

They’re really able to put themselves on a journey that can involve moving, you know, between finance to operations. Our current chief Revenue officer, you may know him, Ben. Dr. Jerry Brogan is a medicine physician by background. He’s been the CEO of one of our hospitals. I came into my role as executive VP & Chief Business Strategy Officer with oversight of the revenue cycle. I had to decide who I thought should be in that Chief Revenue Officer role. And Dr. Brogan has tremendous background and expertise in clinical documentation coding, and I thought he would be a really good fit, even though I don’t believe at that point any other major health system in the US had appointed an MD to be their Chief Revenue Officer. It was really out of the box.

Ben Hilmes [00:10:57]:

Yeah, that is way out of the box thinking.

Richard Miller [00:11:00]:

Yeah, and he’s done an amazing job. He’s also surrounded with some great folks on the front end and the back end, and they’ve done an amazing job in our records.

Ben Hilmes [00:11:09]:

I had a recent podcast guest, Dr. Rob Adamson. He’s a pharmacist by background and he was recently appointed to the CIO position at Barnabas. And you know, just that kind of thinking was kind of unique. Very similar to what you’re talking about relative to not probably somebody’s resume that you would say, yeah, that makes sense to be a CXO in that particular space. But obviously the playbook work though. You guys have grown from 4 billion to nearly 20 billion in your tenure. So highly competitive market takes really bright, capable leaders.

Ben Hilmes [00:11:48]:

Feels like that whole playbook paid off significantly and has differentiated you guys in a very competitive market. How do you think about competition in your market and how are you differentiating yourselves as you continue to grow?

Richard Miller [00:12:04]:

Well, the competition question is interesting because traditionally it’s been other hospitals and health systems and it is still to a large degree that’s true. But I would say, you know, over the last 10 or so years of my career, what has changed a lot is some of the big corporate entities, particularly some of the, you know, what would traditionally insurers, you know, the payer space moving more into the provider space. So the Optum Cares as well as pe, moving into some of the more of the large medical groups. That kind of has been a change, I would say, predominantly over the last 10 or so years. So the competition is probably broader now than it has been in the past. We look always to grow, as you mentioned, we’ve grown about 5x since I had joined the organization in 2008. While we have added hospitals, several of them over those years, we haven’t added a Hospital since 2018. We have a pending acquisition with Nuvance Health up in Connecticut and upstate New York that’s pending final approvals.

Richard Miller [00:13:09]:

If that does go forward, it probably wouldn’t be till 2025 and would be our first hospitals that we will be adding again since 2018. So Mr. Dowling has a saying. He says, I like to date, but I don’t often marry.

Ben Hilmes [00:13:24]:

That’s great. That’s great. That’s a good one. So, yeah, this merger pending merger with New Vance takes you across Dateline into Connecticut, takes you up into the Hudson Valley region. Your point on if you were to lay out, your competitive landscape definitely changed in the past decade because you are seeing a lot of new entries into and it’s not just provider systems like you’re used to competing with. So it’s interesting to hear that and then to know that there was a point in time you guys were in the payer space with Care Connect and then you shut that down. Was the competitive landscape what drove that or was it just, hey, we’re in the payvider business and now we’re not. What was the thinking there?

Richard Miller [00:14:08]:

Well, we had pretty significant financial challenges and even though the product got great customer reviews, the customer experience was great. The market that we were operating in, which was primarily small business accounts and individual on and off the exchange, the membership grew to about 125,000 members at its peak, which was about two years in, it was the largest at its time, the largest narrow network product in the market. So we were able to gain traction with a good product and excellent customer service. The pricing probably was lower than it should have been in hindsight that I’m sure contributed to the membership growth as well. There were some other events in the market that didn’t help. The risk adjuster challenges in the early days of the ACA were very challenging. A lot of the, you know, what were called the co ops at the time, you know, didn’t last. Some of the even larger established firms had some big issues with the risk adjuster and then there was the issue around the risk corridors which were defunded for a period of time.

Richard Miller [00:15:14]:

And then there was later there was a lawsuit which got them reinstated. But there were a number of things, both from a regulatory standpoint as well as pricing in the market that led to some significant financial challenges. And so we decided to exit that market.

Ben Hilmes [00:15:30]:

Do you see Northwell or other health systems in the region getting back into that space after exiting?

Richard Miller [00:15:36]:

We do have an offering now called Northwell Direct to self insured employers. It offers both services and things like, you know, COVID testing, flu shots, those sorts of types of services that we can offer direct and on site to an employer. And then on the other hand it offers the potential to have a replacement product again only for self insured employers, which obviously tend to be larger employers. And we’ve been growing that over, over time. But again with a narrower network product it’s more challenging to do that, particularly in a market where you have a lot of world class healthcare providers.

Ben Hilmes [00:16:15]:

Interesting insight there. So you’re a Finance guy. Well, you were started out as the guy in the gift shop, but then you grew your incredible career into the finance space and certainly in the revenue cycle space. And if you think about leaders in the rev cycle space today, what in your mind are kind of the biggest challenges they face and then if you can think about how to insert some of the innovation and technology into some of those thoughts, I would appreciate it.

Richard Miller [00:16:48]:

Well, there’s a lot of pressure on cost across all healthcare provider organizations. So again, finding ways to, you know, kind of bend the cost curve, bend that cost to collect curve is very, very important. And there’s a lot of changes, as I know you’re well aware from payers in terms of whether it’s pre auth denials. And so there’s a lot of investment that we’ve made and other providers I’m sure have made over the years to put the administrative infrastructure in place to be able to deal with those kinds of issues to the degree that technology can help in that area. There’s a few things that we have done to date that have help, but there’s a lot more that I think can be done down the road. We mentioned a little bit earlier about AI. I think that’s an area that’s right for improvement as we go forward to improve our cost to collect. And that’s something certainly we have a big interest in.

Ben Hilmes [00:17:45]:

So on the topic of AI and RPA, et cetera, is it two years out, is it 10 years out to really start to see the ROI on those things in particular around revenue cycle? I just feel like the answer of throwing more people at it kind of cannibalizes our business a bit. But I think the ant, you know, just throwing more people at something just isn’t the answer today. So how do we start ingesting people who are thinking big picture around technology? Leveraging is going to be important.

Richard Miller [00:18:20]:

Yeah, I think there still are quite a number of what I’ll call mundane, repetitive type tasks. We’ve started to do some work around automating, you know, both in the revenue cycle as well as in the clinical operational space. So, you know, one I’ll give you an example that we’re looking at right now is registries. So we employ quite a number of nurses that, you know, basically spend all their time, you know, excerpting or abstracting from medical records, information that’s needed to populate registries around certain diseases like cancer. And so to the degree that we can automate that process, those nurses can be redeployed to the bedside or the clinical space and not have to be involved in an administrative task that really, with today’s technology can be done in an automated fashion in the rev cycle. Things like claim status checks, where, you know, in the past we’ve had folks that are sitting at a computer screen all day long going out to payers, getting the status on a claim, cut and paste that back into our systems to populate and update the information. Today that can be done in an automated fashion and those individuals can be retrained and redeployed to other more challenging and frankly, better paying roles, you know, within the organization. So as we’ve grown by doing that, it enables us to not necessarily shrink the workforce, but to not have to grow the workforce as the organization grows.

Richard Miller [00:19:48]:

And so our cost to collect can go down as a result of being able to do that.

Ben Hilmes [00:19:53]:

It led me to another thought because I still think one of the biggest chasms today is payers and providers. Do you believe this automation, the innovation, all of this tech is going to bring those two entities together or do you think it’s going to create more challenge?

Richard Miller [00:20:12]:

I’ve always hoped that it.

Ben Hilmes [00:20:15]:

We’ve been hoping for a long time.

Richard Miller [00:20:16]:

Yeah, it’s a great question because I do think that both the payer and the provider have tremendous opportunity to gain efficiencies through automation. And I think besides the financial impacts of that, you know, obviously from those efficiencies is I think the consumer experience could be better as well. I hope there is a time when both payer and provider can get together and just find a way to agree around automated data exchange. I mean, we still have some payers today that we’re still having to send faxes and information by mail and those sorts of things that it just, it’s kind of ridiculous at this point in time with the technology that’s available. So I hope that there is a day that payers and providers can both harvest, you know, those efficiencies that are available. But I have to admit I’m still a little skeptical that we’ll see it. Maybe in the next 10, 20 years we’ll see that.

Ben Hilmes [00:21:13]:

I think we’re both in the same camp. So where I’m very hopeful but skeptical at the same time, just the business models seem to not align well. So everyone on the podcast, we kind of pivot at some point to leadership. You’ve had an incredible history of leading high performing teams, but in particular not, not by choice, you’ve had to lead through some crises. So obviously we talked about 9, 11, early on, you were also in a very senior role at Northwell. During COVID I wondered what you can share with the audience about leading through crisis, leading through tragedy.

Richard Miller [00:21:50]:

One is being present and kind of related to that also is to be authentic. And so I’ll give you an example. During COVID you know, many of the administrative folks were able to and did work remotely, and to some degree, there’s some hybrid work still happening to this day. I felt early on, because we were doing a lot of town bowl meetings with the staff, obviously we sent staff home. I think it was on or about March 10th of 2020, I’ll be honest, I thought it was maybe a month or two. So, you know, we sent people home and, you know, little hiccups here and there, but for the most part, they were able to do their work. But in the revenue cycle, not all of our staff were able to work from home. So people like, you know, ed registrars, people working, you know, on the front lines in the emergency department, people working in the emitting department, financial counselors and so forth.

Richard Miller [00:22:47]:

So there was probably about close to a third of our revenue cycle staff that were still present on site during COVID. Then we had the remainder that were working remote. But what we started to do to keep people plugged in and updated was we started having regular town hall meetings via teams. You know, I thought it was really important that the staff see me in the office. I was coming in every day, even in the early days of COVID because I wanted particularly those staff who were having to come in every day to not see me at home in my home office and think, oh, look at this guy. He’s safe at home and I’m here on the front line. So I was coming into the office every day. We were doing those town hall meetings. We were sharing whatever information that we had available that we could share with the staff to try to keep them informed.

Richard Miller [00:23:39]:

And so I think, you know, communication obviously, is always very, very important. And we. We tried to do that in a way that was just very, very transparent. At the end of the sessions, we would open it up for questions. If we didn’t know the answer to a question, we would tell the team, we would get back to them on that question. But it was very, very open during that period. And again, we tried, if anything, to overdo the communication so that folks felt that they were engaged and they understood what was happening.

Ben Hilmes [00:24:07]:

Rich, we need more leaders like you just across the globe. It’s a fascinating career and thinking about where you started, how you applied critical thinking to solve complex problems or even critical thinking to solve shiftful problems. Obviously you’ve been given challenges along the way, whether they’re small or large. And you’ve always found a way to kind of think authentically and have no doubt made an impression and a difference in a lot of people’s lives. So kind of last parting thought here is what advice do you give to the next generation? You’re handing the reins to the next leaders set of leaders. What do you say?

Richard Miller [00:24:49]:

Well, I think I mentioned earlier about what Northwell has done in terms of professional development. I think having the opportunity to develop and mentor a number of employees over the years, I think listening is really important and I think hearing what’s on the mind of the staff, whether that be in terms of opportunities for efficiency, opportunities for growth, how things in the day to day process can be changed again to improve things overall, improve the experience for the employee, improve the experience for the consumer. I think sometimes leaders can get kind of caught up in their own thoughts about how things should work. And so I think just spending time sitting down with staff and hearing their feedback I think is really important. And that’s one of the things here at Northwell which I think has been amazing, is really the ability to engage right down at the frontline level and take that scene back and be able to incorporate it into our policies and our processes.

Ben Hilmes [00:25:49]:

That’s awesome. Well, Rich, I just want to be respectful of your time here and I really appreciate you spending a half an hour with us on the on the podcast and incredible insights. All the best wishes as you move to this next chapter and I’m hopeful our paths continue to cross. So thank you for your time.

Richard Miller [00:26:07]:

Thanks, Ben. Pleasure speaking with you.

Ben Hilmes [00:26:12]:

There’s so much to learn from Rich and his incredible career. Here are a few takeaways that stuck out for me from our conversation. 1. I love that Rich started in the gift shop and worked his way up to senior leadership. There’s so much opportunity in our industry, in our country for anyone willing to put an effort and do the work. 2. Rich led by example during 911 and COVID by showing up every day and working alongside his teams. Leaders make such a huge difference when they are visible and present during times of crisis. 3. Investing in leadership development has paid big dividends for Northwell. They proactively identify young leaders and provide them with stretch assignments and opportunities to grow. So what did you think? What are your big takeaways from this episode? I’d love to hear from you on our social media channels or drop me an email from our website at healthcareitleaders.com.

Narrator [00:27:06]:

Thanks for joining us for Leader to Leader. To learn more about how to fuel your own personal leadership journey through the healthcare industry, visit healthcareitleaders.com. don’t forget to subscribe so you don’t miss any insights, and we’ll see you on the next episode.