Good morning, everyone. Welcome to Saturday at the Negotiation Cafe. We're very pleased you're spending part of your weekend with us. We're sorry we're not in Nashville, but we're here for you virtually. So this morning, I just wanted to introduce myself. I'm Dr. Michael Lupinacci, for those of you that don't know me. And we have a very distinguished panel of speakers with us to really dive into aspects of negotiation that are really critical for navigating PM&R through modern medicine, which is very complex, as we all know, especially the past two years. So joining me today is Dr. Michelle Gittler and Dr. Steve Natz. I'm very excited to work on this negotiation presentation with them with their vast experience in the world of health care and PM&R. Next. So today, what we're going to do, we're going to look at contemporary literature a little bit to present some modern aspects of negotiation and what's been looked at in the actual literature, as well as what's been looked at in the corporate world to be some really important concepts. The other thing I wanted to mention is that there will be some repetition of concepts here. That was done intentionally because we want to make this a learning session. So we're going to drill down into some things that we think are really important. So you'll hear those a little bit repeatedly through the presentation. And we're really looking at negotiation concepts as they affect our negotiations for our patients, for their care and for their advocacy. But a lot of the concepts also apply to your personal negotiations as well. So that'll be a blend of that. But primarily, we're looking at how did we negotiate for the best care and best advocacy for our patients. If you look at it through that window, that's really our intent here. Next. So a prime leadership skill is going to be the art and science of negotiation. There's no question. All three of us on this presentation would agree with that 100% through our experiences. So a negotiation really comes down to a human interaction. It is an entirely human interaction. And the intent is how do we engage others in a way that yields better outcomes and understanding that facilitates the care of our patients. Next. So we're going to start off with four very simple concepts. The first is the need to focus on what are the interests of the parties that are engaging in this conversation, not what their positions are, but what their interests are. Positions are what they want from negotiation, what you want from it, what they want from it. The interests are why people want it. Why do you want this particular situation to unfold in this way? So I'll give you two quick examples. Trauma team. Trauma certified want the surgical residents to report to them. The surgical team wants the surgical residents to have a trauma rotation to report to general surgery. It's not an atypical battle at trauma services. What usually happens is they realize the trauma surgeons want to have the entity be pure and the surgeons want a good experience for their residents. So have the residents report to the trauma surgeons directly. Right? Everybody's interests were met. MI example, classic example, a patient comes into the ER, has chest pain. They don't want to stay there. But the cardiologists want to admit them and rule out MI, etc. So that's not going to go well. The patient wants to leave. The doctor doesn't want them to leave. So that's their position. The doctor intuitively, the patient signs out AMA, comes back with a coding. Okay. The other way around that, the trauma, the cardiologist says, well, why do you want to leave? And the patient says, well, I have a dog at home. He's alone and no one to take care of him. Okay. Let's call a friend and get them over to the dog. So just to kind of a classic example of positions versus interests. Next. So positions are typically incompatible. They, person A wants this person, B wants that, but they're like the interest as I've just illustrated a couple of very simple examples are most likely compatible. So you have to determine what the underlying interests are. And then the whole process has to move in to satisfy those interests. And so resolution of disputes requires attentions to the interests. And that's where your questions need to be directed as you move forward in any negotiation that you would do. Next. So the second main concept is framing matters. How you ask something, the style and the structure of your ask is as important or more important than the substance of what you're asking for. So to a few quick examples, smoking mug. I asked the Reverend Father if I could, if I could pray when I smoke. And the Reverend Father said, no, no, you know, no, that's not going to happen. And so in the other side of that, well, can I smoke when I pray? And the Reverend Father said, yes, right. Of course you can smoke when you pray if you want to do that. So the other, the other things have to do with status quo biases. And this is again, in the literature, people are more likely to opt into something than opt out of something. And so again, it's just one of those biases that psychology and neuropsychology has seen in patient's choices. The other thing is people are more or less to avoid loss than to get gains. So, and again, in negotiation, if the topics go towards avoiding loss, it's more likely going to be a successful negotiation on that side. And the same thing for hospital systems, they're more margin loss averse than margin gain. Well, if we do this, we're going to lose this much. And again, the negotiation is probably going to yield to minimizing loss. And the last thing I want to talk about with CEO dynamics is that framing matters. You know, when are you going to ask your CEO or your president of your hospital system about a difficult situation between med staff and hospitals? You're going to ask them, you know, after they've had an award for the hospital, after the hospital's done really well with their medical team, you're going to ask them after the hospital's done really well with their metrics. You ask them on a good day when things are going well about a difficult conversation, because it's just better to frame it on a good day. Next. So the other thing to keep in mind is negotiation space. You have to have an eye on everybody, not only everybody at the table, but everybody not at the table. And I'll give you some examples that will resonate with you. One is family dynamics. You know, as families decide on the care of their loved one in rehab hospitals, there always tends to be one dominant family member who influences the other family members and influences the end decision, right? Well, they need to be at the table. If you're talking to the, and they're not at the table with what's the eventual outcome of that patient's disposition, it's not going to go well. And the same thing, we've seen this with COVID, like frontline medical staff, if they're not brought into the discussion, then what seems like a brilliant idea is actually a terrible idea when you include all interested people in their headspace, where they are. So in the negotiation space, those around the table and those not around the table that are affected and need to have input and be stakeholders is critical. And then the last thing is kind of a pet peeve for me is create accurate narratives. In hospital systems, a lot of times narratives are created and the stories, you know, changed and curved a little bit, and then it becomes not an accurate narrative. But you as a physiatrist, and if you're a leader in your institutions, which you always are, whether you're the medical director or staff physiatrist, you need to facilitate creation of the actual accurate narratives of what's happening in this particular problem that you want to negotiate to solution. Next. So there are sources of power in negotiation. It's the information from each side. What information do you know about the other side? What do they know about you? What are their options for knowing more about you? What are your options for knowing more about them? And then the other major thing and a source of power is basically we call the BATNA. It's the best alternative to a negotiated agreement. For instance, the strongest BATNA, let's say if you're in a personal negotiation to get a promotion or a raise, is that you have another position to go to if they don't want to do that for you. So you can just say no and walk out. That's the example of the strongest, best alternative to a negotiated agreement. But there are other alternatives that are lesser in degree of you leaving in a situation. So the other issue is timing. Like, who's in a hurry? Basic point. Whoever is in a hurry, whichever side is in a hurry, they're going to more likely be on the losing side because they're going to make concessions a little more quickly if they're in a hurry to get this negotiation over with. The other thing which is really important, and you have to feel this in your soul when you walk into a situation where you know you're going to be negotiating for anything, patient, staff, your colleagues, the other side may not have all the power you think because most people go into a negotiation and thinking the other side has all the power. But you need to know in the literature, in the corporate world, the other side does not have all the power you think. So next, please. So here's some basic things. Again, we talked about you have to know the other position, what are their needs, what are their challenges, and then you have to be able to show how you can address them to solve their needs and challenges, yet facilitating your position and your side in the situation. Next. So again, I call it tap number one. In any discussion, you always focus on the other side. You never start the sentences with an I or we on your side. Make it about them. So carefully choose your first sentence, your first paragraph, your first negotiation hour. Focus on what the other side needs, what they want, and why. Next. And the other thing is don't talk about rights or your power or fairness. That changes the conversation. It changes the whole altitude of the conversation in a not appropriate way. So avoid ultimatums. Again, go back to interests. What are everybody's interests? Don't talk about rights, power, or deservedness. Focus on the needs and interests of the other side. Next. So negotiation is two ways, right? And basically, you have to do your homework. You have to understand what is different about your side and what is superior about your side. What's the differentiator that makes your position better? How does it distinguish you? And how do you translate what distinguishes your position to what you are negotiating and how you're going to help them and what their interests are? Next. So some general information. Don't be aggressive. Bring up the things that you or your side, your organization, your focus have been, um, you know, what is unique to that situation that developed to be, have it be a best option? Like, what have you done before that's worked and why, and how do you apply that to this negotiation? Generally don't talk about one thing. It's not like I want A, usually because you want A, B, C, and D. Um, so you want to really bring a broad spectrum of asks because it's usually not just one thing in a complex negotiation. Again, emphasize the unique qualifications of your thoughts, your positions, your side's needs, your side's interests. Um, but also concentrate on how those interests could be melded into the other side's interests. And the other thing too, you know, everything's performance based in healthcare. Um, so, so base some of the rewards dependent on the company needs. Like, so you'll give us this if we help the company do this or get there. So it's definitely a two-sided conversation. Next. Next slide. So we talked about, usually you want to present the whole package and not just a part of it. Uh, include some, a couple of things based on performance. If you or your, your, uh, uh, side does well for the hospital that that's, you know, we're gonna, we're gonna put some metrics in here, show them confidence that you can, you can do it. You can carry this, this, uh, whatever you want to propose forward. Um, again, the point of the story is the other side's needs and what's best to address those needs. You need to keep going back to that. Um, some people in who want, um, you know, uh, a promotion, let's say, or, or interested in a position, let them know you're interested in the position. If you're interested in it, um, it's interesting to you, let them know, raise your hand, step forward, and then again, let the negotiation proceed from there. Next. So the other thing is a lot of people have fear of negotiation. That's very common. Um, the modern science actually says, you know, you might want to practice a little negotiation if that happens to be in your domain. And for instance, um, you know, if you want to negotiate for an imperfect sweater, um, you know, ask for a little bit off or, or make a clear ask at a store or a bakery, if the bread's a day old or two days old, you know, what's the day old or two days old, you know, those, those little things to as, as kind of a trite as they may sound, it actually breaks down your fear of negotiation at many levels. That's modern science. Next. So a great book, you can take a screenshot of this as negotiation without fear by Victoria Medvick. Fantastic. She's, uh, in the Kellogg school of management, and it's a contemporary, uh, synopsis of modern day negotiations and all aspects of it. Really a book well worth reading if you're going into a negotiation and you want to have some more confidence in your knowledge based on that. Next. Um, some of the challenges people won't negotiate when they don't think they have to, and that they can't see a problem from any other viewpoint other than their own. That's a problem. Um, and your, your job in that case, if it happens to be the other entity is to help them understand why they do need to negotiate. Um, particularly if you're in a medical leadership position, staff leadership position, you need to take them aside and say, listen, this is not going to move forward. Um, unless we have some further discussion here and we need to give and take, um, the other thing, each side has to understand the other's problems as well as the other side understands its problems. So that's a lot of discussion. So, but it's critical. You have to, you know, the old saying is put yourself in someone else's shoes. You absolutely must do that in healthcare negotiations. Next. So the other, the other real challenges there, there's a diversity and professional cultures in healthcare, you know, physicians and nurses, administrators, the proceduralists are cognitive based physicians. We have a classic cross-cultural problem solving challenges because we all solve problems in different ways. Um, and then you are solving these problems and we've seen this in COVID on a regular basis for those of us dealing with that in a fast pace and stressful environment of patient care. Um, next. So a few key points, make sure that each side understands what the other side is saying, even by having side A repeat from side B, uh, side B repeats the needs of side A, um, get people off positions, get them onto interests. Um, you as a position of authority, let's say you're the medical director or staff leader. Um, you are the one who's listening and understanding and making sure that it's a safe place for everyone to express their needs and wants, right? That's your job as the moderator of, uh, uh, in the healthcare, uh, negotiation. Um, and you need to do reality training and dispel, dispel beliefs that either party party doesn't have to negotiate, uh, by helping them assess what are their alternatives if they don't negotiate. Next. Um, the other thing brainstorming is great. It makes everybody an author bringing workable ideas. You as a leader have the big picture. If you have an idea, you discuss it with each side independently to get their, their thoughts on your idea before you bring it to the group. Um, in the worst case scenario, some large organization needs outside mediators, because it's a very contentious situation. You want to preserve your own capital. That's extremely rare, but it's something to think about in a very contentious situation. Um, and building relationships and structure ways that communications can continue with relationships built on trust. Absolutely huge, hugely important point. Next. So, uh, you can take a screenshot of this. This is a really great article. And this was in the, uh, WSJ in September of this past year. It's a clean way to network and how to win friends and influence people and not feel dirty afterwards. Um, the author was a professor at Duke and Columbia and the management schools. And basically, uh, you know, I can't go through the whole article, but I recommend you, you, um, you search it and it can help you. It'll help you with your organizational relationships. And it tells you how to build relationships over a period of time. And when you can ask for, uh, consideration after that period of time, anyways, uh, it's, it's a really great article. I don't believe physicians in general, uh, work on those relationships ahead of time before they get into negotiation situations. So, uh, this article will tell you how to do it and how to do it and feel really, really pretty good about it. Uh, next. So I wanted to influence, uh, I wanted to introduce our next speaker, Dr. Michelle Gitler. I've worked with Michelle for years. She is a knowledgeable, uh, on multiple situations in hospital settings. She is a patient advocate, which I love about her. Uh, she's the CMO of Sinai health systems, and I'm going to hand it over to Michelle. Thanks, Michelle. Thank you, Mike. Um, and thank you all again for sharing part of your Saturday morning with us. My name's Michelle Gitler. I'm the medical director at Schwab Rehabilitation Hospital. Schwab, in case you don't know, is one of the few freestanding safety net rehabilitation hospitals in the country. That means that over 60% of our patients have Medicaid, uh, which leads to a number of needs for negotiation. I'm also a residency program director. Uh, so I'll be talking about some of that negotiation and, uh, the CMO of post-acute care at the Sinai system, which is a safety net system. Next, please. When we talk about negotiating, I think the first thing we need to do is be honest about who or what we're really negotiating for. Um, is this something that's personal? And I'm not just talking about what I need financially, but is the position that I'm taking something that really only benefits me? Or are there others that are going to benefit from a situation that happens to benefit me. And I say that because oftentimes we can differentiate what it is that benefits me and include what it is that's going to benefit all of us. And I happen to get what makes the world a little bit better for me. What about negotiating on behalf of patients? And this happens many different ways and all of you do it all the time. Whether you're agreeing to do a peer-to-peer, that's negotiating on behalf of your patient, or you're trying to get your patient to the next level of care. The primary service may not see it that way. And let me give you an example. Often we see services starting patients on methadone when they are admitted with a known history of heroin abuse. And this is a patient who doesn't have a methadone clinic. And I know that patient needs rehabilitation. My negotiation on behalf of that patient is to talk with the primary service and explain, number one, why they need to be off of methadone, but to give them tools to safely get the patient off methadone, whether that's recruiting a medication assistance team to switch the patient to suboxone therapy, or to start looking at morphine equivalents so we can get the patient onto opioids that I can taper and continue to work with medication-assisted therapy. This is negotiating on behalf of our patient. Sometimes we're negotiating on behalf of what we do and our specialty. An example of that for me would be that one of our local hospitals really didn't want to have their inpatient rehabilitation unit anymore. At Schwab, we knew that it was critical, though, that there still be an eye towards rehabilitation. So we agreed that we would be the rehabilitation partner in terms of helping to provide consultations and move their patients through a system of care if they were going to close their unit, making sure patients still could come to rehab, preferably to us. Well, that backfired a little bit because as soon as we agreed to help provide the consultation services, that hospital was no longer willing to provide reimbursement for the consultants, which they had been doing previously. COVID then gave us an opportunity to renegotiate that service, which meant that we were going to be doing remote reviews. So we got access to the EMR to do remote reviews. Their patients got reviewed for rehabilitation necessity. And for the most part, it's been a pretty good win-win. What about on behalf of our staff or our trainees? I told you that I work at a safety net hospital. A lot of our patients, most of our patients have Medicaid and managed Medicaid. The reimbursement in Illinois for Medicaid for a routine inpatient visit is somewhere around $11, maybe a little more, maybe a little less. So to have my attendings come in and generate not very much money is a hard sell for them. They may get some RVUs. So we decided that many, many years ago, that while we would be on call on the weekends, of course, we weren't gonna write daily notes. I was trained at a place where patients with Medicaid didn't get a daily note, but everyone else did. And that just didn't seem right to me. So on behalf of my staff, who I know are working really, really hard, they're on on the weekends, they do admissions on the weekends, but they don't have to write those meaningless notes because it doesn't really generate significant revenue for our group. I have a staff that's pretty happy with their call schedule. I have patients that do get excellent care because I don't think anybody would agree that the meaningless notes, when you write 50 notes in a weekend, actually enhance their care. And then on behalf of the trainees, who are we negotiating for? We have in-house call for our residents. There's some things they can do and some things they cannot. At one point, our hospital was going to have med-surg patients during the COVID surge border in our hospital. And while I'm happy to open up the space for them, there was no way that our residents were going to provide the medical coverage for those patients. So that was an important negotiation. I think knowing what leeway you have in negotiating is important. What decision can I make? Can I, at the moment, make a decision that we are not going to do something or do I have to confer with others or go up the food chain? Next, please. So negotiating means very different things for different people. Whether it's the other specialists you're talking with, your staff in the clinic, hospital administrators, I think it's important to know that words matter and often you need to reframe what you're doing or what you're saying. Maybe you're not negotiating. Maybe you're discussing with the neurosurgeon whether or not the patient actually requires a TLSO or you're discussing with the neurosurgeon the timing for the cranioplasty on a patient who continues to fall. It's not that I'm not willing to take that patient, but let's talk about this because if they've already fallen three times in the acute care hospital, there's a good chance they'll fall again and I'm going to have to send them back. Practicing the little negotiations, the very small things, gets you well in the groove for that give and take and it makes other people feel valued. With my clinic staff, I happen to have Thursday afternoon clinics. I've always had Thursday afternoon clinics. And sometimes instead of me saying that we are or are not going to have clinic on the Thursday before a Friday holiday, I ask them what they want to do. What, you know, if they really want to take that day off, I'm okay with saying, go ahead, we'll cancel that clinic. But it's back and forth. How are we going to accommodate all those patients on another time? And then they're willing to schedule and reschedule for me. And sometimes negotiating is debating. It's debating the merits of what you think is right or morally appropriate with someone else who wants you to skip corners and maybe not do the thing that's the best for a patient. I agree with Mike though. We really want to avoid ultimatums unless it's an ethically repugnant choice. And then you got to follow through. I am not going to do X, Y, or Z and then not do it and know that there are consequences. I think the most important thing in this idea of negotiating is to demonstrate that you are going to be the very best partner, no matter what, that you're willing to listen. As an example, we're all having a lot of staffing issues right now. I can't admit as many people as I would like to. And sometimes, sometimes in the morning, I come in and find out that we don't have enough nurses to open up as many beds as we'd like. And I have to talk with my referral sources and let them know why we might not be able or will not be able to admit patients that day. Or if I can only admit one instead of two, the negotiation is the discussion. It's being honest about my Sophie's choice that day. I can't do both things. It is not in my power to do both things. Let me tell you why we had nurses call in. We had a flood and we had to close some rooms. To let them know that I am not trying to make their life difficult. I am trying to be honest with them about what is a very difficult situation for us. Next, please. So what about negotiating for ourselves and our colleagues? Sometimes we're being asked to do things on top of our already busy schedule. And here are some examples of how I've negotiated for myself and for some of my faculty. You know, I'm happy to sit on that committee. It's a great committee. I really wanna be on that. How are you gonna modify my workload? How are you gonna modify the workload of my physicians? For my staff who all teach, when we started talking about their new salaries, their new contracts, I'm thrilled that everyone recognizes that we are teaching. We are in a teaching hospital. How are you gonna modify the RVU requirements for a teaching faculty? And we were able to integrate into our contracts that all of our teaching faculty are assumed to have 10% of their time that's teaching. So 10% of their RVU time is removed or their RVUs are removed. So we understand that teaching takes up time and they cannot be as productive. How about when I ask someone to sit on a committee? For us, we have the Clinical Competency Committee. How do I make it worth the while of the faculty to do that when it's a huge time suck? First, acknowledging to my faculty that it's a time suck. And secondly, also factoring into their bonus and their RVUs that participating in these committees is something we value. Something else that we've all experienced, admissions are coming later and later. Why should the inpatient faculty always be the one who have to stay late and do those admissions, particularly if we've already had a consultant see the patient that day? So what we've started doing is periodically, let's have the consulting physician complete the admission. This aids the inpatient attendings, helps the consulting physicians with their RVUs, enables everybody maybe to either get out at a reasonable time or to acknowledge their difficult workload and take a deep breath and know that, yes, we really do have your back covered. One negotiation that I love having is when my faculty come to me because they've already thought about the pros and cons of their work schedule. I have several faculty with young children and boy, that's already a negotiation. But I had one in particular who's a new mom come to me and say, I figured out that either I come in early, really early to miss traffic. I'll do my admission from the night before so it's still within 24 hours, but then I'm gonna try to leave earlier that day or on another day of the week, I'm gonna come in a little later. I'm going to miss the morning traffic, but that way I'm gonna stay later in the day. She gets to spend time with her kid, but also acknowledges before I even have to ask how the work is gonna get done. And then finally, we had a situation where one of our practitioners left and we had some weekends that needed to be covered, the call needed to be covered. And so instead of just assigning the weekends to an attending, we discussed how we're gonna split the call. And the attendings were able to amongst themselves decide who's coming in for admissions, who's taking phone call at night. And that ended up being a win-win-win. Next please. Negotiating on behalf of our patients is what we do all the time. And sometimes we just have to take a deep breath because we have to remember our patients didn't wanna be in a situation where they needed to be seeing a rehabilitation doctor. They didn't wanna have a stroke, they didn't wanna have a spinal cord injury, they didn't wanna fall and break their hip. So I think it's important that we remember it's not our patient's fault that the insurance plan is asking for additional documentation, that the insurance plan says no and we have to do a peer-to-peer. It is not the fault of our patient that their insurance plan doesn't prioritize them. So we take the deep breath. If our patient needs something, we are going to do the right thing by them. It is also not our patient's fault that the person who is in charge of approving a test, for example, is not well-trained. So me getting mad at the reviewer for an insurance company or for that matter, for the intern on the medicine service doesn't help my patient get what they need. Recently, I was seeing a patient who had a heroin overdose. He had rhabdomyolysis, he had renal failure, he's on dialysis and he gets seen by therapy and he can't walk. And the therapist said he's max assist of two, move in from sit to stand, his legs can't support him. They recommend a rehab consult, go to see the patient. And yeah, he's got sensory loss throughout his lower extremities. He's got weakness. And in fact, in addition to heroin, he'd use cocaine. And I went to the service and I said, I think you need to image their spine, he can't walk. And they said, no, he's a drug addict. That's from being a deconditioned as a drug addict. And yelling at them wasn't gonna get me what I want, but sitting there and talking to them until like they put their hands up, I give, did help this individual get imaged. Sometimes we know that we know more than a reviewer. We know more about the patient. We know more about the expected outcomes. We know what interventions have previously been tried, but the reviewer may not have that information. And we have to collect our thoughts as we negotiate for our patient and tell the story for our patient in a way that draws our reviewer in and does not antagonize them. And then finally, when we're gonna do what we think is the right thing for the patient, we have to consider how we would advocate for it. And is there only one way of doing this? I think we've all at times had the experience of going to negotiate on behalf of a patient who's maybe an iffy inpatient candidate, but the family really wants us to, or the hospital really wants us to. And yet we know that patient really doesn't wanna go to rehab. Sometimes we say to the insurance company, here's how I think we could manage this. I do think that that patient could go home safely if you're willing to approve X, Y, or Z. Sometimes by the time it gets to the peer-to-peer, a patient no longer needs rehab. And I'll be like, hey, listen, I'm about to make your life better because that patient's not appropriate. On the other hand, there are times when a patient absolutely needs a follow-up test or needs inpatient rehabilitation or needs whatever we really believe they need. We have to have in the back of our minds or in our front pockets, the reasons that not only is it the right thing to do for the patient, but what's gonna happen if that patient doesn't get what they need and be willing to give examples of past experience. Next, please. So negotiating with referral sources is interesting because in our situation in healthcare, the referral source or the customer is not always right. I know all of you have had this experience where the service says the patient's ready for discharge. Their case manager has called admitting patients ready for discharge. We know you have insurance approval. And I point out or you point out that, wow, no, that patient's not ready. The insurance may have been approved, but the patient's in renal failure. The hemoglobin's dropped three grams. The white count's 28. And the negotiating point is being explicit about what needs to occur for the patient to be eligible for transfer. Do I care if the white count is normal? No, but I wanna know that you've identified the source of infection. We've started treatment and the white count's gone from 28 down to 15 in the person's afebrile. We all know that there are times where a service, often it's a surgical service, but they want the patient to return in four days for follow-up visit. And they're right there in the hospital. And you know, that's not only just gonna interfere with rehabilitation, but I'm gonna have to pay for transportation. I can't afford that. And so the negotiating point now is, wow, we have telehealth. Can we do a telehealth visit for you? I mean, you're not gonna bill for this appointment anyway. I'll show you the patient. I'll send you a picture of the X-ray. I'll order whatever tests you need, but I'm a doctor too. Tell me what you need and let's make this work for all of us. Next, please. One other area of negotiation is single case agreements. I don't know how many of you do this. Some patients won't have a funding source, but absolutely need rehabilitation. And we've successfully worked with multiple healthcare systems that don't have their own rehabilitation or whose own rehabilitation is not willing to do a single case agreement. We've created a very simple contract. We carve out expensive medications. We carve out dialysis and transportation. And we've created a price point that's a reasonable per diem for rehabilitation. This gets the patient out of the acute care hospital and we treat this as though it's any other managed care plan. There's a point person at the referring hospital that we send updates to and we don't keep them any longer than we need to. And this has continued to be a really great selling point for us with these partners. For individuals that want to pay cash, we utilize the same price point for our single case agreements. We ask for about 10 days of cash upfront. We're interested in helping the patient. We are not interested in gouging anybody. We do the same thing for out-of-state Medicaid plans. We've negotiated our appropriate rate. We negotiate confirmed transportation back to the home state. And are very clear and very upfront about this, so nothing's hidden. But I'd be delighted to talk with any of you about single case agreements. It's the best thing to do for patients. It avoids their readmissions or their bouncing right back into the emergency rooms when they're discharged to the communally not prepared. Next, please. So I cannot overestimate, I mean, overstate how important it is to generate goodwill. When you go back and forth, when you acknowledge that, you know, I only have one bed and I have to pick the right patient who's gonna get into the bed. When I hear you and you're right, and I'm gonna try to change what we do because I've heard what your conundrum is, that goes a really long way. On the other hand, next slide, please. Sometimes you have to say no. Sometimes it's not okay. And sometimes when you're told you have to make a choice right there and then yes or no, you know, you say no because you really cannot compromise on what you think is the right thing. With that, it's my pleasure to introduce you to Dr. Steve Natz. Steve, thank you. Thank you, Michelle. Welcome everybody to our course here. Thank you to Dr. Lupinacci for inviting me to share a little bit of my, hopefully a little bit of wisdom with you from years of negotiating. As many of you know, I'm chief medical officer for integrated rehab consultants, the largest group of psychiatrists in the country doing skilled nursing facility rehab. But of course we do a lot of other post-acute rehab as well. Next slide. So what I'm gonna try to impart with you in the next few minutes is some successful and not so successful real life negotiations. These are all stories from real life that the names have been removed to protect the guilty, but I would say that these are some cases that I thought might highlight both some good and bad and ugly negotiations. Like many of the people on this panel, most of the negotiations that I've had over the years in my various different capacities have been pretty mundane. They go pretty much as you expect and you don't always get what you want, but you get enough to make things right for both parties or any parties that are involved. And I hope in the next few minutes to just impart some pearls of wisdom to you that maybe while I'm not gonna be quite as academic and didactic as my two comrades here, I hope to highlight a few of these pearls for you. So next slide. Of course, my experience, 30 plus years of being in physical medicine rehabilitation, starting off as a medical student, chief resident, attending physician. I put husband in there, of course, I don't really ever win too many of those negotiations so we can leave that out. But I put an asterisk by chairman of a PM in our department because that's really, when I look back at it, that's where a lot of these, you had to be very astute in your negotiating strategy. And I never really got any type of training other than some reading and a master's in health administration to really help me with negotiating. But I think as some of the other speakers have talked about, you need to try to think outside the box and come up with a solution that works for everybody. Next slide. So here's an example of what I would consider a lose-lose situation. So some of you that know, I ran for about 10 years, a very nice rehab unit in a hospital, 32 beds, all private rooms, had its own therapy gym right on the floor, had great outcomes, was literally, other than interventional cardiology, was the highest per square foot reimbursement and profit center for the hospital. But I knew for many, many years that the hospital wanted my real estate. The hospital was landlocked, they weren't gonna build another building or even add on floors. So I knew they wanted my space. And we ended up getting a new administration, which is always a little dangerous when you get a new administration come in. But I thought, knowing that they want my space, it's an opportunity for a win-win situation, right? I went to the new administration and I kind of said to them when they put some feelers out about, would you be willing to move? I said, yes, I'd be willing to move. You move us out of the hospital and design a new space for us. We had another freestanding hospital not too far away that had lots of space. And I said, we don't need to be in the hospital necessarily. Design us a new space at a nearby site, I propose. And they say, they come back with, this is their negotiation, they come back with, we'll move you to that site, but we're not gonna do any renovations. It's an older hospital. They have a general medical unit, which is semi-private rooms. We're gonna downsize your unit and cram you into this general medical unit, which is not really even wheelchair-accessible. Bathrooms weren't wheelchair-accessible. Semi-private, all semi-private rooms with therapies on another floor. I said, well, that's really not acceptable. And I basically took Michelle's position. Sometimes you have to say no. I said, over my dead body, and they said, bye. So kind of that was the end of that negotiation. Now, luckily, as Mike pointed out, I had a great BATNA. I basically at that point was being asked to be Chief Medical Officer for Integrated Rehab. So I got to give up weekends and call and all that stuff and take a new position. But the last I heard, the unit was a 32-bed unit that for years and years and years had a census of about 30, because it was really undersized for the size of the medical center that it was at. And the last that I heard, they had a census on the new unit of about eight. So clearly the hospital didn't do well. The administration actually shortly thereafter left. And of course, that type of thing, they got out as well. But it's just, I think, a classic illustration of a lose-lose all the way around. The system didn't really get what they wanted. And I didn't, obviously, I got what I wanted, but that was because I had the BATNA. I had the other position in my pocket. Let's go to the next one. So this is, I think, an example of a win-win situation, but kind of suboptimal. So when I was a vice chair of a department and I knew that my chair, who had recruited me, was interested in retiring. And I didn't realize he was gonna retire quite as fast as he did. He retired pretty quickly. So the dean calls me into the dean's office. And if you've ever been a faculty on a track to become a department chair, you know that it's a little scary. You basically get called into the dean's office. The dean says, what do you want in order to take over the reins of this department? Department had about 20 faculty. It was a well-run department, well-established. So me, I say, well, I've been working with this old computer. And the dean says, so you want one computer? And so I said, yes, sir. And he's like, well, that's a deal, son. And I became chairman of the department. So while you would say this is a great win-win, the thing that I didn't realize at the time was that this is an uncanny, this is the only time that you're ever gonna be in this position that you can negotiate for your department, right? If you're coming in as an outside candidate, you would say, well, I need to have more space. I need to have this, I need to have that. And the dean's kind of over a barrel because he wants to hire you. So the dean will give you the things that, hopefully they'll negotiate, but they'll give you some things that are needed for the department. I didn't know that. And so my saying, I needed a new computer, got me a new computer, but it also didn't really help my department. And later on, of course, I kicked myself as I was realizing how hard it is than to fight as the chair of a department in order to get all these things that were needed by the department. And so that's, it's a win-win, but I didn't really recognize going into the situation what my leverage was. And so I think that you have to, some of that was just my own inexperience at the time, being a relatively young faculty member and being put in this position of having the dean say, do you want to be the chair? Yes, of course I want to be the chair, but I didn't realize that the power that I had to negotiate. So let's go to the next example. So here's a win-lose example. So later on as a department chair in the same department, I had a division, which will remain nameless, that the division director reckoned that his faculty deserved a bigger proportion of the salary bonus than had been allocated to them by me as the chair. So I had developed, I had worked previously for John Melvin, who's one of my great mentors, and John had taught me this wonderful faculty reimbursement and faculty salary plan that was very scientific, as you can imagine, down to how many RVUs you're producing, how many dollars are coming in for you. And the division was not contributing financially to the department. And this was according to the formula that had been agreed upon by all the faculty. So I had trotted this formula out, everybody agreed to it. And yet this division and this division director in particular felt that they were not getting enough money. So what did I do? Well, of course, by that time, not being completely an experienced negotiator, I kind of tried, floated out a lot of several non-monetary types of perks. Would it have been okay if they had a little bit more time off or if they had a little bit, something changed in their duties? I couldn't pay them anymore because that really wouldn't have been fair to my other faculty. But all of these non-monetary perks that I tried to flow out, looking at interest, looking at, as Mike was saying, trying to say, well, what if we, as Michelle said, what if we had you come in later in the day, go earlier, things like that. Nothing was acceptable. So the division director filed a formal complaint to the university based on discrimination. Very, you don't wanna be accused of discriminating. And so that went through the process of a university tribunal that ultimately found that, as I knew, that it was up to the discretion of the chair to allocate any salary bonuses. So the division and the division director lost and I won, but you sit there and you go, well, yeah, I won the battle, but did I really win the war? Because now I've got disgruntled faculty, I've got faculty that don't really feel like they were treated unfairly. And so here's a situation in which, had I been able to come up with a better solution for it, might've been, could've been turned into a win-win. Ultimately, it wasn't. And so, and I'll just, I'll kind of leave it at that. I look at this as kind of a win-lose situation because I should have been able to come up with a better solution for it, but ultimately I wasn't. Let's go on to the last one, which I think is one of my favorite. Next slide. So this is one that I consider to be really a true win-win. And this was, again, a department chair. When I took over as a department chair, I had already made the mistake of asking for just one computer, but I also inherited a department administrator that had risen up through the ranks. This is a very well-established department and this department administrator had risen up, according to the Peter principle, you know, the famous, I don't know if he was an economist or whatever, but he said, you know, people rise to the level of their incompetency and then that's where they kind of end up. So I had this department administrator that was very nice, had a lot of great administrative skills, good historical knowledge, but had gotten to the level of being an administrator for, at that point, about a hundred employee department and was clearly overwhelmed at that level, was not able to really effectively run the department. But so then, you know, being a new chair, I go to the HR and I go, well, you know, there must be some thing in this department administrator's file that says that, you know, they're not capable at this level. And of course, all they had was glowing reviews from this person's prior supervisors, which, you know, if you ever are in a situation, probably happens more times than not, that, you know, all you've got is people that are just being, you know, bumped up and up and up and there's only glowing reviews previously. So what do you do at that point? I mean, as a department chair, I can't have a department administrator that clearly, you know, is at a level of, they've risen to the level of their incompetence. So how would you negotiate that? Well, you know, you could fire that person, you could demote them. Those are really not good options for a new chair coming and I don't want to be stamping around, you know, the department, having people think that I'm, you know, just throwing my weight around. So a large, very large grant came in, actually a grant that was, you know, really the size of say 20% of the department. And I had a little light bulb moment, that's why the light bulb was on this slide, because I said, well, maybe I can make a lateral move in the university system, basically to move to a grant administrator as compared to a department administrator for someone with this type of experience and longevity, they could get the same pay, they could get the same seniority, they could have a bigger office, I could move them and they could have a smaller staff. And so it actually worked out quite well. I mean, the rest of the time that I was the department chair there, this person functioned quite well as a grant administrator, and I was able to hire a new department administrator that met the needs of the department. So that really turned out to be, I think, you know, an example of a true win-win. So next slide. So in terms of the pearls that I'm gonna impart to you, that you should seek these types of win-win solutions whenever possible, and sometimes they're out of the box solutions, as in the case that I think I just mentioned, that, you know, maybe it was a little fortuitous that I had this huge grant come in, but, you know, there might've been an out of the box solution that I could have thought of. You need to know the strength of your position. When I walked into the dean's office, I didn't know the strength of my position, and I walked out with a brand new, you know, brand spanking new computer, but, you know, my department could have used other, there were other resources that I could have negotiated for. You need to understand the weakness of your position. Sometimes, you know, as the division director didn't understand the weakness of their position, and that ultimately ended up with them, you know, in the kind of the losing proposition. But if you don't understand that weakness, you know, you may not really be able to negotiate effectively, knowing the strengths of your position. I think I said that twice, anyway. Ultimately, don't be afraid to fall on your sword, you know, as the example of them downsizing my rehab unit, and just walk away. You know, unfortunately, the system suffered under that case, but, you know, it's one of those things where you can't win all your battles, because when a door closes, another one opens, as they say. So thank you very much, and I will turn it back over to Dr. Lupinacci. Thanks, and Michelle and Steve, those were amazing. Life lessons in PM&R negotiation and leadership. We had a very active chat room. Two things I wanted to emphasize and get some input that came out. One was about dead ends in negotiation. How do you know when you reached a dead end? What's next, and maybe that's walk away, right? So just a couple of comments on that, and then we have another thing I wanted to bring up, as well, from the chat room. I'm just going to chip in when, if you're curious about when you've hit a dead end. Yes. There's your dead end, you know, when people aren't engaging. It's okay to say, I think we need to get back together. I think we just need to agree to disagree at this time, but we will reconnect, and then you set up the reconnection. Yes, and I have to second that, having been through recent negotiation, which was very, it was stressful, and it reached an end where we agreed not to agree and to come back later. So I think that's great advice. Was that with your wife, Mike? Well, that would be an everyday thing. Okay, all right. So the other thing was, there were a number of comments on, from the participants, and thank you all the participants for being so active in the chat. We appreciate that. Was on the distinctive need for leadership and mentoring in PM&R at all levels, at every level. So I'd love to get comments, Michelle and Steve, from you on that. Yeah, I think somebody directed that one to me, like maybe I should have had better mentors going, and I had great mentors. I had John Melvin and Marty Grayboys. I couldn't think of better mentors that I had going into this, but they forgot to tell me that you're in the best negotiating position when the dean calls you in and says, do you want to be the chair? And I think that sometimes those things are just something that you just, they're life lessons. So, yeah, I would say that I don't harbor any misappropriations from my mentors. I think they all did a great job at bringing me up. And as you guys know, I mean, I was a chair at a fairly young age. I think today that there's probably people that were younger chairs, but it was an interesting time and I bring up that anecdote just to kind of let people know that sometimes there are things that you just don't know what you don't know, right? Yeah, also, we forget that sometimes people that we work with who are not people we report to can be our mentors. You learn a lot from other people's life lessons, so it doesn't have to be someone necessarily who has more experience than you. The other thing is that often you can learn as much from someone you don't want to be like as someone you want to emulate. And I say that because sometimes you can see the way one individual approaches a situation and recognize how that didn't work and create this idea of who you want to be is by what you don't want to do. So you don't necessarily have to find the perfect one mentor. We get to pick and choose from who, the juiciest part of everyone's fruit or whatever your analogy is. And I just want to thank the people on this screen who've helped me. Mike and Steve, those conversations in a hallway, on a couch, with a cup of coffee that you don't even know you're mentoring me when we all have those talks. I think we need to keep in mind mentoring is not just an official act, it's that ongoing communication. And we're all available to each other, we just have to remember that, phone call away. But thank you, thank you all. I think there were- I don't think we did too bad. There's some great comments in the chat about how our field needs mentoring now more than ever. And we have this association with the Kellogg Business School coming up. So if any of you leaders on the call, and I know there are many of you here, please just recommend to your younger faculty that they get an introduction to leadership and leadership training from the beginning, right? Because we all needed it from the beginning, we learned it along the way. So let's help out the next generation of PM&R leaders. So we'll close up the session and let me just check the chat room once more. And, okay, excellent. Thank you all very much for spending time with us. We really enjoyed the presentation, we enjoyed you all being here and loved all your chat input. Thank you all for what you do for the field as well. Thanks guys. Thanks Michelle and Steve very much. Thank you, thanks Mike.

Negotiation Cafe

medical field

Dr. Michael Lupinacci

Dr. Michelle Gittler

Dr. Steve Nats

negotiation techniques

interest-based negotiation

power dynamics

alternatives to negotiated agreements

timing in negotiations