Future of healthcare & physicians

Bain & Company, a major consulting group recently reported that they feel that it will take a hands-on approach by physicians as the best way to shape a better future for healthcare.

Their survey (conducted in 2017, included a total of 980 physicians, 100 procurement officers and 100 finance officers from the US) shows that “bringing physicians back into the decision-making process helps create greater momentum for change. Physicians who are not aligned and engaged with their organizations have more reasons to resist new structures and systems, such as value based payment models. By contrast, those who have a say in management decisions are much more satisfied with their working environment and more willing to lead change.” They also state “60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape.”

  • > 70% still prefer fee-for-service even though they recognize the cost because they don’t yet believe that vale based payments work.
  • > 80% of surgeons and others involved in hospital purchases cooperate with hospitals with dealing with vendors.
  • “Seventy percent of nonsurgical physicians believe payer restrictions (prior authorization requirements, appeals process) limit their prescribing decisions, and 59% believe these restrictions decrease their ability to deliver high-quality care, both percentages up slightly from our survey in 2015. However, just how constrained physicians feel varies by specialty.”
  • > 2/3 believe delivering care will be even more difficult in two years.

Are Physicians ready for MACRA?

Starting in 2019, the Quality Payment program (QPP), which was put into place by the Medicare Access and CHIP authorization ACT (MACRA) of 2015, will begging to adjust payments to physicians. The Merit-based Incentive payment system or MIPS is one option and calls for reporting some quality measures and EMR use. The other option the Advanced Alternative Payment Model (APM) will consist of a 5% lump sum payment (and exclusion from MIPS) if a physician has a certain portion of their revenue or patients in APM. This was in place of repeal of the SGR or Sustainable Growth rate

A KPG/AMA survey of 1000 practicing physicians showed that 51% of physicians were somewhat aware if MACRA/MIPS and 70% were preparing to meet QPP requirements in 2017. Only 8% feel ‘very prepared’ for long-term success. There was no difference between primary care or specialist physicians.

56% expect to participate in MIPS in 2017 and 2% expect to meet APM standards. However, of those participating in MIPS 90% felt that these requirements were burdensome with the time requirement representing the most challenge. Multi-specialty practices were more knowledgeable about issues. The most difficult questions to understand were: how the quality basis was going to be measured and reported and which practice improvements were going to be acceptable.

As far as lower fee-for-service payments from Medicare in 2017, about 500,000 clinicians (half physicians) are anticipated to lose about 2% in payments because Physician Quality Reporting System (PQRS) in 2015.( http://www.medscape.com/viewarticle/881870)

An interesting take on MACRA and increasing physician employment by hospitals comes from FITCH, the bond rating agency. "MACRA could provide the nudge needed for markets with less physician employment and integration to consolidate and integrate physicians, disrupting long standing referral patterns and increasing costs as these markets sort themselves out," according to Fitch Ratings. (http://www.beckershospitalreview.com/hospital-physician-relationships/fitch-macra-encourages-hospital-employment-of-physicians.html) A FITCH director also says “"Employing physicians, when executed well, can help solidify a hospital's market position and grow its clinical footprint - offsetting their associated expenses."

 

Comment: The operative phrase here is ‘when executed well!” We all know that part is rare.

Best and worst states for physicians

WalletHub recently posted their analysis of the best and worst states for physicians in the USA. (https://wallethub.com/edu/best-and-worst-states-for-doctors/11376/)

They take into account: average annual wages, average monthly starting wage, insured population rate, hospitals per capita, quality of the public hospital system, primary care shortage, projected share of elderly, current and projected competition, number of CME credits required, punitiveness of state medical board, Malpractice Award Payout Amount per Capita, Annual Malpractice Liability Insurance Rate and Presence of Interstate Medical Licensure Compact Law. They used their own weighting system.

Best states with highest score: Iowa, Minnesota, Idaho, Wisconsin, Kansas etc.

Worst states: No surprises here, mostly East Coast states like NY, NJ,MA, MD, CT etc.

I might disagree with their parameters and the weighting but in general most of us know what they are saying. Most physicians give up some things because of family, quality of life but some because it would be a big hassle to move and start all over again.

One of my medical school classmates moved after almost 30 years to FLA and has been very happy. (You know who you are!) It takes courage but eventually the circumstances and even the weather gets to you.

Why are Locum Tenens positions taking off??

Growth of locum tenens physicians

 

Locum tenens (meaning ‘take the place of’) is a perfect match for hospitals and physicians for many reasons.

In a survey conducted by Staff Care, healthcare facility mangers usedLT all 91% at least once in 2014, 73% at least once in a typical month and 18%  said they used 4 or more LT a month. Primary care physicians (PCP) were in the most in demand as almost 35% of stated they used PCPs at least once in 2014. Following PCP's behavioral health was next at 30%, hospitalists at 22% and surgeons at 14.7%.

68% of these managers said they used LT primarily to fill in till they hired a permanent physician and 71% rated the LT physician skills as excellent or good and 81% felt it was worth the cost. Next, LT is used to fill in a vacancy left by a departing physician. With supply constant and demand rising, LT is just one option for health systems. These physicians have already been screened and vetted and provide continuity of care and prevent loss of revenue due to a vacancy. Daily rates can vary from several hundred to 41500 a day or more.

In a Merritt Hawkins 2014 survey for the Physicians Foundation, 27.6 of physicians were considering cutting back or retiring and 9% working LT. The latter group has increased from6.4% on 2012 to 9% in 2014 and younger physicians choosing LT is increasing. That is, almost 65,000 physicians were considering LT. Flexibility, pay rates, a political nature of work, travel, professional development are main reasons for choosing LT. Disadvantages stated include travel, uncertainty of work, lack of benefits and learning new rules/equipment.

It appears that younger physicians are increasingly choosing LT and for older physicians over half indicate they start LT work in mid-career having walked away from hassles, rising overhead and politics and clash of values at work. What will this do for increasing shortage of full-time physicians? Increasing utilization of ANP’s and PA’s will not be enough.

Jeremy Siegel says he was right about the stock market!

Jeremy Siegel is the Russell E. Palmer Professor of Finance at the Wharton School at Upenn.

His first book was ‘Stocks for the long run’ in 1994 and his second book was ‘The future for investors in 2005. http://www.jeremysiegel.com/ He is a regular on several TV shows and newspaper columns as an expert on finance and markets and is known as the ‘wizard of Wharton.’

In his first book he said that were the “best long-term investment and that buying and holding through volatility is the best approach for investors.” http://www.wsj.com/articles/as-dow-nears-20000-stock-market-believer-jeremy-siegel-gets-a-told-you-so-moment-1481371200

He says his research shows that “generated 6.7% in total annual returns, after adjusting for inflation, compared with 3.6% for U.S. government bonds and 0.6% for gold.” He is continuing to say that the stock market will go higher because of the anticipated cut in personal and corporate taxes as well as decrease in regulations. Most people are worried about not only the volatility but an overheated market with a PE of about 24 for the S&P and 21 for the Dow and remember the dot-com crash when the PE of the S&P was close to 30. He favors passive investing and including global stocks as part of a balanced portfolio.

His view on India versus China? “By 2060, India’s economy is projected to be larger than China’s because of its greater population growth. India is forecast to produce about one-quarter of world GDP from 2040 through the rest of this century.”

In April 2013, when the Dow was trading around 14,600, he said it would end the year between 16,000 and 17,000. It closed at 16,577.

In January 2014, he predicted the Dow would finish the year near 18,000. It finished at 17,823.

In March 2015 he said “Dow 20,000, Here We Come.”

http://www.thinkadvisor.com/2015/03/27/jeremy-siegel-dow-20000-here-we-come

 

I guess we should pay him some attention if we have the stomach for volatility!!

What does the ‘dream’ team have in mind for CMS (Medicare & Medicaid)?

That is what President-elect Trump called his proposed nominees Dr. Price and Ms. Verma as Secretary of Health & Human Services and Administrator Centers for Medicare & Medicaid, respectively.

Dr. Price is a six-term Republican Georgia Congressman from Georgia, practiced as an Orthopedic Surgeon in Atlanta and also served on Speaker Ryan’s task force, which authored “A Better Way.” He proposed his own 2015 alternative to the Affordable Care Act (aka Obamacare) called “Empowering Patients First Act”.  His 2015 comprehensive proposal has several items common to other Republican bills and includes federal block grants to states for establishing high-risk pools for people with pre-existing conditions, replaces means-tested tax credits in the ACA with fixed-dollar, age-adjusted premium tax credits, expansion of health savings accounts, including preexisting condition coverage, sale of insurance across state lines, association health plans, balance billing and ability of physicians to collectively bargain with insurer companies etc.

Ms. Seema Verma is the President, CEO and founder of SVC, Inc., a national health policy consulting company.  For 20 years, Ms. Verma has consulted and worked on projects dealing with Medicaid, insurance, and public health as well as several Governor's offices, State Medicaid agencies, State Health Departments, State Departments of Insurance, as well as the federal government, private companies and foundations. Vice-President Pence had Ms. Verma design the state of Indiana’s Healthy Indiana Plan (HIP), which was also then used as a model for Michigan, Maine etc. She also negotiated the waiver of the Indiana HIP program design (1115 Medicaid waiver) with the Centers for Medicare and Medicaid Services (CMS), supported implementation efforts, developed the waiver renewal application and negotiated a financial agreement with the Indiana Hospital Association for the Hospital Assessment Fee program.

Indiana’s Medicaid expansion has covered as many as 410,000 persons and was different in that it supported ‘personal responsibility’ in having those who were able to afford it pay something towards their healthcare as well as take some responsibility for ther health. Although the poor were not required to pay any premiums, of those who were able to afford minimal monthly premiums as low as $4, non-payment made them ineligible for as many services and warranted a six-month lockout from coverage if even a single payment was missed.

Summary: Most experts predict that most parts of the ACA may be repealed but the effects of ACA may be delayed to prevent loss of coverage for over 20 million people. This is likely for several reasons. First, new legislation will need to be ‘scored’ (budget positive/negative) by the Congressional Budget Office and then passed by both houses. Second, if ACA is repealed all the taxes to fund any replacement go away including taxes such as the Medicare surcharge tax, tax on individual investments, health insurer fees, taxes onmakers and importers of drugs. Finally, people covered by exchanges and on current Medicaid expansion plans will gradually switch over to the new replacement plan. Will there be enough revenue if these taxes are repealed to fund the new plan? The President-elect has called for insurance policies to be sold across state lines. However, this may mean 50 different regulatory bodies to oversee insurance companies. How will this work in practice? A Sermo survey of 2,239 physicians including VS showed a 50/50 split on whether to keep or repeal the CA whereas in a previous survey by the Physicians Foundation, 46 percent of physicians gave Obamacare a D or F grade.

We should get a glimpse of the answer within a few weeks.

Physicians and politics

The totally unbiased (!!) NYT recently reported on a Yale study that although physicians overall are almost equally divided between liberal and conservative voters, there are differences based upon specialty.

I am somewhat skeptical of conclusions based upon the assignment of physician political views of just 36,000 physicians based solely upon party registration in just 29 states. The authors say that these states constitute almost 60% of the population leading me to conclude that maybe these are metropolitan areas. Some data from a different study is reported for 20,000 primary care physicians only.

It does appear that more female physicians tend to be liberal and younger physicians also tend to be more liberal leaning. What happens over a few years when the consequences of high taxes tied to higher tax brackets as they age is anyone’s guess. Also, the authors do point out that higher paid specialties tend to be more conservative leaning. I presume these are economic conservatives and not necessarily social conservatives. So, for instance physicians in Orthopedics, Surgery, anesthesiology, Urology, ENT etc. declare themselves to be conservatives whereas primary care, medical specialties, pathology and psychiatry lean liberal. In contrast to two decades ago, more political contributions are now going to liberal politicians.

Can this change be more linked to the switch from self-employed business owners to employees of large corporations and health systems where physicians generally tend to be critical of their employer??

Is the grass greener over there?

A recent survey shows that Private practices showed an average loss of $13,982 per physician and health systems lost $211,961 per physician. However, this is not an ‘apples to apples’ comparison for many reasons not the least being all the non-professional revenue hospitals collect from physician services, which is probably not included in their numbers. https://www.amga.org/wcm/PI/Surveys/wcm/PI/surveys_pi.aspx?hkey=e1644902-2c96-468b-a670-1cb7d97fb036

In another report the happiness was examined between 5000 employed and independent physicians.http://www.medscape.com/viewarticle/863852?src=WNL_bom_160926_MSCPEDIT&uac=137306AY&impID=1201851&faf=1

Over 50% were happy not to deal with the business aspects of a practice but overall, self-employed physicians were more satisfied than employed physicians (63% vs 55%) mainly because as owners they could count on being listened to and active participants. 40% of employed physicians had a patient quota but were happier with EMR compared to independents (40% versus 31%).

We all know the grass is not always greener on the other side. So, to build cliché after cliché: look before you leap!!

Are you a good listener?

I am better at it than I used to be but have a long way to go. It is hard breaking old bad habits. And being a surgeon does not help. This happened frequently when my children were growing up. I wanted to get the gist and to the bottom line quickly without any waste of time. So, my prime concern was for my own time as I saw my anxiety rise with each second and a strong itch to interrupt and ask “So, what finally happened?”

The latest thing is being distracted with an email, text or your phone making it impossible to give the other person a fair hearing. The link below correctly explains that as we listen we are simultaneously “in our head that is constantly judging, evaluating, criticizing, analyzing, and editorializing everything that we hear.” For me, I am already trying to get ahead and formulate a response or if I know the person I think I know what he or she is going to say!

So, there are good strategies in the article on how to be a good listener.

Why do you need to be a good listener? Many reasons especially if you are leading people. If you want to be understood, you have to try and understand others and for that to happen you really have to listen.

http://leadchangegroup.com/9-strategies-to-become-a-fantastic-listener/

 

Top ten innovations coming in medicine

Consulting firm Deloitte has it’s take after surveying leaders in healthcare. They think the areas where progress will occur or is already occurring are : Aligning financial incentives, Rise of consumerism and Data privacy, security, and interoperability.

The top ten innovations are:

1.       Next-generation sequencing (NGS)

2.       3D-printed devices

3.       Immunotherapy

4.       Artificial intelligence (AI)

5.       Point-of-care (POC) diagnostics

6.       Virtual reality (VR)

7.       Leveraging social media to improve patient experience

8.       Biosensors and trackers

9.       Convenient care: Retail clinics and urgent care

10.   Telehealth

Popular innovations that didn’t make the list: Gene therapy, Regenerative medicine, Robotics,

Concierge practice for surgeons?

You have heard about Concierge medicine or boutique practices of course.

But, we think it is for primary care physicians. Some think it is time for surgeons now to jump into the pool. http://www.outpatientsurgery.net/newsletter/eweekly/2016/06/21#1

The attraction is 24/7 ‘top’ surgeon access. The company is starting with spine care with a $99 annual fee giving a statewide list of a guaranteed appointment within 2 weeks from a statewide network. A VIP fee of $495/year gets you an appointment nationally within a week and a phone number of the surgeon.

Full concierge service is $2500 per quarter to 24/7 global and national coverage and access via text/email, a personal assistant to schedule, a rehab program for spine surgery etc. The company has 16 surgeons signed up covering orthopedic sports, spine surgery, gynecology and robotics procedures.

Again, time will tell whether there are enough patients who can afford the service as well as enough ‘top’ quality surgeons who have time to provide 24/7 coverage. Concierge service for primary care has worked to some degree. http://nymag.com/scienceofus/2015/06/how-physicians-make-money.html. In the link noted, the PCO provided a hybrid model with a $1000 annual fee for patients aged 36-64.

For physicians fed up with EMRs, rushed visits, hassles with insurers and rising overhead, it is certainly an option.

 

The MACRA problem for physicians

Medicare is on steroids trying to base reimbursement for physicians tied to quality of care (value based payments) delivered despite there being no real empiric measures yet scientifically validated. The other object is to force closer cooperation with hospitals.

In the proposed rules (MACRA), physicians will have to bill under either merit based incentive based system (MIPS) or alternative payment model (APM). MIPS will probably apply to a majority of physicians and the first performance period when it will apply will be January 1st 2017 although the program goes into effect in 2019. The risk may be up to 4% the first year but could exceed 9% a year later. CMS says that about 761000 physicians will be eligible for MIPS and between 30,658-90,000 will be exempt from MIPS and be able to participate in APMs. MIPS components include: 50% for quality (PQRS & VBPM), 25% for something that will replace ‘meaningful use’, 15% for clinical practice improvement and 10% for cost.

Physicians will increasingly be held responsible for in-patient hospital spending!! The idea is that it is physicians who cause the hospital to spend the $! Although APM will have more flexibility, the standard for eligibility will be stricter than MIPS and necessarily involve being part of an ACO.

 

Is your head spinning with all the new acronyms? We will need to hire translators to understand the new language. Maybe we need to get together and form a consulting group to make all this understandable?

 

Some risk measures in investing

Some people have compared a portfolio to the waves of the ocean in terms of volatility. The view is that if you own one or a few individual stocks you could lose it all (unless you are lucky or King Solomon) so you should diversify to allow investments to remain stable like the still water beneath the waves. This is why the traditional advice has been to reduce equity holdings as you age in favor of stability i.e. bonds or bond like investments.

I have described previously the application of standard deviation to investments. As a general rule, returns in the future on average fall within one SD 68% of the time and within three SD 99% of the time. As Larry Frank author of the book, Wealth Odyssey explains: “A portfolio has $100,000 in value (75% short-term bonds, 25% stocks) and a 6.29% standard deviation. Most of the time (more precisely, 68% of the time), the portfolio likely will go up 6.29%, down 6.29% or any point in between. It means at least $93,710 ($100,000 minus 6.29% of $100,000) of the portfolio is unaffected. And 95% of the time, $87,420 of the portfolio value is intact. The waves might go down three standard deviations, 18.87%; still, $81,130 of the portfolio is fine.”

I have also mentioned the Sharpe Ratio (how much return you are getting in exchange for the level of risk you are taking). The higher the ratio, the more an investor is compensated for the risk. If you go to Morningstar.com it lists, you can find it under a fund's "Ratings & Risk" tab. This is another measure that will help in assessing risk. Of course, it has downsides also. For one, it is a measure of past performance only and second when returns are low or negative in comparison with Treasuries, the ratio is hard to interpret.

 

New era for financial advisors

Financial advisors are never free. Most of the time the fees/commissions are either not disclosed or are more than the client estimates.

The so called 'fiduciary' rule issued by the Labor Department (1,028 pages of which 208 pages define what a fiduciary is!!) is meant to require brokers to act as fiduciaries, meaning they have to give advice, which is in the best interests of the client and not simply offer 'suitable' advice. This will be followed by lawsuits as billions of dollars hinge on this rule for brokers and advisors. Sounds great but many experts say that it is watered down so that fine print in the contract with the advisor may allow previous behavior. Apparently, 317 pages are about a 'best interest contract exemption' which allows actions not favorable for clients. Besides, a lot of provisions in the new rule do not go into effect till January 1st 2018.

Fee based advisors charge an hourly fee or a fixed percentage (often 1% of assets under management but one has to be sure that small commissions are not thrown off by mutual funds or insurance policies. If a advisor acts as a fiduciary, they have to disclose this to the client.

Recently, several 'blind' spots were detailed about perceptions from the client and the advisor's perspective. .http://wealthmanagement.com/client-relations/financial-advisor-blind-spots

Best advice is to get a good referral, screen advisors an d insist on full disclosure.

Preparing physicians for leadership positions.........................

This article of mine was recently published in THE major physician leadership society's journal this month. The link is here: http://www.physicianleaders.org/news/plj-articles/2016-march-april/2016/03/07/preparing-physicians-for-leadership

and a recent national newsletter; http://www.fiercepracticemanagement.com/story/4-insights-developing-physician-leaders/2016-03-23?utm_medium=nl&utm_source=internal&mrkid=%7B%7Blead.Id%7D%7D&mkt_tok=eyJpIjoiWXpKa05USXdOMk14WmpZNCIsInQiOiJHcXFpWVNEbURybXJlU25NSEdXTU9lRndZemdia1g2SWMzV054OFFFdkJQekdBamg3OCtcL2h6dXNLYWlmdjNXajhXYml5b092b2U2Y0lMSjBwRUUyWHlvQjJtSjR3OW1PRHNzelVTXC9ObEswPSJ9

The point is what has worked so far (picking the best clinicians to leadership positions) may not work often due to the complexity of the new environment and the lack of necessary new skills required to lead health systems.

Hospitals and health systems are just starting to play catch up by trying to train physicians with these new skills. 

Will private practice thrive?

It depends.

You have heard that line before! It depends if the playing field evens out. It depends if the Federal Trade Commission has a spine. It depends if physician groups coalesce into moderate to large groups in order to compete with health systems. Etc. Etc.

I have laid out some thoughts here http://www.acssurgerynews.com/practice-economics/practice-management/single-article/pointcounterpoint-self-employed-community-practice-is-still-a-viable-proposition/05be23899f34765abef2f24391d95694.html

What will interest rates do??

Importantly, almost all financial experts have been wrong about interest rates going up very soon. I remember the conversation with my advisor almost 8 years ago. Luckily, I did not listen to him.

Understanding how interest rates work is important.

If you want to get into the nitty gritty of interest rates here is a very good discourse on how interest rates work

Here is the link: http://www.iris.xyz/alternatives/are-higher-interest-rates-inevitable

 

Problem with financial incentives for physicians

Incentive or performance pay has been a common tactic in the business world to entice workers mainly the sales force to increase productivity. The pay for performance (P4P) language started becoming common in the medical world a couple of decades ago. Certainly, private practice and increasingly now some academic practices have incentive bonuses for productivity in employment contracts.

I am more interested in the macro environment in healthcare rather than individual employment contracts although as I have argued, there is a powerful conflict sometimes between institutional versus physician interests if incentives are not aligned. See “Physician incentives may not be aligned with their health system employer. What is a physician to do?” athttp://www.surgjournal.com/article/S0039-6060(12)00154-7/abstract.

There are some positive and some unintended consequences of incentive pay in medicine. Now, we are migrating from productivity pay to quality based reimbursement and compensation.

An older Harvard Business Review article https://hbr.org/1993/09/why-incentive-plans-cannot-work  lays out some interesting arguments on this topic arguing that incentive plans cannot work. The author points out that research shows that incentive plans do work but temporarily. They change behavior only while the incentives last and that the work output is not any better. At the executive level, the author says, there is often a negative correlation between pay and performance! The points they make are: rewards ignore the reasons for the behavior desired, discourage risk taking and rupture relationships.

Do these conclusions apply to medicine? Who knows? Reach your own conclusions.

Hospital mergers & acquisitions in 2016

A survey of 250 healthcare executives about mergers and acquisitions for 2016 revealed some interesting thoughts.

·         41% say the growth will be via mergers and acquisitions (M&A) rather than growth of the organization through internal efforts.

·         60% are optimistic about financial results for 2016 compared to 35% who say performance will be the same and 5% predicting weaker results.          

·         The majority say implementation of the ACA aka Obamacare and regulatory scrutiny will be top challenges.

·         36% estimate they will benefit from ACA whereas 38% see no benefits.

·         Almost 90% anticipate greater capital needs than in 2015.

What is driving this? The realization that developing competencies to deal with value based payments and managing population health as well as managing cost will be required. So, they see partnerships through M&A with experienced entities to lead them through 2016. Smaller entities are increasing participation in M&A. For instance, in approximately 40% of the transactions announced in 2015 the target acquisition had less than 100 beds.

McDonaldization of medicine

Interesting post by Ray Dorsey in JAMA Neurololgy. If you are like me you will not have come across a neurology journal here http://archneur.jamanetwork.com/article.aspx?articleid=2469513

The authors relate what we all see around us: the "principles of the fast-food restaurant—efficiency, calculability, predictability, and control" applied to medicine.

They take each of these four principles and point to problems when applied to medicine in the extreme. No one (at least rational) will argue that we need these principles to challenge us to aspire to be better but taken to the nth degree, what are the consequences?

For instance they say that efficiency taken too far may lead to long lines and mistakes by workers pushed to do more with less leaving patients at a loss. Calculability or emphasis on numbers taken too far may shift the focus from humanistic care to speed. Predictaibility as per Demling may lead to a predictably mistake free car but what if individual patients require more or less time to solve their problem? Finally, controlthrough technology has the possibility of generating more precise data to allow better modeling but at what cost? Physicians are already unhappy at the enormous time spent on their computer rather than looking at patients, who are similarly upset at being objects rather than persons.

The article is however an emotional piece. True but lacks real solutions. As long as the healthcare system is led by people who are not accountable to the people and there is lack of transparency, patients and physicians have little say. Part of the solution is both stakeholders pushing to be in control and be at the table in decision making to make sure their voices are heard in the jumble of technology and finance.