International Strategy in Healthcare

                                                      Cleveland Clinic in Abu Dhabi

Many healthcare systems work across multiple countries. Many firms can also leverage their resources and capabilities by engaging in activities in different countries. It is mostly common in technology and manufacturing industry. Companies like Apple, Cisco, IBM operates in dozens of countries so does beverage companies like Coca-Cola, Pepsi and hotel industries like Hilton, Marriot and Best Western. Automobile industry is extremely global. In the healthcare industry it is an emerging market. Healthcare tourism is popular where people travel to different countries to take care of healthcare issues at a cheaper cost. Many hospitals in Asia and Caribbean are working are popular with healthcare tourism. Each year thousands of patients come to Cleveland Clinic and St. Jude’s from around the world for specialized medical care.   Many hospitals have started operating in other countries.  Cleveland Clinic also operates in Abu Dhabi, Riyadh, Guatemala, Honduras, Panama and multiple other countries. Methodist healthcare has ties in Bangladesh and China. Operating in international countries can be challenging as the protocols, regulations, taxes, insurances, payment system and competition are varied and challenging.

 Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Sources: Gaining and Sustaining Competitive Advantage by J. Barney

Merger and Acquisitions in Healthcare

Merger and Acquisitions are the buying; selling, dividing and combining of different companies that can assist an organization grow without using a joint venture. Merger is association of two companies into one, whereas an acquisition happens when one company takes over another and becomes the new owner (a large hospital system buying a home health company or a smaller regional hospital).

In the healthcare industry this is primarily driven by competitiveness and profitability. The final goal is to increase one’s ability for success. As the company wants expands its core business of healthcare service, often they also participate in different new areas of services that they are not proficient; aligning with a company who can help with that part is one option and the other could be by merger and acquisition.   

 Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Sources: Gaining and Sustaining Competitive Advantage by J. Barney

                      http://www.methodisthealth.org/

Strategic Alliance in Healthcare

Strategic alliance is usually an official relationship between two or more organizations to pursue a set of joint goals or to meet a critical business need while continuing to remain independent organizations. Strategic alliances can be very useful in healthcare as a business when common goals are set based on the resources of the organizations. The final goal is to increase your ability for success. As the company expands its core business of healthcare service, often they also participate in different new areas of services that they are not proficient; aligning with a company who can help with that part is often the key. In the Greater Memphis area, Methodist healthcare in Memphis has aligned with several organizations to provide services to its customers. One of their key alignments is with Health-South rehabilitation, a national leader in inpatient rehabilitation.  As the patients are discharged from the Methodist hospitals often they are in need of inpatient rehabilitation. A similar alliance has been with the signature health, another national provider in Skilled Nursing and long term care.  In both the scenarios, the expertise required to successfully manage the business is complicated and needs plenty of resources. Aligning with the organizations who are experts in this area helps both the organizations. Alliances are common throughout the healthcare industry be it in Rehabilitation, Lab, pharmacy or food and nutrition, the goal remains the same, providing care while maintaining the competitiveness.

 Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Sources: Gaining and Sustaining Competitive Advantage by J. Barney

                http://www.methodisthealth.org/
                http://www.caycon.com/blog/2014/05/how-is-that-strategic-alliance-working-out/

OUTSIDERS ON THE BOARD

In the recent times much attention is given to recruit board members from outside the board. The issue of how the power should be shared between the board members – inside or outside– is often debatable but both have merits.  The argument is that the outsiders can be more objective as they have less self-interest.

Similarly in the health care industry, members from the community, independent physicians, and family partners are often encouraged to serve on different boards. It definitely adds value as they can add their perspective without focusing on the internal issues of the system. But at times, too much control can cause shift from the operational focus. Having the right balance where they can complement each other is the key success.

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Vertical Integration In Healthcare

Vertical integration is a strategy in microeconomics which describes about a company to compete with it’s competitors by gaining control over its supplies or distributions and thereby increasing the firm’s power in the marketplace. The more they are integrated the more they are vertically integrated. For a hospital system, when they invest on the physicians who can admit patients directly  to their hospitals helps the hospitals with their admissions and census and after they discharge the patients, patients will need multitude of services like medications and pharmaceutical, lab and other test requirements, services like home health , inpatient rehab, outpatient services etc. The more a hospital can provide services the more they can control the market. 

               Methodist healthcare system and their major competitor in Memphis area, Baptist healthcare, both have invested  heavily on their physicians. They both have dozens of outpatient services, surgery centers. They both own home health services. Baptist partners with Nashville-based Centerre Healthcare to service inpatient rehabilitation and Methodist provides this service via Healthsouth a national chain in this area. Providing the services before a patient is admitted to the hospital (backward integration) and the services they require after they are discharged from the hospital like various home-health and outpatient needs (forward integration) is vital for their business.

Cardiocom, explains their vertical integration (http://www.cardiocom.com).

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Tacit Collusion in Healthcare

Tacit collusion exists when two or more firms coordinate their production and pricing strategies indirectly by agreeing a production and pricing decisions of other firms.  Usually this can lead to under production and prices above the competitive levels. This are more common in the oligopoly markets where there are mainly two major competitive organizations.

The healthcare market in Greater Memphis area has about six major players but the two large companies, Baptist Healthcare and Methodist healthcare controls most of the market share. In a real sense, this should create an Oligopoly market where they both can dictate the price. But in USA, healthcare market rates are partially dictated by CMS (Center for Medicare and Medicaid services), private insurances and organizations like AMA (American Medical Association) and others. In rural areas, where there are monopoly, healthcare can negotiate special rates with the insurance companies but in urban areas, where the market is more open and competitive, tacit collusion is minimal.

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Flexibility in healthcare

Flexibility in the healthcare industry is the  ability for the organization to change directions quickly and at low cost, given unanticipated changes in the competitive situation. 

Though there are several types of flexibility, but the top ones are: The options to defer; The option to grow; The option to contract; The option to shut down; The option to abandon; The option to expand.

Methodist healthcare in the greater Memphis area remains flexible and competitive. The examples of some of their actions are tabulated underneath.

Types of Flexibility and Examples of Actions That Can Create

Types of Flexibility	Examples
The option to defer	Option to defer purchasing transportation van, instead contracting service through a 3rd party.
The option to grow	Methodist Healthcare, decides to open up a new hospital in Olive Branch, MS.
The option to contract	Contracts temporary staff to cover week nights and weekends
The option to shut down and restart	Recently shut down the hospital at Fayete County in TN.
The option to abandon	Recently abandoned the SNF program and outsourced the whole program to the Signature health care.
The option to expand	Recently added the new service by aligning with West cancer center and opening of the hospice house.

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Economies Of Scale In Healthcare

Many healthcare systems are using economies of scale to standardize operations across chain of hospitals while introducing an innovative model of care. In the Greater Memphis Area both the Baptist Healthcare System and the Methodist Healthcare System have added multiple hospitals and dozens of physician practices in the recent past.

In the areas that they currently serve, one can reach either of the facility or one of the participative practitioner with in minutes.

The changes in health care today is driven primarily by three factors:

• System that allows more patient care to move out of hospitals and into ambulatory settings

• Increased regulation making the hospitals expensive to build and maintain

• Cost shifting to patients, prompting them to empower lower-cost options for health care

To address these changes, both the hospitals are building a future delivery system that will meet the outpatient-centric needs of patients in this economies of scale systems.

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

http://www.acodatabase.com/blog/economies-scale-and-accountable-care-organization-aco

http://www.dailykos.com/story/2010/09/05/898866/-Healthcare-Economics-Scale-Scope-and-Standardization

http://www.quora.com/What-is-the-difference-between-economies-of-scale-and-increasing-returns-to-scale

http://www.methodisthealth.org/about-us/our-culture/affiliations.dot

VRIO Analysis - Methodist Healthcare

Is the organization Valuable?  Is it Rare? Is it Costly to Imitate? And this firm Organized to Exploit? Capabilities that meet all four requirements can bring sustained competitive advantage for a company.

In order to recognize the competitive advantage, firms are using many tools to analyze their external (Porter’s 5 Forces) and internal (Value Chain analysis) competitive strength.  One of such tools that analyze internal assets is VRIO analysis. This tool was designed by J.B Barney in 1991. In order to sustain competitive advantage; VRIO is often used across the organizations.

In the Memphis area, Methodist healthcare plays an important role and has been one of the leaders in this region.  In 1924, Methodist healthcare started with the lone hospital in the Memphis downtown.  Currently with 6 hospitals and more than 12,000 employees, Methodist healthcare system treats more than 63,000 patients in the hospital and more than 343,000 outpatients (2013 data). 

Valuable: Having a strong regional presence is an important asset for the company trying to increase their size, patients, and market share. Currently with 6 hospitals and new lines of service, it is a great way to gain more customers and keep the insurance companies in their network.

Rare: Their top of the line organ transplant unit and the pediatric hospital is uncommon in this area but as a hospital system, there are two other major hospital systems besides Methodist healthcare.

Imitable: In the recent time, no competitors of Methodist healthcare have gained such a patient volume but with the opening of the new ER system by Baptist healthcare, healthcare in Greater Memphis is far from non-imitable.

Organized to Exploit: By treating a variety of disease process and continually changing their service lines, Methodist healthcare is taking advantage of this capability. With the new hospice center and collaborations with West Cancer center they are pushing themselves to the new service lines and reaching new patient populations.

The VRIO analysis of Methodist healthcare:

VALUE?	RARE?	IMITABLE?	ORGANIZED TO EXPLOIT?	COMPETITIVE IMPLICATION
YES	YES	NO	YES	Temporary competitive advantage

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Sources:

http://www.methodisthealth.org/

http://www.strategicmanagementinsight.com/tools/vrio.html

Gaining and Sustaining Competitive Advantage, Fourth Edition

Converting Threats In To Opportunities

Although the five forces model 1. Entry 2. Rivalry 3. Substitutes 4. Suppliers 5. Buyers, describe some important threats firms face, it also describes some possible opportunities. Each threat is also an opportunity. By choosing the right strategies one can neutralize these threats. With the ever-changing healthcare environment in USA, where the major hospitals are struggling to stay profitable making right strategies are extremely important.

In a city like Memphis where the population is close to 700,000 and more than 5 hospital systems, competition is substantial. The two major players Baptist Healthcare and Methodist Healthcare has been successful regarding keeping the rivalry between the two. Between theses two systems, they service more than 70% of the Memphis patients. 

1. Entry: They have been successful in restricting new entrants to this market by mostly aligning with the major medical groups of the city, a deterrent for the new entities. By increasing their presence in this area (Methodist has 6 hospitals and Baptist has 3 hospitals), they have exploited the economies of scale in their favor.

 2. Rivalry: They have been able to keep the rivalry between the two only and are able focus product differentiation. e.g. Methodist is known for their pediatric specialties and Baptist with their heart transplant program. 

3. Substitutes: To compete with substitutes , entities can reduce the cost (cost leadership), can improve the perceived quality of its products (product differentiation), can align with substitute manufacturers and by aligning to the smaller clinics / systems Baptist and Methodist systems have converted their threats in to opportunities. 

4.Suppliers: Uniqueness of a supplier can be a threat but by aligning with their suppliers and dealing with many can neutralize the threat. 

5. Buyers: Same way as Suppliers, a few buyers can be threat but increasing that number or becoming your own buyer can be beneficial. Most hospital system also provide different outpatient care, home health services and DME supply in a way becoming their own buyers and serving the patients with in the system.

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Source: 

Gaining and Sustaining Competitive Advantage, Fourth Edition by Jay Barney

http://figures.boundless.com/22099/full/porters-five-forces.png

Greater Memphis Healthcare Market

With 21 hospitals in Shelby County,Tennessee, one may wonder about the huge Healthcare market in the Memphis area and the market must be a near perfect competitive one. As we know a perfectly competitive market is a market where competition is at its highest level with multiple competitors and Knowledge is freely available to all participants, which means that risk-taking is minimal and the role of the entrepreneur is limited.  Neo-classical economists argued that perfect competition would produce the best possible outcomes for consumers, and society. On a quick glance to this hospitals reveal that there are actually 8 different entities who owns them. Of these, Baptist healthcare has 5 of them (not counting the ones they own in the neighboring counties in TN, MS and AR) and Methodist healthcare owns 6 of them (not counting their Olive Branch hospital in MS). Further, we can see  that Methodist Healthcare defines 41% market share, Baptist Health continues to hold the next leading market share at approximately with 33%, with for-profit Tenet a distant third with 14% and Regional One Health at under 10% (2013 data). With 74% market shared by the top two giants, it is fair to say that Memphis market is definitely not a competitive market but more of an Oligopoly one. An oligopoly is a market structure in which only a few firms dominate at a time and market share is uneven. To compare the present Memphis market one can compare this with the present Airline industry in the US or the Telecom industry with a few giants covering most of the consumer base. This type of market gives more power and freedom to the major players but “with great power comes great responsibility". Methodist and Baptist healthcare will have to continue the legacy of high quality service at a competitive price otherwise the consumers will suffer.


The listed hospitals in Shelby County, TN:

Baptist Mem. Restorative Care Hospital
Baptist Memorial Hospital for Women
Baptist Memorial Hospital-Collierville
Baptist Memorial Hospital-Memphis
Baptist Rehabilitation-Germantown
Delta Medical Center
Department of Veterans Affairs Medical Center
HealthSouth Rehabilitation Hospital Memphis
HealthSouth Rehabilitation Hospital North
Methodist Le Bonheur Children's Hospital
Methodist Extended Care Hospital
Methodist Le Bonheur Germantown Hospital
Methodist North Hospital
Methodist South Hospital
Methodist University Hospital
Regional One Health
Regional One Health Extended Care Hospital
Saint Francis Hospital
Saint Francis Hospital-Bartlett
Select Specialty Hospital-Memphis
St. Jude Children's Research Hospital

Methodist Healthcare's flagship hospital in downtown Memphis

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Source:
http://www.economicsonline.co.uk/Business_economics/Perfect_competition.html
https://www.moodys.com/research/Moodys-affirms-Methodist-Le-Bonheur-Healthcares-TN-A2-and-A2VMIG--PR_310428
http://www.economicsonline.co.uk/Business_economics/Oligopoly.html
http://www.methodisthealth.org/about-us/our-culture/affiliations.dot

GRANDMASTER (Short Film)

(2007)

Written by; Anupam Lahiri

FADE IN:

SCENE 1

EXT.

(Shot of an outside of a warehouse - day time. Very quiet neighborhood, no one around.)

CUT TO:

SCENE 2

INT.

A large semi dark place, with a table at one end. There is a light hanging on the top of the table.

There is a middle aged man - sitting - slightly heavy set - he has a chessboard in front of him. He has a drink and a cigar. He is playing the game by himself. (He is the Boss).

CUT TO:

SCENE 3

EXT.

The warehouse - a car pulls up. Two men get out of the

car.

MAN 1

Looks around, scans the area , nods at man-2.

MAN 2

Opens the trunk of the car and brings out a man (Victim),

blindfolded, hands`are tied in front , with a rope.The two men escort the victim (blindfolded man) in the warehouse.

CUT TO:

SCENE 4

INT.

The two men escorts the victim to the boss. The boss is unmoved. Still playing chess.

THE BOSS

While looking at the chess board, gestures his men to leave.

Man-1 opens the blindfold of the victim and then leaves with man-2.

VICTIM

Tries to say something (clears his throat)..

THE BOSS

Gestures him to be quiet, still looking at his game

(showing the chess )do you play ? ( gestures ).

VICTIM

Shakes his head (to say no).

THE BOSS

Takes a deep breath - moves aside his chess board - tells

him to sit and extends his arm across the table.

VICTIM

Extends his arm - still tied with the rope.

THE BOSS

Pulls out a knife and cuts the rope - from the middle,

then ties one end of the rope to the leg of the table.

He pulls out a cork board and puts it on the table - and

stabs the knife on top of it.

THE BOSS (CONT'D)

Holds the knife at the shoulder height and brings it down

slowly to the victims hand.

VICTIM

Manages to move his hand.

(The victims face is -

pale - surprised.)

THE BOSS

(the boss's face emotionless)

Picks up the knife and brings it back to the table - the

hand moves again - knife comes down again - this time

scrapes the hand - blood comes out -

VICTIM

Loud scream from the victim.

THE BOSS

Stops, pulls out a blindfold from his pocket - puts it

around his eyes (own) and starts stabbing - at a slow

speed .

shot of the hand on the table - escapes every time.

The speed increases - shot of the knife coming down - at

a rhythmic pace (almost as if the boss is playing a

musical instrument).

VICTIM

The victim screams.

THE BOSS

Unmoved, keeps on with his stabbing, the speed increases

again - quite fast - shot of the boss's face - his teeth

are clenched.

VICTIM

Screams again ….stabbing continues... screams - quiet -

you can hear the knife striking the board at a very fast

pace.

(After a few moments)

THE BOSS

Breathing a little heavily , stops the stabbing - and

takes the blind fold off.

(POV of the Boss)

- the rope on the table is cut and the chair in front is

empty.

THE BOSS (CONT'D)

The boss is by himself - a little smile on his face

- looks at the cork board -- it is smeared with blood.

The boss lifts the board close to his face and takes a

deep breath - then moves the board aside and pulls his

chess board back and makes a move .

FADE OUT.

http://youtu.be/wwJVtAqsD1Q

An obvious competitive advantage

Ability to exceed the average for the industry is the differentiation advantage for the Methodist LeBonheur Healthcare in the mid-south region. 

      Competitive advantage enables Methodist LeBonheur Healthcare to create superior value for its customer. MLHC (Methodist LeBonheur Healthcare) operates as the only stand-alone children's hospital in western Tennessee with the nearest competition in Nashville, TN and Little Rock, AR, and holds regional referral status in the state, providing contracting leverage with the payers. Children's hospital volume shows continuous growth and the overall $1.58 billion multi-facility (currently 7 hospitals) system largely in greater metro-Memphis and a single facility in the neighboring Mississippi area, leading with 41% market share (2013 data) in the primary service area, providing certain unique services like transplants, pediatric emergency and intensive care unit (e.g. transplants, pediatric intensive care unit); In addition, US news has recognized MLHC as the top regional hospital in cardiology and heart surgery, neonatology, neurology and neurosurgery, orthopedics, pulmonology and urology shows the leadership and speaks volume about the quality of care and acceptance by the local community. Rightly, Moody's Investors Service has confirmed the A2 and A2/VMIG1 ratings to MLHC.  MLHC (Methodist LeBonheur Healthcare) a not for profit organization’s partnership with University of Tennessee Health Science Center has enabled focus on research and continuous quality improvement further enhancing the advantage.

Disclaimer: Opinions expressed are solely personal and do not express the views or opinions of any other person or entity.

Sources:

Picture credit: http://communitywealth.com/competitive-advantage-matters-for-nonprofits/

https://www.moodys.com/research/Moodys-affirms-Methodist-Le-Bonheur-Healthcares-TN-A2-and-A2VMIG--PR_310428

http://www.methodisthealth.org/

http://www.beckershospitalreview.com/finance/8-hospitals-receive-credit-downgrades-in-past-month-may-2013.html

Emergent Strategy is a must for healthcare industry

Healthcare in the US is one of the most dynamic and volatile industry. There are ever-changing regulations and reimbursements. The entries and exits of the different Insurance companies, the government regulations like Affordable Health Care, the stipulations and requirements by the bodies like Joint Commission, the ever changing expectation from the patients and the different providers makes it so dynamic.  The emergent strategy provides an adaptive approach to these complex issues – one that goes beyond the intended or the initial strategies.  

  While a hospital delivers solution to disease and illness, providing access to a population in need is extremely critical. The strategy will have to differ considering the geographic, political, cultural and socioeconomic situations. Any changes to above mentioned situations will also affect the hospital operations and their strategies.

Though the changes are often unclear and political but the impact it creates are substantial and the industry needs to be flexible enough to take advantage of new opportunities. Emergent strategy is therefore an undeniably perilous component in the current turbulent healthcare business environment. It cannot be ignored, and establishments must create strategies for emergence to occur. Organizations cannot sustain any form of competitive advantage without considering the emergent strategy. 

http://scholar.google.com/scholar_url?url=http://www.researchgate.net/profile/Wendy_Bodwell/publication/236625602_Organizational_ambidexterity_Integrating_deliberate_and_emergent_strategy_with_scenario_planning/links/0c9605187df95222bb000000.pdf&hl=en&sa=X&scisig=AAGBfm23djRN2t_jGSbyWdh8B4G5wHSgIg&nossl=1&oi=scholarr

http://intersector.com/a-model-of-emergent-strategy/

ROLE REVERSED

by Anupam Lahiri

Four men, carrying him on their shoulders

Walking hurriedly through the leaf-filled ruts,

On a lesser known trail into the woods.

He is lying on a cot holding on the side rails,

Bouncing side to side, with grimace on his face

From pain and fear. They are carrying machetes and his rifle!

It is getting dark; they stopped and lit the campfire.

The place is known for wild animals.

They stand with faces toward the flame talking!

Him, still in the cot with pain from the broken ankle.

He came here to find them, but they

Found him instead. He is thinking about his

3 month old daughter and wife back home.

Will he see them again? Do they know

He is captured, and now a prisoner of war?

Competitive strategies used by Methodist Healthcare in the Greater Memphis area

Though Memphis population is roughly around 650,000 but the greater Memphis metropolitan area, including adjacent counties in Mississippi and Arkansas, had a 2010 population of 1.3 million. This makes Memphis the second-largest metropolitan area in Tennessee after Nashville.

In the healthcare industry, it is dominated by a few big players like the Baptist Healthcare, Methodist Healthcare, St. Francis (Tenet Healthcare) and The Med. Memphis has 17 community hospitals, 30 nursing homes and is accounted for over $2 billion in revenues per year and approximately one of every nine jobs in the area (Tuckman and Chang 1984). There is a healthy rivalry between the Methodist Healthcare and the Baptist Healthcare system each trying to expand their market reach.

To reach the local market, Methodist Healthcare focused on: Horizontal integration by buying large number of small practices like the West clinic, LeBonhuer Children’s hospital and hundreds of other practices; Product diversification includes organ transplants, stroke care programs etc. ;  Product specialization includes their pediatric hospital, cancer treatment center, organ transplant center;  Resource-based quality improvement: Methodist healthcare, a JCHAO certified for stroke care has adopted several in house and external programs for continuous quality improvement; Institutional differentiation: Besides joining with UT Health Science Center, Methodist healthcare has aligned with various renowned physicians, constructed modern buildings, advertising to attract the local market.  Public relations and physician-centered marketing is achieved by closely working with the physicians and empowering them has helped to regain top regional hospital by the U.S News.

Disclaimer: Opinions expressed are solely my personal and do not express the views or opinions of any other entity.

Source:

http://www.methodisthealth.org;  https://academics.ochsner.org/uploadedFiles/Education/Library/Portals/M4.pdf

http://www.bizjournals.com/iframe/welcome?r=http://www.bizjournals.com/memphis/

http://jhppl.dukejournals.org/content/13/3/547.short

There is a beginning !

Well, one has to start somewhere and I feel it is time to officially start a blog. I have written now and then and here and there without a system or a structured plan. A few even got published but mostly got lost. Yes, I have written on napkins and sometimes on back of receipts ; well what else can you do? You got to write when you got to write, right? So, here I am, officially pronouncing myself a blogger and promising to keep blogging until I break my promise. One thing I have learned that if you are going to bore people don’t make it long and painful, unless of course you make it long enough that you have bored people to numbness and they don’t feel the pain anymore. In either case, I would like to keep you mostly pain free. And by the way, opinions expressed here are solely my own and do not express the views or opinions of any other person or entity. So until next time, NAMASTE.