Nashville Post Winter 2020

WINTER 2019

NURSES NEEDED Employers innovate as the shortage intensifies

STREET CRED Eyeing Eighth’s next growth spurt

Building health tech success Execs talk about hitting scale, anticipating what’s next

Becoming More Exact Peeling back the promise and pitfalls of precision medicine

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- Hayley Hovious, President, Nashville Heath Care Council

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12 SPEAKING SPECIFICALLY State’s TennCare block grant requests would yield broad powers; advocates fret about cuts and want details

22 REIMBURSEMENT TRENDS Waller partner J.D. Thomas sees False Claims cases spreading beyond big entities

24 NURSES NEEDED Recruitment innovation, ‘joy retention’ help hospitals confront worker shortage

26 HIT TING SCALE, EYEING THE NEXT

Consuelo Wilkins

WINTER 2019

VITALS

8

YOU SHOULD KNOW Walmart’s ex-clinics chief now delivers data on (and to) doctors

9

DATA BANK A statistical look at VC telehealth and clinic fees

2

WINTER 2019 | NASHVILLEPOST.COM

14

Becoming More Exact Peeling back the promise and pitfalls of precision medicine

10 THREE QUESTIONS Urgent Team CEO Tom Dent discusses rise of new model

Four Nashville-area execs share insights on managing a high-growth health tech company

LEADERS

34 YOU SHOULD KNOW New Metro Councilmember Zulfat Suara focuses on education, wages, budget

36 AYRE EYES MLS SUCCESS Ex-Liverpool CEO reveals ‘the size and weight’ of what’s ahead

38 THE JOURNEY Studio Bank CEO Aaron Dorn on how his job is changing after Year 1

ERIC ENGLAND

RELATING TO THE PATIENT TO CREATE A SENSE OF COMFORT We were asked to design a healthcare environment that would be sensitive to the needs and fears of children on the autism spectrum and with other cognitive and physical developmental disorders.

Our designers accepted the challenge.

Following research and listening to the client and other professionals, a modern interpretation of a treehouse took shape on the campus of the Hamilton Health Care System in Dalton, GA. Anna Shaw Children’s Institute, providing services for diagnoses and treatment, welcomes children with calming, relatable images of woodland animals, butterflies and birds and a 40-foot tree sculpture.

architecture interior architecture master planning space planning

615-329-9445 www.esarch.com

50

Street Cred Eighth Avenue’s changes the past five years offer insight into the future

TECHIE

40 ‘BUILD THE RIGHT QUESTION’ LBMC audit pro makes case for firm’s recent analytics acquisition

42 COMFORTABLY NOT KNOWING Health care tech companies can improvise to spark innovation

46 DATA-DRIVEN

BOOM

48 THREE QUESTIONS Adaptive reuse-focused developer Nathan Lyons talks partnerships

53 PREACHING A DIFFERENT SERMON Real estate pros give former church buildings new uses

CREATE

56 CULTIVATING COMMUNIT Y CreativeMornings Nashville wants to connect, inspire, be ‘fully honest’ FAVORITES

60 WALK WITH ME Watkins President J. Kline stays close to town for a good golfing challenge

Navigating seas of growth, a promising tech entity’s lighthouse is unchanged

4

WINTER 2019 | NASHVILLEPOST.COM

ERIC ENGLAND

SPON SOR E D

Virsys12 is focused on transforming the business of healthcare.

With our agile software implementation and healthcare-specific Salesforce expertise, we help healthcare leaders successfully drive their digital transformation and get the results they envision, for their business and their patients.

Virsys12 278 Franklin Road, Suite 300 Four CityPark Brentwood, TN 37027 Website Virsys12.com

PUT THE PATIENT FIRST, AND THE MONEY WILL FOLLOW Putting the patient first is hardly a radical concept. Patient-centered care is widely seen as not just the right thing to do but also the wise thing to do. It has been shown to improve clinical outcomes and patient satisfaction rates while driving down costs.

But when it comes to the economics of healthcare, patients are often entirely removed from the picture. With all the conflicting parties involved, one person’s upside is often another person’s downside, particularly when you look at who benefits and who loses from a change in reimbursements or delivery of care.

Ultimately, it comes down to who has the influence and pull to maintain the status quo or make changes to improve their situation. And under those circumstances, the patient consistently comes last.

The tide may be turning. Now that patients are picking up more of the tab for their healthcare, they want more control over their healthcare journey. They want transparency, seamless experiences and to know who’s providing the best outcomes. They want a billing process that’s clear and simple, not one that adds insult to injury when they’re at their most vulnerable. And they want the retail experience

they’ve become accustomed to in all other areas of their life: personalized, convenient, straightforward.

Today’s patients are behaving more like consumers, and like consumers, they’re deciding who they want to spend their money with. In other words, patients are beginning to put themselves at the center of the equation.

Healthcare’s Transformation and the Empowered Patient Empowered patients are a good thing. The more informed patients are, the more responsibility they can take for their health. These patients are typically more engaged in their care, and that often leads to better adherence and better outcomes. And the hospitals and providers that can proactively respond to their expectations will be the ones that succeed going forward.

But change is never easy. In the context of the massive digital transformation healthcare is experiencing, it’s even more overwhelming. The good news is, technology is rising to the occasion. Yet the myriad platforms, apps, devices and services that are cropping up

Twitter @virsys12 Linkedin linkedin.com/company/virsys12 Founded 2011

seemingly by the day make the process anything but simple.

In order to leverage new technology in a way that works not only for patients but for everyone in the healthcare ecosystem—including payers, providers and staff—you need to be able to integrate all these disparate systems and stakeholders. Salesforce has revolutionized the customer experience in industries like retail and finance by simplifying complex integration, personalization, workflow and data challenges. Now it’s doing the same for healthcare by connecting every point along the journey, with the patient at the center.

Healthcare executives that partner with technology providers to help them keep the patient at the center of the issue are the ones that will remain successful. That’s why investing in the right technology will inevitably pay off. Because when you put the patient first, the money will follow.

Phone: 615-800-6768 Email: solutions@virsys12.com

OPEN

Ever more evolution Change is the only constant in many parts of life and the business of health care is no exception. New treatments, technologies, regulations and reimbursement rates are constantly shifting how providers, patients and payers interact. And yet, true progress in health care too often feels frustratingly out of reach, bottled up by bureaucracy or fended off by various vested interests.

Here’s hoping that precision medicine, a not-new-anymore concept that has patient-specific information driving targeted treatment plans, doesn’t fall victim to that toxic cocktail. Our cover package explores the concept and some of the thorny topics that surround it, and I expect we’ll have plenty of chances in coming years to flesh out our reporting on the idea.

The idea of managing change runs through plenty of other parts of this issue. From the leaders of Studio Bank, Nashville SC and XOi Technologies to the transformation of Eighth Avenue and the conversion of churches, a lot of the stories on these pages speak to the dynamism of a Nashville ever on the move.

As another year winds down, the Post team is again turning part of its attention to compiling our In Charge list of the region’s most important business, political and civic leaders. If there’s someone you think we should consider, please let us know via incharge@nashvillepost.com.

And picking up on the theme of change: Our list of about 500 people typically has about 20 percent turnover from year to year.

In Charge will be a key feature in our first-quarter magazine, which we’ll publish in early March. In the meantime, we’ll continue to bring our growing audience the daily news and notes from Middle Tennessee’s business, political and sports arenas at nashvillepost.com. If you aren’t yet a regular, we hope you’ll stop by more often and subscribe.

We’ll keep up abreast of the city’s changes and help you know precisely where things stand.

Geert De Lombaerde, Editor gdelombaerde@nashvillepost.com

editorial EDITOR Geert De Lombaerde MANAGING EDITOR William Williams CONTRIBUTING EDITOR Felicia Bonanno STAFF WRITERS Stephen Elliott, Michael Gallagher Kara Hartnett CONTRIBUTING WRITERS Lena Anthony, Megan Seling

art & production ART DIRECTOR Christie Passarello STAFF PHOTOGRAPHERS Eric England, Daniel Meigs PRODUCTION COORDINATOR Matt Bach GRAPHIC DESIGNERS Mary Louise Meadors, Tracey Starck

publishing ADVERTISING DIRECTOR Daniel Williams DIRECTOR OF MARKET STRATEGY Jennifer Trsinar BUSINESS DEVELOPMENT DIRECTOR Heather Cantrell Mullins ACCOUNT EXECUTIVES Maggie Bond, Debbie DeBoer, Robin Dillon, Sue Falls, Michael Jezewski, Carla Mathis, Brandi Nash, Mike Smith, Stevan Steinhart, Keith Wright SALES OPERATIONS MANAGER Chelon Hill Hasty ACCOUNT MANAGERS Emma Benjamin, Gary Minnis

marketing EVENTS DIRECTOR Olivia Moye EVENTS MANAGERS Ali Foley, Caleb Spencer

circulation SUBSCRIPTION MANAGER Gary Minnis CIRCUL ATION MANAGER Casey Sanders

business PRESIDENT Frank Daniels III CHIEF FINANCIAL OFFICER Todd Patton CREATIVE DIRECTOR Heather Pierce IT DIRECTOR John Schaeffer SPECIAL PROJECTS COORDINATOR Susan Torregrossa

FW Publishing, LLC

On the cover Consuelo Wilkins Photo by Eric England

OWNERS Bill Freeman and Jimmy Webb 210 12th Ave. S., Suite 100 Nashville, TN 37203 nashvillepost.com

Nashville Post is published quarterly by FW Publishing, LLC. Advertising deadline for the next issue is Thu., Feb. 13. For advertising information, call Daniel Williams at 615-744-3397.

For subscription information, call 615-844-9307.

Copyright © 2019 FW Publishing, LLC.

6

WINTER 2019 | NASHVILLEPOST.COM

As a practice, we have an orthopaedic-specialized team of healthcare professionals and some of the best and well known board-certified, fellowship-trained surgeons in the country. We provide innovative surgical and nonsurgical treatments of musculoskeletal disorders and injuries. From the rapidly growing areas of Orthobiologics—including stem cell therapies and platelet rich plasma treatments—to being on the cutting-edge of robotic joint replacement, we are constantly striving to provide the best-possible options for our patients. We have specialists in hand, elbow, shoulder, spine, orthopaedic trauma, hip, knee, foot and ankle, joint replacement, and sports medicine, who provide the most up-to-date treatments used today. Our goal is to provide the quickest return to sport and to life that our patients want. We partner daily with our patients to work toward their goals and the best possible outcomes for the life they want to live.

Jon Cornelius, MD, President

DICKSON Hughston Clinic Orthopaedics at TriStar Horizon 111 Highway 70 East, Suite 103

HERMITAGE Hughston Clinic Orthopaedics at TriStar Summit 5655 Frist Boulevard

NASHVILLE Hughston Clinic Orthopaedics at TriStar Centennial 2400 Patterson Street, Suite 300

HENDERSONVILLE Hughston Clinic Orthopaedics at TriStar Hendersonville 353 New Shackle Island Road, Ste 141C

LEBANON 100 Physicians Way, Suite 110

Hughston Clinic Orthopaedicsat Harding Place 394 Harding Place, Suite 200

SMYRNA Hughston Clinic Orthopaedics at TriStar Stonecrest 300 StoneCrest Boulevard, Suite 200

Hughston Clinic Orthopaedicsat TriStar Skyline 3443 Dickerson Pike, Suite 190

Malcom E. Baxter, MD

Arthroscopic Rotator Cuff Repair, Hip Arthroscopy, Joint Replacement, Shoulder & Knee Surgery, and Sports Related Injuries

Adam R. Cochran, MD

Hand & Upper Extremity Surgery, Microsurgery, Peripheral Nerve Surgery, and Arthroscopy of the Hand, Wrist, & Elbow

Jonathan P. Cornelius, MD

Arthroscopic Reconstruction of Shoulder & Knee, Hip, Knee, & Shoulder Replacements, Minimally Invasive Partial Joint Replacement, Orthopaedic Trauma, Shoulder & Sports Medicine Disorders, and General Orthopedics

Robert P. Fogolin, MD

Arthroscopy, General Orthopedics, Joint & Partial Knee Replacement, Orthopaedic Trauma, and Orthobiologics

Christopher M. Jones, MD

Arthroscopic Reconstruction of Shoulder, Knee, Hip & Elbow, Hip Preservation, Sports Hernia Repair, Knee & Shoulder Replacements, Minimally Invasive Partial Joint Replacement, Orthopaedic Trauma, Ligament Reconstruction of the Shoulder, Knee, Hip, and Elbow, Shoulder & Sports Medicine Disorders, and General Orthopedics

Christopher P. Kauffman, MD Orthopaedic Spine Specialist

Philip J. Kregor, MD

Hip and Orthopaedic Trauma

William C. Mayfield III, MD

Arthroscopy, Knee & Shoulder Reconstruction, and Sports Medicine

Tiffany Feltman Meals, DO

General Orthopedics, Hip & Knee Surgery, Total Joint Replacement, Sports Medicine, and Orthopaedic Trauma

Gregg A. Motz, MD

Arthroscopy, Sports Medicine, Knee, Shoulder, Orthobiologics, and General Orthopedics

Shawn P. Mountain, DO

Arthroscopic Surgery, General Orthopedics, Joint Replacement, Knee & Shoulder Injuries, and Sports Medicine

Todd A. Rubin, MD

Hand and Upper Extremity Surgery, Arthroscopic Surgery, Orthopedic Trauma & Fracture Care, and Joint Replacement of the Shoulder, Elbow, Wrist, & Fingers

Matthew Sarb, DO, MPH

Anterior Hip Replacement, General Orthopedics, Total Joint Replacement, Sports Medicine, Orthopedic Trauma, Knee & Shoulder Injuries, Arthroscopic Surgery, Minimal Invasive Surgery, Carpal Tunnel Release, Hand & Upper Extremity, and Foot & Ankle

Joseph C. Schaffer, MD

Arthroscopic Surgery, Sports Medicine, General Orthopedics, Joint Replacement of the Shoulder, Knee, & Hip, Direct Anterior Hip Replacement, and Orthopedic Trauma & Fracture Care

Marc A. Tressler, DO

James Renfro, Jr., MD

Foot and Ankle Specialist, Joint Reconstruction, Orthobiologics, and Orthopaedic Trauma

Lucas B. Richie, MD

Arthroscopy, General Surgery, Joint Replacement, Sports Medicine, and Orthopedic Trauma

Arthroscopic Surgery, Joint Replacement, Knee & Shoulder Injuries, Sports Medicine, and Anterior Hip Replacement Arthroscopic Surgery, General Orthopedics, Joint Replacement, Knee & Shoulder Injuries, Orthobiologics, Sports Medicine, Robotic Assisted Knee Replacement, Upper Extremity, Hand & Wrist, and Orthopaedic Trauma

Visit our website: tn.hughston.com

Joseph A. Wieck, MD

VITALS

YOU SHOULD KNOW

Daniel Stein Walmart’s former clinics chief delivers data on (and to) doctors with Embold Health

DANIEL STEIN might tell you science isn’t his forte but he’s not fooling anyone. With an educational background studying ethics and politics at Yale, a medical degree from John Hopkins and an MBA from Harvard, the founder and CEO of Embold Health has positioned himself to be something of a Swiss army knife for the health care industry.

“I wish I could say it was that intentional,” Stein says. “It’s just kind of been this progression from policy to clinical medicine to business now to entrepreneurship, exploring how we can improve health care and improve the quality of health care across this country.”

Stein has worked on staff for the U.S. Senate Committee of Finance, as a clinician and as the chief medical officer for Walmart’s network of clinics. That has given him the institutional knowledge and perspective to connect parts of health care that feel disjointed — such as the relatively archaic way patients make decisions about who provides their care and the fact that there are few sources of feedback for clinicians.

“Regardless of whether it was in government or working for the biggest company in the world, I realized that we just didn’t have a data-driven, objective way to identify those physicians who are consistently delivering high-quality care, and that didn’t make a lot of sense to me,” Stein says. “We use data analytics in every other aspect of our life.

Yet when it comes to health care and picking a doctor, we are still relying on word of mouth or anecdotes or an online review.”

Enter Embold, which identifies high-performing doctors and health systems in markets across the country. The two-year-old company recently launched a partnership with Stein’s former employer and has grown its team to nearly 30. A funding round is aiming to raise $22 million and Stein says a number of other partnerships are in the works for late this year and into 2020.

“One of the things I feel really fortunate about with my background — having worked in policy, business and clinical but also in the world we live in right now — is to be a trusted, objective source of information,” he says. “That’s really how we view our role.”

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WINTER 2019 | NASHVILLEPOST.COM

DANIEL MEIGS

VITALS

Data Bank HEALTH CARE INNOVATORS continue to account for an outsized portion of the venture capital dollars flowing in Middle Tennessee, so it’s likely they have something to do with the maturation of the region as an investment destination. They’ll also have a vested interest in the growing adoption of telehealth and in spending anomalies between different care settings — something our cover package on precision medicine also speaks to.

A MATURING INVESTMENT In its recent “The State of Startups in the Southeast” report, an Atlanta investment firm says Nashville’s venture capital investing market is still maturing — versus more fleshed-out markets such as Atlanta or the Research Triangle — based on the average valuations being accorded early-stage companies from this area.

SPENDING GAPS Researchers at Rice University and BlueCross BlueShield of Texas say a group of more than 500,000 PPO members in four large Texas cities spent 5.8 percent more on average when treated by hospital-owned physician groups than when treated by independent doctors. The spending, researchers say, “appears attributable to greater service utilization rather than higher prices” and does not create a consistent difference in the quality of care.

Here is how some of the study’s numbers break down.

Adjusted gap between hospital-owned and physician-owned Inpatient facility services ........................................................... -6.6%

MARKET

2017

2018

2019

Nashville

$17.8M

$20.0M

$23.8M

Charlotte

$12.5M

$18.3M

$20.7M

Atlanta

$16.8M

$16.6M

$16.6M

Research Triangle

$18.5M

$18.3M

$18.3M

Boston

$17.5M

$17.7M

$17.5M

New York

$19.6M

$19.5M

$19.3M

Bay Area

$18.9M

$19.0M

$20.0M

Outpatient facility services ....................................................... 21.7% Evaluation and management...................................................... 2.3% Procedures ..................................................................................... 3.2% Imaging ......................................................................................... 13.0% Testing..............................................................................................2.1% Durable medical equipment ..................................................... 12.9% Source: Journal of General Internal Medicine

Source: BIP Capital

Meanwhile, a report published this spring compared, among other things, the amounts charged by different clinic settings for a traditional evaluation and management visit. Here’s how those broke down in 2017 for visits lasting 20 minutes and 30 minutes.

20-minute charge

TELEHEALTH TRENDS Telehealth usage soared 53 percent in 2017. Here are the six types of treatments that accounted for more than 5 percent of telehealth claims submitted to insurers that year.

30-minute charge

RETAIL CLINIC $104 $129 OFFICE $138

Injury ......................................................................................................... 13%

$207

Acute respiratory infections ................................................................. 13% Digestive system issues ........................................................................ 13%

URGENT CARE $160

General signs and symptoms ................................................................ 9% Mental health reasons ............................................................................ 7%

$213

Joint/soft tissue issues ........................................................................... 7% Source: Fair Health Inc.

Source: Fair Health Inc.

NASHVILLEPOST.COM | WINTER 2019

9

VITALS

‘Simplicity is the future’ Urgent Team’s CEO discusses the rise and maturation of a new model

BY FELICIA BONANNO

om Dent is chairman and CEO of Urgent Team, a Nashville-based urgent care company currently growing at a rate of 15 centers a year. With 63 centers operating as of October, all located within a day’s drive of Nashville, Urgent Team is on the front lines of the booming retail health care industry. And Dent — a health care veteran with PhyCor and Healthcare Realty Trust, among others, on his résumé — has some insight into the industry’s future and evolution thus far.

T

From 2008 to 2015, there was a significant shift from emergency department use to the use of non-ED venues, such as urgent care facilities, for the treatment of low-acuity conditions. This was mainly driven by the high costs of ED visits, according to findings published in JAMA Internal Medicine. Why are patients opting for urgent care and are they truly becoming more savvy spenders of health care dollars?

There are several factors at work. Firstly, if you look at the statistics, while urgent care activity has continued to grow at a rapid pace, the visits to the emergency department have continued to grow also. Urgent care is a great complement and alternative to the ED. [But] ED volumes have continued to increase as well.

In general, people are accessing health care as much as, or more than, they ever have.

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WINTER 2019 | NASHVILLEPOST.COM

What’s driving all of health care is the need [for] its most efficient and lowest-cost opportunity. And patients, with the whole consumerism movement, are purchasing and thinking about health care in the same way they think about other forms of retail purchases. They want access, efficiency, high quality, high value, low cost and speed. Urgent care provides those things as opposed to an emergency department.

Now, where you have a life or a limb threatened, you better get to the emergency department. But for many conditions that have historically been seen in the ED — because it was the only place you could access health care — urgent care now replaces them. So spending two or three hours, or longer, in the ED is no longer required. You can walk into an urgent care center and be in and out of that environment in 45 to 50 minutes and pay maybe oneeighth of the cost you would have paid in the ED. And I believe you will have a much better experience because urgent care centers are designed around a retail orientation, whereas the

EDs are … there to save and protect lives. Urgent care has to focus on providing the patient a [service business] experience.

We think of our patients as customers. The minute they walk into the exam room, they are patients. But up until that time, they are customers — just like any other retail environment you can think of. Ultimately, what’s driving all of health care is lower cost, greater access and the most efficient environment for patients.

What are companies doing to stay competitive as the retail health care industry rapidly evolves?

Customers want connectivity in everything, so being able to offer patients the opportunity to go online and actually schedule a [time slot] like you would in a restaurant is very important.

With Urgent Team, customers can schedule an appointment for [for example] a Saturday morning. And when they walk in — regardless of how many people [are waiting] — they’re moving to the front of the line and into the exam room.

SHANNON FONTAINE

VITALS

Not everyone wants to access that technology, but we think it’s very important to offer. We also have patient portals where patients can go online and receive lab results, as opposed to having a telephone call, if they choose. Those are just two things that are very important in a retail environment and what customers want in health care.

What are some other ways you see retail health care changing?

Within the lower acuity end of health care — I’m talking about non-institutional hospitals and specialty care — the environment is somewhat fragmented between the continuum that goes from urgent care to primary care to chronic care management to occupational health. If you look around the industry, you’ve got primary care that’s segmented from occupational health care companies.

It’s segmented from urgent care, and chronic care often falls under primary care only. We believe that patient simplicity is the future and those organizations that focus on simplifying things for the patient are going to be more successful. Patient simplicity is ultimately what’s going to drive all of us who [provide] these lower-acuity-level services to rethink our delivery models and become more integrated.

The second thing that I believe is going to occur is the integration of urgent care with health systems.

For example, we have [Urgent Team affiliate] Baptist Health Urgent Care in Little Rock. Again, the patient pathway is much more integrated and connected. And it’s one of the reasons we’ve chosen to be involved with health system organizations so that we can be better integrated in the clinical pathway of care for our patients.

It seems Urgent Team is one of the major players in these industry shifts. What are your priorities heading into 2020 and into a future where urgent care is increasingly prevalent?

It’s always foremost about focusing on the customer experience and the quality of care that’s delivered. The patient will define that experience by the questions, “Was it a really efficient and quick visit? Was I diagnosed and treated in an accurate and kind way, and was I in and out of there in a quick period of time?” That is a challenge we have for every single patient that we have.

It’s just like a restaurant. Every single meal that you serve has to be perfect. We have over half a million patient visits a year, and every one of those visits has to be perfectly executed. It’s nice to be a big thinker. But in patient care, you better be thinking about the small things that matter to patients every single day. That is first and foremost.

Secondly, we intend to increase our number of health system joint ventures because we think that’s ultimately where health care needs to go, and it will be good for our patients.

Thirdly, we continue to build scale. We are going to create more density in the markets were we are. We want more centers so that we can have more access to patients. And it helps with operational efficiency to have concentration and density of centers within a marketplace because it allows you to be more efficient as you operate. Efficiency is highly important. So those are our simple, straightforward objectives, and we have the right team in place to accomplish them.

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VITALS

1,500,000

1,000,000

2019

2018

500,000

2017

ov. Bill Lee and TennCare Director Gabe Roberts’ wide-ranging plan to convert federal TennCare funding into a modified block grant went through its public comment period this fall — where it failed to garner much support — and was scheduled to be sent to the Centers for Medicare and Medicaid Services for approval from the federal government by Nov. 20.

TennCare covers 1.4 million Tennesseans statewide and the shift to block grant-style funding could drastically change the way Tennessee funds the health care of its most vulnerable populations.

G

2,000,000

2016

BY KARA HARTNETT

TennCare’s enrollment has risen a bit this year but is down about 13 percent from its recent peak in 2016.

2015

The state’s TennCare block grant requests would open the door to broad powers, but advocates fret about cuts and want details

SHRINKING NUMBERS

2014

Speaking specifically

The contents of the proposal have raised several questions among the health care industry and advocacy groups across the nation.

Critics say the plan creates a massive financial incentive for the state to cut program benefits and enrollment — despite promises from the administration not to make them. But within the proposal, the administration asks to waive specific federal regulations, positioning the state to execute such feared cuts without federal oversight. (See below.)

“The proposal itself doesn’t propose to make cuts, but it creates this tension where the state would have unprecedented federal authority to make cuts to benefits and eligibility without federal approval for public notice, and then creates a very significant financial incentive to make those cuts,” says Hannah Katch, a senior policy analyst for the Center on Budget and Policy Priorities.

Lee and Roberts have repeatedly asserted that won’t happen. However, as this publication was going to press, they had yet to write that commitment into the proposed amendment going to CMS Nov. 20. They also won’t be making any substantive changes to the proposal, despite more than 2,200 pages of feedback with less than 1 percent of the comments supporting the proposal. On Nov. 6, Roberts told reporters his team was making “a lot of clarifications” to their proposal but reiterated no cuts or benefits limits are in the works.

Regardless, those changes and others won’t be available to the public until after it is in the hands of the federal government.

Source: Bureau of TennCare

It’s worth noting Tennessee already has seven other pending amendments with CMS that have yet to be approved. Those propositions include a work requirement standard for TennCare that was mandated by the Tennessee General Assembly, restructuring the process by which TennCare pays hospitals for uncompensated care and the Katie Beckett amendment, which would provide supplemental benefits for caring for chil-

OPENING THE DOOR The state’s proposal to overhaul TennCare’s funding system includes several requests for exemptions from federal rules that could open the door to bigger changes than those voiced this summer and fall by Gov. Bill Lee’s administration: • The Lee team seeks to waive a portion of the statute that restricts TennCare from limiting medical coverage to vulnerable populations such as pregnant women and children, low-income families, the terminally ill, individuals with disabilities, COBRA beneficiaries or those receiving hospice care. Relief of the waiver would allow the government to prioritize funds within the program, rather than providing equal coverage to all.

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1,500,000

1,000,000

2019

2018

500,000

2017

ov. Bill Lee and TennCare Director Gabe Roberts’ wide-ranging plan to convert federal TennCare funding into a modified block grant went through its public comment period this fall — where it failed to garner much support — and was scheduled to be sent to the Centers for Medicare and Medicaid Services for approval from the federal government by Nov. 20.

TennCare covers 1.4 million Tennesseans statewide and the shift to block grant-style funding could drastically change the way Tennessee funds the health care of its most vulnerable populations.

G

2,000,000

2016

BY KARA HARTNETT

TennCare’s enrollment has risen a bit this year but is down about 13 percent from its recent peak in 2016.

2015

The state’s TennCare block grant requests would open the door to broad powers, but advocates fret about cuts and want details

SHRINKING NUMBERS

2014

Speaking specifically

The contents of the proposal have raised several questions among the health care industry and advocacy groups across the nation.

Critics say the plan creates a massive financial incentive for the state to cut program benefits and enrollment — despite promises from the administration not to make them. But within the proposal, the administration asks to waive specific federal regulations, positioning the state to execute such feared cuts without federal oversight. (See below.)

“The proposal itself doesn’t propose to make cuts, but it creates this tension where the state would have unprecedented federal authority to make cuts to benefits and eligibility without federal approval for public notice, and then creates a very significant financial incentive to make those cuts,” says Hannah Katch, a senior policy analyst for the Center on Budget and Policy Priorities.

Lee and Roberts have repeatedly asserted that won’t happen. However, as this publication was going to press, they had yet to write that commitment into the proposed amendment going to CMS Nov. 20. They also won’t be making any substantive changes to the proposal, despite more than 2,200 pages of feedback with less than 1 percent of the comments supporting the proposal. On Nov. 6, Roberts told reporters his team was making “a lot of clarifications” to their proposal but reiterated no cuts or benefits limits are in the works.

Regardless, those changes and others won’t be available to the public until after it is in the hands of the federal government.

Source: Bureau of TennCare

It’s worth noting Tennessee already has seven other pending amendments with CMS that have yet to be approved. Those propositions include a work requirement standard for TennCare that was mandated by the Tennessee General Assembly, restructuring the process by which TennCare pays hospitals for uncompensated care and the Katie Beckett amendment, which would provide supplemental benefits for caring for chil-

OPENING THE DOOR The state’s proposal to overhaul TennCare’s funding system includes several requests for exemptions from federal rules that could open the door to bigger changes than those voiced this summer and fall by Gov. Bill Lee’s administration: • The Lee team seeks to waive a portion of the statute that restricts TennCare from limiting medical coverage to vulnerable populations such as pregnant women and children, low-income families, the terminally ill, individuals with disabilities, COBRA beneficiaries or those receiving hospice care. Relief of the waiver would allow the government to prioritize funds within the program, rather than providing equal coverage to all.

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BIG BUDGETS

WHERE IT GOES

State officials are aiming to land nearly $8 billion in block grant funding based on the past three years of TennCare activity. Here’s how their projections break down.

TennCare’s 2019 budget is about $12 billion.

Here’s where the state is spending that money.

Avg. member months in fiscal 2016-2018

Federal projection of per-member cost

Proposed block grant amount ($M)

Children

9,882,651

$514

$3,299

Adult

4,281,728

$1,025

$2,852

64,979

$1,194

$50

Administration .................................................... 4.2%

Disabled

1,603,682

$1,590

$1,657

Hospital supplemental payments ................... 4.0%

TOTAL

15,832,740

$7,859

Children’s services ............................................. 2.4%

Elderly

Clinical services................................................ 74.2% Intellectual disability services.......................... 8.0% Medicare services ............................................... 7.1%

Source: Bureau of TennCare

dren at home. If Tennessee was exempted from federal oversight, they would no longer require CMS approval to be imposed.

Some observers also are concerned about the state putting itself in a position of financial risk. Rising costs and other factors could result in higher-than-projected per-capita spending, and Tennessee would have to front the difference — but that scenario doesn’t align with current spending trends.

“Even if expenses increased in any year, sizable savings will still be generated because the projected expenditures will be inflated in each new year by an amount that is, generally, higher than the annual inflation that TennCare experiences each year,” Division of TennCare spokesperson Sarah Tanksley tells the Post. “TennCare’s actual expenses have been compared to this CMS projection every year for more than a decade. In that time,

Tennessee has underspent that projection by billions of dollars, which means we have saved billions for the federal government.”

That money, if available, could go toward population health initiatives, rural hospital capital infusions and, in time, perhaps expanded dental coverage. Lee has promised to reinvest funds back into the TennCare program and not use them anywhere else in the state budget, but again, that commitment has not formally made its way into the amendment.

TennCare is already a relatively lean program, as Lee has touted. In light of some of the cuts made in recent years to its services, advocates would like Lee’s administration to better communicate its goals for the program.

And that includes one of the biggest entities in Tennessee health care.

“Given that the proposal states that there is no intention of reducing benefits or tighten-

ing eligibility requirements, however, and given TennCare’s history of large-scale planned disenrollment, providing concrete examples of extensions of eligibility and services is particularly meaningful at this juncture,” a letter from Vanderbilt University Medical Center’s Center for Health Policy to Roberts reads.

As to whether the federal government will approve the amendment, there has been some speculation. Many components of the block grant proposal have been shot down by the federal government in the past, and some conflict entirely with statutory law. Even Lee has admitted he doesn’t expect CMS officials to approve the first draft of the proposal and that negotiations would have to continue to build toward a shared savings model and regulations.

And that’s before, as most observers predict, this ambitious and big-dollar amendment winds up in the courtroom.

• A section of the state government’s plan removes federal oversight and the review process for changes to TennCare. Not including the ones being discussed now, Tennessee has seven pending amendments requesting changes to the state Medicaid program. The propositions include a work requirement standard, restructuring the process by which TennCare pays hospitals for uncompensated care and the Katie Beckett amendment, which would provide services and support to minors with disabilities or complex medical needs who do not qualify for TennCare because of their parents’ income or assets.

• Tennessee’s proposal specifically seeks to repeal two sections of federal regulations protecting an individual’s ability to apply for TennCare as well as eligibility parameters.

The Lee administration justifies the request as a freedom that would give the state the ability to unenroll individuals who have been determined to have committed TennCare fraud and prevent them from re-enrolling for up to 12 months. But complete exemption from the statutes also has other implications because the statutes protect medical assistance to pregnant women and children, low-income families, the terminally ill, individuals with disabilities, COBRA beneficiaries and general hospice care.

• The team drafting the model says it will create hundreds of millions of dollars in annual savings — the difference between CMS’ per-capita spending on TennCare outlays — that would be split 50-50 with the federal government. Some stakeholders have criticized the model, saying it incentivizes the state to cut services, something Lee and TennCare Deputy Commissioner Gabe Roberts have promised they won’t do. But there are few unnecessary administrative costs within TennCare, so it appears cutting benefits or skimping on provider reimbursements — which already run significantly lower than commercial rates — are two of the few ways to save a lot of money.

NASHVILLEPOST.COM | FALL 2019

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BIG BUDGETS

WHERE IT GOES

State officials are aiming to land nearly $8 billion in block grant funding based on the past three years of TennCare activity. Here’s how their projections break down.

TennCare’s 2019 budget is about $12 billion.

Here’s where the state is spending that money.

Avg. member months in fiscal 2016-2018

Federal projection of per-member cost

Proposed block grant amount ($M)

Children

9,882,651

$514

$3,299

Adult

4,281,728

$1,025

$2,852

64,979

$1,194

$50

Administration .................................................... 4.2%

Disabled

1,603,682

$1,590

$1,657

Hospital supplemental payments ................... 4.0%

TOTAL

15,832,740

$7,859

Children’s services ............................................. 2.4%

Elderly

Clinical services................................................ 74.2% Intellectual disability services.......................... 8.0% Medicare services ............................................... 7.1%

Source: Bureau of TennCare

dren at home. If Tennessee was exempted from federal oversight, they would no longer require CMS approval to be imposed.

Some observers also are concerned about the state putting itself in a position of financial risk. Rising costs and other factors could result in higher-than-projected per-capita spending, and Tennessee would have to front the difference — but that scenario doesn’t align with current spending trends.

“Even if expenses increased in any year, sizable savings will still be generated because the projected expenditures will be inflated in each new year by an amount that is, generally, higher than the annual inflation that TennCare experiences each year,” Division of TennCare spokesperson Sarah Tanksley tells the Post. “TennCare’s actual expenses have been compared to this CMS projection every year for more than a decade. In that time,

Tennessee has underspent that projection by billions of dollars, which means we have saved billions for the federal government.”

That money, if available, could go toward population health initiatives, rural hospital capital infusions and, in time, perhaps expanded dental coverage. Lee has promised to reinvest funds back into the TennCare program and not use them anywhere else in the state budget, but again, that commitment has not formally made its way into the amendment.

TennCare is already a relatively lean program, as Lee has touted. In light of some of the cuts made in recent years to its services, advocates would like Lee’s administration to better communicate its goals for the program.

And that includes one of the biggest entities in Tennessee health care.

“Given that the proposal states that there is no intention of reducing benefits or tighten-

ing eligibility requirements, however, and given TennCare’s history of large-scale planned disenrollment, providing concrete examples of extensions of eligibility and services is particularly meaningful at this juncture,” a letter from Vanderbilt University Medical Center’s Center for Health Policy to Roberts reads.

As to whether the federal government will approve the amendment, there has been some speculation. Many components of the block grant proposal have been shot down by the federal government in the past, and some conflict entirely with statutory law. Even Lee has admitted he doesn’t expect CMS officials to approve the first draft of the proposal and that negotiations would have to continue to build toward a shared savings model and regulations.

And that’s before, as most observers predict, this ambitious and big-dollar amendment winds up in the courtroom.

• A section of the state government’s plan removes federal oversight and the review process for changes to TennCare. Not including the ones being discussed now, Tennessee has seven pending amendments requesting changes to the state Medicaid program. The propositions include a work requirement standard, restructuring the process by which TennCare pays hospitals for uncompensated care and the Katie Beckett amendment, which would provide services and support to minors with disabilities or complex medical needs who do not qualify for TennCare because of their parents’ income or assets.

• Tennessee’s proposal specifically seeks to repeal two sections of federal regulations protecting an individual’s ability to apply for TennCare as well as eligibility parameters.

The Lee administration justifies the request as a freedom that would give the state the ability to unenroll individuals who have been determined to have committed TennCare fraud and prevent them from re-enrolling for up to 12 months. But complete exemption from the statutes also has other implications because the statutes protect medical assistance to pregnant women and children, low-income families, the terminally ill, individuals with disabilities, COBRA beneficiaries and general hospice care.

• The team drafting the model says it will create hundreds of millions of dollars in annual savings — the difference between CMS’ per-capita spending on TennCare outlays — that would be split 50-50 with the federal government. Some stakeholders have criticized the model, saying it incentivizes the state to cut services, something Lee and TennCare Deputy Commissioner Gabe Roberts have promised they won’t do. But there are few unnecessary administrative costs within TennCare, so it appears cutting benefits or skimping on provider reimbursements — which already run significantly lower than commercial rates — are two of the few ways to save a lot of money.

NASHVILLEPOST.COM | WINTER 2019

13

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Precision medicine comes with much promise — and a few big question marks

BY KARA HARTNETT

Technology is reshaping health care in myriad ways just about every day. But few concepts can claim to be as potentially impactful as precision medicine, generally defined as the tailoring of care to a patient’s specific characteristics — genetic, lifestyle and environmental. The tech-based concept has been widely called a game-changer for its potential to improve the quality of care, in part by incorporating social factors such as housing and nutrition, while at the same time cutting costs by nearly eliminating trial-and-error medical tests, unnecessary procedures and ineffective drug treatments. It is also seen as a catalyst to enabling truly effective preventative care by creating something of a medical road map for individuals.

Not surprisingly, Nashville is at the forefront of the evolution of precision medicine. In the summer of 2016, the National Institutes of Health awarded Vanderbilt University Medical Center a $71.6 million grant to launch a data and research support center as part of a wide precision medicine push by the Obama administration.

At the time, U.S. Sen. Lamar Alexander called the funding “one of the most exciting developments for Vanderbilt, Tennessee, and for medicine in a long, long time.”

But adoption has been frustratingly slow — a 2018 paper by University of California — San Francisco and Duke University researchers said closer coordination between various initiatives around the world will be crucial to changing that — and there remain questions about unfulfilled potential and overall cost-effectiveness.

On the next few pages, we dip our toes into the concept of precision medicine and some of the local conversations about its potential, the health equity dynamic and accompanying ethical issues.

And while it’s not clear exactly where things go from here, it’s a good bet that Nashville’s health care community will have much more to say about it.

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VITALS

Precision medicine comes with much promise — and a few big question marks

BY KARA HARTNETT

Technology is reshaping health care in myriad ways just about every day. But few concepts can claim to be as potentially impactful as precision medicine, generally defined as the tailoring of care to a patient’s specific characteristics — genetic, lifestyle and environmental. The tech-based concept has been widely called a game-changer for its potential to improve the quality of care, in part by incorporating social factors such as housing and nutrition, while at the same time cutting costs by nearly eliminating trial-and-error medical tests, unnecessary procedures and ineffective drug treatments. It is also seen as a catalyst to enabling truly effective preventative care by creating something of a medical road map for individuals.

Not surprisingly, Nashville is at the forefront of the evolution of precision medicine. In the summer of 2016, the National Institutes of Health awarded Vanderbilt University Medical Center a $71.6 million grant to launch a data and research support center as part of a wide precision medicine push by the Obama administration.

At the time, U.S. Sen. Lamar Alexander called the funding “one of the most exciting developments for Vanderbilt, Tennessee, and for medicine in a long, long time.”

But adoption has been frustratingly slow — a 2018 paper by University of California — San Francisco and Duke University researchers said closer coordination between various initiatives around the world will be crucial to changing that — and there remain questions about unfulfilled potential and overall cost-effectiveness.

On the next few pages, we dip our toes into the concept of precision medicine and some of the local conversations about its potential, the health equity dynamic and accompanying ethical issues.

And while it’s not clear exactly where things go from here, it’s a good bet that Nashville’s health care community will have much more to say about it.

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Precision medicine opens the door to pairing clinical, genetic and environmental data points

odern health care has typically been provided through a one-size-fits-all model that has ignored genetic variances — even though those differences play a big role in how human bodies metabolize medicines. Depending on the DNA of an individual, certain medications or dosages of medications simply won’t work.

In fact, a sizable sum of the drugs prescribed to you in your lifetime will be somewhat ineffective because of your genes. Physicians know this but haven’t had a sustainable way to measure medicines’ effectiveness prior to prescribing them — a shortcoming that has left prescribing entities playing a guessing game.

They prescribe a drug and specify a dosage and if that combination doesn’t work, the patient comes back to try something different. Rinse and repeat until the patient is cured.

This inefficient model drives up costs and insurance claims and adds to the risk of medical complications for a patient. In an economy where health care makes up about 20 percent of spending and prescription drug spending tops $325 billion annually, the economic promise of using genetics to improve drug compatibility is substantial.

M

ERIC ENGLAND

Consuelo Wilkins

Medications aren’t the only inefficiency a mass-market, all-encompassing health care system has produced. Health equity also has been compromised by the disparities in clinical research work over the decades. Some 85 percent of health care research in history has been conducted on men of European descent with much of the remaining research focused on people of Asian descent. Only four percent of genome-wide studies have involved the third of the U.S. population represented by African Americans, Hispanics and Native Americans.

That disparity has helped shape a system with huge structural barriers to women and minorities. For example, African Americans and Hispanics have a higher susceptibility to

contracting asthma but benefit less from medications meant to relieve its symptoms. That means they have a stronger likelihood of ending up in the emergency room due to complications — and thus have to pay more for care that may not relieve their symptoms the same as if they were a white male.

This is where precision medicine steps in.

Precision medicine analyzes patients down to their individual genomes and helps identify genetic variances that could impact their health outcomes, disease susceptibility and more. It can help create a more individualized care model than the one-size-fits-all guessing game. Precision medicine is still in its early stages of adoption in the market — and few commercial in-

NASHVILLEPOST.COM | WINTER 2019

15

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surers have signed up to reimburse related expenses — but researchers in the field are encouraged by the work being done and see a future where health care is rendered on a far more personal and effective basis.

An alliance between Vanderbilt University and Meharry Medical College, the oldest historically black medical college in the country, is active in the field. Funded

by National Institutes of Health grants and part of a national network, the partnership has created a unique center — one of five across the country — to research precision medicine and health disparities.

Consuelo Wilkins leads that mission as executive director of the alliance. A specialist in geriatrics and health equity, Wilkins also serves as the vice president for health equity at Vanderbilt University Medical Center and associate dean for health equity at the Vanderbilt University School of Medicine.

“The individual focus has to be front and center for any population,” Wilkins says. “I think people are less comfortable with the inherent variability and differences among us, and we just have to get more comfortable with it.”

Beyond looking into genetic differences, Wilkins and her team are looking at precision medicine through the scope of certain social health determinants and their propensity to impact health.

“I am always quick to say, ‘No, no. It’s not just about genes and genetics.’ Although that has been a huge focus and is certainly important,” she says. “There are some conditions ... where we see, even when we control for things like the environment and access to care, there are still some disparities related to race and ethnicity.”

Asthma is on that list, as are pre-term births. African-American women are more likely to give birth before 37 weeks, increasing the likelihood their babies will be underweight and have complications during delivery and gestation. Social determinants can be a lot of things: Socioeconomic status and access to nutritious food, transportation and housing all play a role in how healthy an individual is. So whereas humans are really just a compilation of genes, those genes cannot be evaluated outside the context of their environment.

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Wilkins sees a future where physicians have the means to identify how these environmental factors affect health conditions and outcomes. From there, they could be incorporated into treatment plans and electronic health records. To do that, Wilkins and her team have begun looking into a range of indicators that use a patient’s ZIP code to identify social determinants faced by a broader community. The area deprivation indices look at things such as median income, the share of people who own a car and the percentage of homes led by single mothers to help identify at-risk patients.

‘People are less comfortable with the inherent variability and differences among us, and we just have to get more comfortable with it.’

CONSUELO WILKINS, VUMC

For instance, the alliance is gathering data on food swamps — where communities have access to unhealthy foods but not fresh fruits or vegetables — and how healthy food accessibility plays into the health equity of a community. Incorporating into a patient’s health record as many of these data points as possible — and in an ethical way — would be invaluable information to a provider, but Wilkins says there is still much more work to be done.

“We really need more researchers and people from different sectors who are not just focused on clinical medicine,” she says.

“We really need people to think differently about how we combine data and how we look at risk and assess opportunity.”

Better medicine, better experience Murfreesboro doctor group integrates genetic data into EHR

T

HE FULL SCOPE of precision medicine in the commercial arena remains more about promise than implementation. But pharmacogenetics, the study of how genes affect the ways people metabolize certain medicines, is making strides in the market — including locally.

Murfreesboro Medical Clinic, which is home to more than 70 doctors, earlier this year announced a partnership with 2bPrecise, an Allscripts genetic data and clinical information platform that integrates data received from gene panels with a patient’s electronic health record.

Nicholas Cote, chief medical information officer and president of the board of MMC, says the technology adds another element of science into a physician’s prescribing practices. Before the 2bPrecise platform, he says, physicians found it difficult to apply genomic insights to medical decisions during patient encounters because test results were not integrated with clinical information or easily available within EHR workflows. This takes out that element of uncertainty and allows clinicians to look at a patient’s individual needs by matching data from the gene panels with available prescription drugs.

Cote notes the use of pharmacogenetic test results is especially beneficial in family medicine, allowing doctors to track the genetic variants in patients in correlation with their family members. The 2bPrecise solution can serve as the foundation for long-term needs, enabling MMC to help clinicians identify patients at risk for heritable diseases across specialties, arrive at precise diagnoses earlier and ultimately select the best treatment based on the patient’s genetic profile.

“We recognize that using science to drive medical treatment is infinitely more effective than trial and error,” Cote says.

“The 2bPrecise platform will help equip our clinicians to identify the best medications for individual patients, achieving better results faster and with fewer side effects. Not only is this good medicine, but it greatly enhances the patient experience as well.”

S PON S OR E D PROFIL E

HEALTHCARE INTEGRATION IS BROKEN...

COMPA N Y PROFIL E Bridge Connector is a technology company changing the way healthcare communicates. It connects disparate data systems more quickly and affordably, allowing any size business and any technical skill-level user to achieve more simple integrations, along with the valuable data insights that are needed to improve patient care.

Radiology network bolsters marketing efforts through Bridge Connector

...WE FIXED IT.

www.bridgeconnector.com

Premier Radiology is the largest outpatient diagnostic imaging network in Tennessee and a joint venture organization of Saint Thomas Health, Advanced Diagnostic Imaging and Midstate Radiology. Premier Radiology’s network includes 20 diagnostic imaging locations, serving patients with over 400,000 studies annually, with a network of over 5,000 referring providers. With the company’s exceptional growth, Premier’s marketing team was struggling with labor-intensive manual reporting. This sometimes resulted in their sales reps calling on referring providers with monthly reports containing data up to 30 days old.

“Thanks to our engagement with Bridge Connector, we have been able to unlock all of our physician referral data —no more speculation,” said Gail Bedlack, Chief Marketing Officer at Premier Radiology. “We now have realtime, accurate data for our marketing team to do their best work.”

Premier Radiology was facing a business challenge that is not unlike many other organizations, particularly those in healthcare. They required access to real-time data to make more strategic business decisions —a data-driven marketing plan, in their case, enabling more accurate forecasting and targets with their referral network. Healthcare

data integrations have historically been deemed too expensive, timeconsuming or ineffective, and how to achieve interoperable systems in healthcare continues to be one of the most pressing industry challenges to fix.

Bridge Connector, the health technology company who is changing the way healthcare communicates, has an end-to-end suite of products which deliver integration solutions more simply, rapidly and costeffectively, making them accessible to any sized organization. The company recently announced the launch of Destinations, an integration platform that can be used by technical users and business users alike, to reap the benefits of connected data systems without the need to code.

For Premier Radiology, these connected systems mean 10X growth in data transparency for marketing efforts, to encompass their full network of referring providers.

“We knew how complicated our challenge was but didn’t fully realize the level of business ramifications until our solutions were enacted, which Bridge Connector delivered with simple processes and clear communication,” said Bedlack. “Having real-time data insights, especially around our referring provider network, allows our marketing team to do their job more effectively, in less time.”

Website: bridgeconnector.com Phone: 844.727.4343 Bridge Connector bridgeconnector Bridge Connector bridgeconnectUS

PROD UC T S DESTINATIONS -

an integration platform as a service (iPaaS) that rapidly and easily connects health data systems without the need for code.

CARESERVICE CONNECT -

an application available on the Salesforce AppExchange that addresses social determinants of health by allowing care providers to connect their patients with the social services they need.

AUDIE N C E S Ambulatory Care Behavioral Health Skilled Nursing & Long-Term Care Hospitals & Health Systems

VITALS

An ambitious effort looks to accumulate data from a million people — most of them historically underrepresented

nly four percent of genome-wide research studies have involved African Americans, Hispanics and Native Americans, groups that make up nearly onethird of the U.S. population. Now, researchers are having to make up for lost time including women and minorities in their work — something Consuelo Wilkins, vice president for health equity at Vanderbilt University Medical Center, says that must start by changing policies and practices honed over decades.

That’s where the All of Us campaign comes in. The research program was initiated in 2015 by the Obama administration and aims to advance precision medicine by collecting data from one million diverse participants to provide a foundation for accelerating research and improving health. The program has been enrolling participants 18 years and older from a network of 340 recruitment sites, including VUMC. As of this past August, more than 182,000 people had contributed biospecimens such as DNA samples and more than 112,000 people had shared their electronic health records.

The entire program has enrolled more than 230,000 research participants and All Of Us investigators say they are on track to reach their million-person goal by 2024.

O

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Josh Denny

“A lot of people talk about it kind of like being the next human genome project,” says Josh Denny, a professor in VUMC’s departments of biomedical informatics and medicine. “We really desire to make this a diverse cohort to capture individuals who are underrepresented by medical research traditionally.”

Denny serves as VUMC’s vice president of personalized medicine and is one of three primary investigators for the All of Us Data and Research Center. Four out of five participants in the cohort he oversees are from groups that have been historically underrepresented in biomedical research. He says the opportunity to lead this research allows his team to really think about diversity broadly: from race, sexu-

‘You will learn more faster by studying more variety.’

JOSH DENNY, VUMC

ERIC ENGLAND

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al orientation and people in low socioeconomic strata to the rural, elderly and young.

He says preliminary research proves having a diverse cohort for this research will benefit All of Us — pun intended — and produce insights that can be applied to the development of cures. For instance, the study of a small population of African Americans in Dallas with low cholesterol and low rates of heart disease, Denny says, enabled researchers to create antibodies used in the latest class of cholesterol drugs that have proved to be extremely effective in the clinical space for all populations.

Anecdotes like these, Denny says, are a glimpse into the future of precision medicine — and are innovations he hopes the data collected through his team’s campaign can accelerate.

“You will learn more faster by studying more variety, essentially,” he says. “Most of my research has been using electronic health record data with genetics and you just see different alleles and different genetic variances are carried by different ancestral populations. You can think something is pathogenic or basically miss a pathogenic allele by virtue of not having the right diversity or large enough population to really understand what is going on.”

The research being done at VUMC and elsewhere under the All of Us umbrella will lay the groundwork for innovations to come. In the meantime, Denny is grappling with how to present those data sets to the public when they are complete. His team is building webbased tools that will allow other researchers to analyze the data using statistical packages and programming languages. The goal is to give them the ability to apply the All of Us data sets into some of their own research.

“It’s going to fuel a lot of stuff none of us ever thought about,” Denny says. “When you collect a really rich data set which has information about diseases and treatments, responses to treatments, who goes on from a given disease to doing really well with that disease to who has a worse course… There will be all sorts of things people will do that I won’t be able to even begin to think of now.”

Denny says some of these tools will be launched as early as next year. But he adds that he hopes the data collection will go on for decades to come.

Conflict of interest?

A reformed TennCare drug formulary would narrow options

A

key component to TennCare’s block grant proposal (see page 12 for more on that plan) is its request to create a commercial-style closed drug formulary, effectively allowing the state’s safety-net insurance program to not cover all prescription drugs approved by the Food and Drug Administration.

One of the main things precision medicine has shown is that drugs’ effectiveness relies heavily on an individual’s genes. The proposed TennCare formulary could limit prescription medicine coverage to one drug per therapeutic class — the state could approve more — meaning that patients who aren’t compatible with the chosen drug will have to pay out of pocket to get the treatment they need. And since pharmaceutical research has long skewed toward white men, any narrow formulary could very well be a health equity concern, too — including for cheaper generic drugs.

The medical community’s growing understanding of genetic variances — and their ability to impact the way a person metabolizes drugs and responds to dosages — is incompatible with another one-size-fits-all health policy.

These variances are why many African Americans need higher doses of certain depressants and individuals of Asian descent don’t correctly process the blood

thinner Plavix, to name a few, according to Vanderbilt University Medical Center professor Josh Denny. The formulary model could be a cost-saver for the state as officials seek a hefty incentive to save money, according to Hannah Katch, a senior policy analyst for the Center on Budget and Policy Priorities.

“If TennCare were simply able to not cover high-cost drugs, that would save an enormous amount of money,” she says. “But it would save money at the expense of individuals who need access to their medications.”

And a shorter list of approved treatments also wouldn’t drive down health care costs as much as it might appear at first blush. If the single drug covered

by TennCare — assuming the state’s block grant plan is approved — is not effective for a patient, the individual will have to pay out-of-pocket costs for an alternative. A more fiscally responsible method, pharmacogenetics specialists argue, is using gene paneling to more quickly figure out the proper medication and dose, sparing the patient and the system the guessing factor involved in prescribing as we’ve known it.

Beyond the proposed TennCare policy’s incompatibility with genetic variants, Katch says the closed formulary approach is actually in direct conflict with federal law.

“The federal statute is very explicit about this requirement that, if Medicaid programs are going to cover prescription drugs, they must cover all prescription drugs. That is for a good reason, right?”

Katch says. “That’s so they don’t pick and choose what drugs they want to cover, and so that patients have access to the prescription drugs that they need.”

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Our parameters for precision medicine’s gathering, using and sharing of data are still being formed he exponential growth of health care data — and the chance that precision medicine’s rise will put much more of it at risk of cyber attacks — understandably has many consumers, researchers and law enforcement professionals skeptical about the accumulation and storage of masses of genomic information in databases governed by the health care industry. Researchers studying the integration of genomics and precision medicine into electronic health records have recognized this hesitation and are having conversations about the ethics of their research and the future implications of the way it’s applied.

Ellen Clayton, co-director of the The GetPreCiSe Center, an NIH Center of Excellence in Ethics Research located on Vanderbilt University’s campus, is leading some of those conversations. From confidentiality and patient protections to public perception of genetic screenings, Clayton says the thing to remember is that the tough questions that need to be asked about precision medicine initiatives — their medical necessity, moral responsibility, legal implications and privacy — are exactly the kind of questions we ought to be asking about everything in medicine. On top of that, there are questions about the age at which it is appropriate to start genetic screening and whether an individual should be held liable for refusing to take a genetic test. More broadly, could precision medicine widen health disparities instead of narrow them?

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Ellen Clayton

“We make our decisions based on an assumption that people will value the information, that they will be in a position that they can act on the information,” Clayton says.

“We assume people will have access to health care and have access to clinicians that know what to do but the thing that is interesting about this is it’s really no different from any of the other things we do in medicine.”

First, Clayton believes genetic screening needs to come with a clear need. She says it’s hard to make the case for full genome sequencing, for example, because there is a lot of information collected that isn’t necessary for clinical decisions.

“There is no set of circumstances under which doing a whole genome sequencing for healthy people meets any sort of screening criteria,” she says. “There are times when that kind of approach is warranted — critically ill newborns is one. But thinking about that in the context that we must, in the context of clinical care, it has to meet criteria for when things are warranted to be used in the health care setting.”

Expanding on the idea of testing a newborn, the industry already has set some precedents when it comes to frivolous screening practices. Newborns are generally scanned for a number of disorders. The technology used to perform these screenings can test for hundreds

DANIEL MEIGS

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‘It’s really no different from any of the other things we do in medicine.’

ELLEN CL AY TON, VUMC

of things but is used in practice to only search for 50 disorders. So the idea of creating technology to potentially detect a lot of things but only use it in more narrow ways seems to be an accepted standard today.

Some critics of this approach, though, are advocating for sweeping liability for people who do not take full advantage of genetic screening due to its potential relevance to family members.

Clayton believes that position is largely unfounded for now as the technology is “not ready for prime time — yet.”

Another important aspect is confidentiality. For research purposes, confidentiality is maintained by encrypting or de-identifying health records and data sets so none of the information available to researchers can be tied to a specific individual. Encrypting also is a standard practice in the health care market today but, as in other industries, it remains imperfect even on a good day. Each year, hackers gain access to millions of patient records — compliance analytics firm Protenus says 32 million were stolen in the first half of this year, more than double the number for all of 2018 — and sell them for far more than poached Social Security numbers or credit card information. Thus, the idea of beefing up medical records with even more personal info makes for a tricky conversation.

Much of what Clayton studies is public perception of genetic research and data. A 2018 study she co-authored noted that many people are concerned about the privacy of genomic and medical information but that opinions vary widely on how much control they want over the use of their data. Many of those surveyed expressed more concern about potential uses of their data by employers, the government and insurers than about medical researchers and commercial entities. The upshot: People are generally willing to give up some privacy in exchange for goods.

Even if there is broad acceptance of a quid pro quo involving genetic information and better health outcomes or ancestry.com results, Consuelo Wilkins of Vanderbilt University Medical Center says it’s important to recognize that precision medicine can also widen health access disparities.

“As we develop these approaches and tools, we have to make sure we aren’t just increasing the price or creating new programs that you can only get if you have health insurance or access in some way,” Wilkins says.

“There are important opportunities to not just connect the information related to health equity but to leverage and bring in those community organizations that have the ability to help improve health for those people.”

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Behind every headline and ranking is the hard work of the Nashville Area Chamber of Commerce.

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Sources: Policom, Forbes

for that matter). The longer an expansion goes, the more malfeasance seems to appear. Is that so and does that mean we should expect many more cases in the next few years?

I think the number of health care fraud prosecutions should remain steady no matter what happens with the economy. Health care is somewhat countercyclical, especially with respect to Medicare and Medicaid, where most investigations and prosecutions are focused.

The real limiting factor to pursuing cases are the resources — in the form of federal agents and prosecutors — that the government can bring to bear.

‘A good bet is to follow trends in reimbursement’ Waller partner and incoming TBA health law leader J.D. Thomas sees False Claims cases spreading beyond big entities aller Lansden Dortch & Davis partner J.D. Thomas is the incoming chair of the health law section for the Tennessee Bar Association, a role in which he says he will look to continue his predecessors’ work on continuing education. Ahead of stepping into his role, Thomas — a former assistant U.S. attorney who specializes in government investigations and prosecutions — took some time to answer a few questions about regulatory priorities and trends in health care.

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You’ve been with Waller since 2014.

How have you seen the government’s investigative priorities evolve?

Two ways: First is the government’s renewed focus on investigating and prosecuting individual

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providers. In September 2015, the Department of Justice issued a memo directing U.S. attorney’s offices to focus on individual culpability.

In the past couple of years, we’ve really seen the fruits of that directive here in Nashville and the rest of Tennessee with significant criminal prosecutions of individual doctors, pharmacists and other health care practitioners.

Second, the government has become increasingly comfortable with litigating health care fraud cases and, if necessary, bringing them to trial. We’ve seen this trend here in Nashville, throughout the state and beyond.

It seems like there’s an economic cycle element to fraud and whistleblower cases in health care (and elsewhere,

Can you talk about the investigative process and the length of time cases take to be brought? It seems like various opioids cases have taken form more quickly in recent years.

The typical length of a case really depends on whether it is civil or criminal. Criminal cases tend to move faster, since the government is usually investigating specific actions by individuals, rather than entities and is looking for evidence that can be proved beyond a reasonable doubt. Depending on the conduct being investigated, there can also be more resources or investigating agencies involved in criminal cases.

The recent flurry of opioid-related criminal prosecutions is a great example. They are a direct result of the resources being funneled into that area and the Department of Justice’s focus on those prosecutions. Nashville is home of the Appalachian Regional Prescription Opioid Strike Force committed to those efforts. It is comprised of dedicated prosecutors, data analysts and special agents with the FBI, HHSOIG and DEA working in conjunction with other state and federal law enforcement agencies, including the Tennessee Bureau of Investigation, which is why we’ve seen so many prosecutions here in Tennessee.

Civil cases, on the other hand, are often brought against entities. They involve significantly more documentation and can revolve around questions of medical necessity or interpretations of complex regulations that are not always black and white. Often, these types of cases are brought by whistleblowers who are often pushing their own interpretation of those issues.

These cases can take years to resolve and/or for

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the government to pursue and decide it doesn’t want to intervene. Overall, I think the length of prosecutions — both criminal and civil — have remained largely the same. We’ve just seen more of both in the time since I left the U.S. Attorney’s Office.

Are you seeing emerging pockets of fraud as the health care sector continues to evolve?

We are seeing a lot of recent activity in the clinical laboratory, compounding and vision spaces. We are also seeing an increasing number of larger-scale False Claims Act cases brought against physician practice entities. As practices continue to expand and more capital is deployed, they become attractive targets for whistleblowers and the attorneys that represent them.

Beyond that, the government has continued to focus on Stark Law and Anti-Kickback Statute investigations and prosecutions. It is always hard to say what the next area of focus will be, but a good bet is to follow trends in reimbursement. Areas of growing reimbursement are followed by fraud investigations and prosecutions. Behavioral health and medication-assisted treatment are two areas where I think we can expect additional activity.

The requirements and market practices around reporting, sharing and using health care data have ballooned this decade. Has that made monitoring and investigating potential issues easier?

Data is a huge driver in government investigations.

New reporting requirements have certainly made it easier for whistleblowers and others to identify suspected fraud waste and abuse and bring it to the attention of the government. That said, the government has been leveraging provider data for some time and is getting better at it every day, especially in the post-acute space. For clients that have a good handle on their data, it’s also made it easier for them to manage compliance challenges.

However, sometimes the data can be overwhelming or lead in the wrong direction. I always counsel clients who are audited by various Medicare and Medicaid contractors to make sure they take a close look at what data is requested and what other data may be available to support services billed.

What are some notable cases around the country that you’re tracking that could have repercussions for Nashville and/or Tennessee?

There are two big ones: The first is United States v.

AseraCare, a recent 11th Circuit decision involving

medical necessity claims brought by the government under the False Claims Act. The court held that the government needs to show “something more than the mere difference of reasonable opinion” between two medical practitioners to establish that a claim isn’t medically necessary and therefore false. This decision will raise the bar for the government to prove that a claim is “false” because it lacked medical necessity.

In short, it will require more than a difference of opinion between a government expert reviewing the claims after the fact and the treating physician.

I like to refer to this requirement as “medical necessity plus” with the “plus” being something more, like pressure to make an admission, bonuses based on services rendered, to recognition internally that claims may not be medically necessary.

The second is U.S. ex rel. J. William Bookwalter, III, M.D. et al. v. UPMC et al., a 3rd Circuit case where the court overruled a dismissal of a False Claims Act case brought on by alleged violations of the Stark Law. The court held that the case should not have been dismissed and discovery could go forward because there appeared to be a connection between physician productivity-based compensation and the volume of those surgeons’ referrals for inpatient hospital services. One allegation the court focused on is that some of the physicians received compensation in excess of collections for the professional services they rendered. While this decision may be at odds with some of the proposed changes to the Stark Law and Anti-Kickback Statute, it’s still good law and is sure to invigorate some Stark Law-based False Claims Act cases.

The UPMC decision is a bit disquieting for physician employers. While the court seemed to focus on the weight of all the allegations taken together, some of the allegations the court focused on are not uncommon for many facilities.

Nashville General Hospital’s case against Momenta Pharmaceuticals was recently granted class-action status, marking the first time in nearly half a century that a city entity has led such a case. How unusual is it to see a publicly owned safety-net hospital in the lead of a case like this?

It is becoming more and more common. As hospitals face ever tighter budgets, we’ve seen more and more of them turn to class actions and other litigation to try to recover money they believe they improperly paid. Antitrust actions like this one are particularly popular, and the benefits to Nashville General as the lead plaintiff could be substantial.

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Nurses needed Innovations in recruitment and a focus on ‘joy retention’ are helping hospitals confront a worker shortage

BY LENA ANTHONY

he demand for nurses continues to increase as new care models and aging Baby Boomers depend on their services. The federal Health Resources & Services Administration estimates demand for registered nurses will grow 22 percent between 2014 and 2030. At the same time, the nursing workforce is aging: The average age of an RN is 51, which means a large number of nurses are nearing retirement age.

Meanwhile, the nursing profession is suffering from a burnout problem. A recent survey by RNnetwork found that 49 percent of nurses have considered leaving the profession in the past two years, citing complaints such

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as feeling overworked at facilities that feel understaffed. Educators are trying to keep supply balanced with demand but their capacity to increase enrollment hinges on their ability to staff and fund their programs. Unfortunately, the American Academy of Colleges of Nursing found that U.S. nursing programs turned away more than 75,000 qualified applicants in 2018 due to staff, space and budget constraints.

Despite those setbacks, supply is expected to keep up — for the most part. The government is actually predicting a surplus — of 293,800 RNs — by 2030. Even if those numbers do shake out on paper, there are still several issues facing health care providers that are collectively challenged in their efforts to recruit nurses. The exodus of long-time RNs leaves a gap in clinical knowledge, institutional knowhow and bedside experience. Demand for specialty nurses beyond medical-surgical exceeds supply. And when looking at state data, there are actual nursing shortages today, with many areas across the country — among them populous states such as California, Texas and Georgia — graduating fewer nurses than there are job openings.

Tennessee is not one of those states predicted to have a nursing shortage, but try telling that to Michelle Robertson, COO and chief nursing officer of Saint Thomas Health, a part of national Catholic health system Ascension, which has 150 hospitals in 20 states and Washington, D.C. Ascension this summer launched a Nursing Center of Excellence, and Saint Thomas West in Nashville is home to the center’s transformation unit, a working med/surg nursing unit whose co-focus is nurse retention.

“It’s not just about recruiting nurses, it’s also about keeping them here,” says Robertson. “And today’s nurses have different expectations. We have to be flexible, nimble and provide them with more control over their work environment and allow them to create an environment where they want to stay. We call that joy retention.”

The unit serves as a test environment for nurse-generated ideas that, if they work well, could be expanded across the entire Ascension network.

“We have challenged them to be innovative and create new processes that work for the care team and at the same time allows them to have more joy and more control in what they’re doing,” Robertson says.

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Two ideas being tested are a modernized shift-change handoff communication protocol and the addition of a third shift during peak operating times, which would help alleviate the burnout associated with long, 12hour workdays. The unit is new, but with tests happening in two-week sprints, Robertson expects improvements to be implemented system-wide in months, not years.

Meanwhile, Saint Thomas has hired a professional practice coach to help new nurses eager to chart their career path. “Today’s nurses are looking at the entire career in front of them and are quickly moving from bedside to specialty when the opportunities arise,” Robertson says. “Some see this as turnover, as something we need to prevent, but we see it as desirable. The coach is there to help our staff progress through their practice environment.”

And, she adds, ideally this growth happens within the organization. Ascension also has a program in place that allows nurses to rotate into different specialties, instead of keeping them in the same one they started in.

Creative benefits and innovative retention strategies aside, Robertson faces a major challenge that really only money can buy: the increasingly high cost of living in Nashville.

“Everyone wants to come here,” she says. “But the reality is many can’t afford to live here.”

As Saint Thomas considers adding housing to its list of specialties, companies like AMN Healthcare, one of the country’s largest health care staffing agencies, sees Nashville as one of its top sources of travel nurses, whose average assignment is 13 weeks.

“A large percentage of our travel nurses, who work in all 50 states, come from the Nashville market,” says Ralph Henderson, president of professional services and staffing for the San Diego, California-based company. “It’s a great place to recruit from.”

Henderson says travel nurse demand peaked in 2014, a sign that nurses were finally recovering from the Great Recession and ready to retire or make a career change. In the past six months, he says, those dynamics have returned.

When Henderson started working in health care staffing 12 years ago, he says hospitals saw travel nurses as a solution to a short-term problem. These days, they’re viewing travel nurses more strategically as a possible solution to their recruitment challenges.

‘We have challenged them to be innovative and create new processes.’

MICHELLE ROBERTSON, SAINT THOMAS

“About a third of nurses travel to a new market, fall in love, and start working there permanently,” he says. “That’s the best-case scenario for a hospital, because they can really know who they’re hiring after a 13-week trial period.”

A growing service line for AMN is outsourced recruiting, especially in regions experiencing a shortage. Henderson says AMN can bring best practices, including recruiting outside of the community through targeted marketing, to help understaffed hospitals increase efficiency and success with their hiring efforts. But don’t expect Henderson’s team to suggest a signing bonus.

“In a crisis, those kinds of things are probably necessary. But if everyone offered it, it wouldn’t be very effective,” he says. “It can also lead to lower satisfaction among employees who didn’t receive this benefit.”

While AMN will sometimes offer a bonus for completion of an assignment, more so in markets that find it hard to attract even travel nurses, Henderson recommends hospitals focus on becoming the types of workplace where nurses will want to work by providing more flexible schedules and mobility between specialties — the type of changes in the works at Saint Thomas.

Building supply Of course, creative recruitment strategies like these do little to increase the pool of qualified nurses — one nurse recruited to Nashville is one less nurse somewhere else in the country. Instead of encouraging burned-out nurses to return to the workforce or waiting for nursing schools to graduate more nurses, Nashville-based Shearwater Health has another idea — recruiting nurses from other coun-

tries. Previously called HCCA Connections, the former HCA subsidiary got its start providing staffing services for international hospitals. Nurses based in the United States and the United Kingdom would go on assignment, mostly in the Middle East. The company pivoted in the early 2000s after recognizing the Philippines as an ideal source of nurses for the U.S. market.

“They speak English well and are trained to American nursing standards, and they produce more nurses than they can employ,” says Nathan King, senior vice president of global nursing recruitment for Shearwater Health.

Today, Shearwater recruits from about a dozen countries that fit the same criteria, including Ethiopia, India, Jamaica, Kenya and Nigeria. It can take between two and four years from the time nurses apply until they arrive here, depending on the country of origin and the time it takes the government to grant an EB3 visa. Within that window, the company helps nurses study for their licensure exams and provides them with cultural and clinical skills training. They also have to pass an English test.

The company places between 250 and 400 nurses a year in three-year agreements, after which the majority of them are either hired by the hospital or find nursing employment elsewhere in the United States. Compensation is regulated by the Department of Labor, which requires workers on an EB3 visa to receive a prevailing wage based on country data.

Shearwater has experienced rapid growth in recent years, but it’s not necessarily from relocating foreign-born nurses to the United States. Its team operates three care delivery centers in the Philippines, where more than 3,000 clinicians handle non-patient-facing administrative and clinical duties such as utilization management, population health management and health coaching for U.S. providers, insurers and pharmaceutical companies. Its newest facility opened this year and King says already there’s demand for additional growth.

“Let’s say you were able to wave the wand that caused the nursing shortage to be eliminated,” he says. “The changing landscape of health care is still very complicated, and there will always be a need to reduce the administrative burden on nurses that doesn’t impact the patient.”

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Hitting scale, anticipating what’s next Four Nashville-area execs share insights on managing a high-growth health tech company

ne of the strengths of Middle Tennessee’s $50 billion health care sector is its ability to incubate, finance and rapidly grow entrepreneurial firms that address emerging challenges and opportunities facing the industry’s biggest names. Our Vitals event in October brought together executives from four such companies — Zach Evans, CTO of Xsolis; Tod Fetherling, CEO of Per-

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ception Health; Britt Groomes, CFO of EvidenceCare; and Elliott Wood, president and CEO of Medalogix. With Post Editor Geert De Lombaerde, they discussed some of the tricks of the trade when it comes to running rapidly growing health technology businesses.

Here, lightly edited for brevity and clarity, are excerpts of their conversation.

DE LOMBAERDE: So many of the interesting stories that we write day to day are about companies getting venture funding, launching new products or hiring new key people. They open up questions about what those landmark events look like in practice. What does it look like when a company lands $5 million? When the plans that earned that money actually get implemented? So I’ve really been looking forward to hearing what that looks like, what the thinking is behind the decisions that create jobs and wealth.

So let’s start by having you tell us a little bit about your businesses. Britt, want to kick us off?

GROOMES: Welcome everybody. Evidence-

Care is a medical decision-support tool that helps to drive the decision-making to get the best diagnosis for the patient and then the best medical records for the documentation and then reimbursement. There’s a big war on the reimbursement side; if you get the diagnosis on the front end with documentation right, that really helps to drive the right reimbursement on the back end.

FETHERLING: At Perception Health, we are focused on building the largest health data repository in the U.S. — we’re at about 24 billion records today. We’re really trying to translate that into more efficient care management and care prediction tools for the health care industry.

EVANS: Xsolis is a predictive analytics and

artificial intelligence company working in the health care space. Our main focus is reducing the friction that exists between providers and payers and helping solve a couple of problems,

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one of which is the concept of patient status, which is a niche issue that drives a tremendous amount of medical claims, denials and a lot of friction in the marketplace.

WOOD: Medalogix is also a predictive modeling company, an AI company and focused primarily on clinical decision support. As a company, we’ve really evolved into, “How do we not only create data science that is meaningful that can drive different outcomes, but how are we holding hands with the providers — and in some cases, the payers — to help them understand what they should be doing with it to create better outcomes? To help them work better together.”

DE LOMBAERDE: And then you might have

‘You can trust the black box to help point you in the right direction. It’s the communication that we have to get right.’

ZACH EVANS, XSOLIS

FETHERLING: About 8 million a day.

these other sexy terms. But the communication is ultimately where the friction gets reduced between the provider and the patient. A provider today has to communicate that you’re at risk for a disease that you don’t even know about. That is really different than 5,000 years of health care, when we’ve been waiting for somebody to walk in the door and treat them.

DE LOMBAERDE: That boggles the mind.

EVANS: It’s also about the idea that just

DE LOMBAERDE: Our Vitals panel last year

focused on getting more from health care data and we learned a lot then about effectively using massive amounts of data. Tod, you mentioned having 24 billion records. How many new ones are you adding?

With so much data being generated, how do you make sense of where the value is and talk to clients about being able to help? What’s that process like in terms of finding a product niche that works?

FETHERLING: I think the simple answer is — and if any of my investors are in the room, I hope I get this right — it’s what the customer will pay for, right? So how do we ultimately determine what the value is? I think a lot of us experience this on a day-to-day basis as we’re bringing new innovation and new ideas into the practice of medicine. You will run into the old guard of health care and they have a very hard time thinking about disease prediction, where the patient is going to be in 24 hours or 48 hours. I think that is the ultimate communication challenge I see in the market right now.

DE LOMBAERDE: Not about the techno-

logy per se, but about the idea of using it in these ways?

FETHERLING: Right. The technology has been around for a pretty long time but now we’re calling it AI, machine learning and all

having the volume of data isn’t enough. It’s actually making it actual and actionable in that moment in time. EMRs by their nature are very transactional. They are not all that actionable. You oftentimes have to go search for things, go pull the information to know what comes next. So by interjecting and by disrupting that transaction — by saying, “No, go pay attention to this. And not only go pay attention to it, but here is exactly what you need to do with it” — that’s where you unlock the power of data.

Tod is exactly right. You can trust the black box to help point you in the right direction. It’s the communication that we have to get right.

WOOD: And not all data is valuable. More data is not better. The way we’ve talked about data is that it’s a lot like the oil rush. You’re going out to get data in the same way that you would go buy land. And then you’re going to get that land and you’re going to go set up an oil rig. And if there is oil on it, then there’s a ton of value there. But there are tons of land acquisitions that happen that don’t have any oil. So it can be garbage just as well as it can have a ton of value.

some of the folks Tod mentioned — the ones having a hard time adjusting to technology — saying, “See, I told you!”

FETHERLING: Yeah.

GROOMES: These three guys, the majority

of their business is more with the data on the back end and helping with reimbursements or driving accounts receivable or decision-making. We’re a little bit more on the front end with content that helps drive the clinical decisions. There are quite a few players that used to sell these encyclopedias to hospitals.

They are still out there. They have that content but they haven’t brought it to the point of care. And unless it’s at the point of care in the emergency rooms when a decision needs to be made, it’s not valuable. So we’re trying to bring it to that point of care where it can help drive decision-making.

DE LOMBAERDE: Elliott, I wanted to pick

up on Tod’s comment about value is what the customer will pay for. You’ve been able to take a different approach with Medalogix over the past couple of years by bringing on some of your biggest customers as investors. Walk us through that process a little bit. How does a conversation go from, “Hey, we have something that will bring value to what you do” to them saying, “You know, you’re right — and here’s a big check.”

WOOD: The way that that evolved really had everything to do with vision. The vision of the customer and what they felt like they could accomplish using Medalogix strategically. In the home health space, there are just incredible shifts that are happening in reimbursement. Most of our customers have built their businesses on fee-for-service. That is changing everywhere but it is changing very drastically in 2020 for home health. So our customers are now really trying to figure out how they can diversify their payer mix.

Part of what we’ve been able to do is help our customers develop an internal capability of doing population health management and taking risks. Part of what is going to help the customer survive through this transition is their ability to do more than just be a reliable visitor in the home. They have to do more in terms of adding

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BUILDING PROCESSES DE LOMBAERDE: Zach, Xsolis has had a little bit of a different management challenge of late. How many people have you hired so far this year? Are you at 100 yet?

EVANS: Yeah, really close to 100.

DE LOMBAERDE: And that was from a base of about 30 at the end of last year?

EVANS: That is about right.

DE LOMBAERDE: How do you hire 100 peo-

ple in Nashville in that short a time first of all?

And secondly, how do you go from 30 to 130 in the space of 10 months and not just come apart at the seams?

Elliott Wood

value to the plan. Medalogix represented a technical solution, a very tangible thing that would allow them to participate in different types of contracts very creatively and take risk.

So a huge part of the investment itself was alignment around vision. There was a lot of shared vision about what our customers were wanting to do with the plans and things that we would want to do strategically as a business.

DE LOMBAERDE: Have there been compro-

mises in terms of running the company a certain way and then saying, “You know how we were going to do that little thing? That’s just going to have to go on the backburner or just be moved out of the way altogether.”

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WOOD: Not yet. I’m sure that will come; may-

be we’re still in the honeymoon period. There have been other companies that we’ve talked to that have had similar cap table structures and so there are little things that we have to do that are very important in the board room.

One thing that has been very important for us is that the majority of ownership has remained with our primary financial sponsor.

So they can play Switzerland if there is an issue and I can kind of let them play Switzerland without getting too deep into it. So I think that has been more of the dynamic: How do you manage the board and have conversations about strategy as opposed to the day-to-day type of cooperation stuff.

EVANS: A lot of coffee and a lot of really passionate people! Recruiting talent, attracting talent is a challenge for every organization.

When you add on top of that an industry that is large in Nashville, it gives you a large pool to pull from but also you have a tremendous amount of competition. And then, when you deal with technical resources…

I always remind our VP of people management and our recruiting team, “You can’t just look at how we compare to the HCAs of the world or to the Healthways of the world.” Like, hello Amazon, nice to meet you! Right? Those are retail-based jobs but we’re competing for the same teams. So as a leadership team, we spent a lot of time in the last year really digging into our company culture and having to take a hard look in the mirror at times. Because sometimes when you start shining that flashlight, you don’t always like what you find, right?

We’ve focused on making that first-day experience, the first-week experience a really loud experience for the employees. That actually starts well before they even show up for the first day. One of the sponsors here today talked about how it’s the little things that make the difference and that has absolutely been our experience.

For instance, letting a candidate hang out in an unknown status for weeks at a time without communication is not the best way to recruit

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talent. And it’s amazing that sometimes managers don’t understand that. “Well, but I told him I’d get back to him in two weeks.” Yeah, but they are also talking to four other companies and that’s your top talent. You can’t wait that long.

So we spend a lot time focusing on those processes and company culture. How do we keep the feel of that small organization where you know everybody when you are hitting a scale where it’s hard to know everyone on a personal basis? It takes a lot of focus and a lot of energy.

WOOD: I was just going to add: Our rule for hiring is 48 hours. If you know that’s the candidate you want, we need to close that candidate in 48 hours or they are probably taking another job. Especially the technical specialists because there is so much competition that they are usually having a couple of different conversations. We’ve made that decision: “This is who we want and we are doing everything we can to close within 24, 48 hours.”

DE LOMBAERDE: Tod, you worked at HCA

in the past and, Zach, you have as well. How much can you take away from your experiences at the largest hospital company and apply it to your entrepreneurial ventures now? What’s different and what’s the same?

FETHERLING: In my case, it certainly has been helpful. I was given a whole new department to create in the ’90s in a whole new industry called the internet. And so I talk frequently to people about being an entrepreneur inside of a corporate behemoth. But the expectations were the same: We want high growth. The first time I brought a check to finance, it was a real problem because they were like, “No, we get paid for patient care, not for selling ads on the internet.” That was a pretty different concept.

So I think the two things that I learned at HCA that I still use every day are: Listen to your people in the company; they are usually the ones with the best ideas. They can see things that are happening with clients and within the industry that maybe you’ve got a little blind spot to. And then there’s the discipline that you learn at HCA and the corporate structure. Model-Netics was a great framework for employees and managers to communicate and I still have that book in my car. I still use it every day.

GROOMES: Maybe this is coming from a

‘You have to bring in a marketing sales guy who knows the industry or else you will spin your wheels.’

BRIT T GROOMES, EVIDENCECARE

EVANS: Tod is exactly right. You launch an organization and you’re chasing that first handful of contracts and those clients oftentimes are maybe smaller. And as you mature as an organization, oftentimes — or hopefully — those contracts start moving upstream in the marketplace, right? One of the things that I always talk about that HCA taught me was what it looks like to operate in scale. The concept of an organization operating with 250,000-plus employees in 170 locations on multiple continents…

All that is is really focusing on people. It’s hiring the right people; good people will get good people. It’s about focusing on process and how the process helps you operate at scale.

It gives you an understanding to anticipate what comes next. Even in our current phase of growth, it’s about having an eye on when we reach the top of the marketplace. Where will we need to be from a company perspective or a product perspective? How do we need to be structured to accommodate that? You know the demands that come with the top of the market.

All of those were lessons that I rely on every single day from my time at HCA.

slightly different perspective but it’s an original analogy that was given to me recently.

Who has seen the movie Big with Tom Hanks?

We talk about that a lot where we’re a handful of entrepreneurs and it was just like Tom Hanks’ experience where you’re this kid. You go to this fair, there is a weird game to play and the next day you wake up and you’re in an adult’s body. For us, it’s like, “We have a company. We have got to figure out how to run like a company because this is a business now. It’s not just an idea.”

We have had to really think through how to operate at scale. These are the things we need to think about because those entrepreneurs, they don’t think about that stuff until it’s too late and they’re in an adult’s body and they’re still kids. What they are talking about in terms of thinking about how you operate at scale, we’re right in the thick of that right now.

DE LOMBAERDE: You see a lot of your role

as being about what Tod and Zach described.

GROOMES: Definitely. I’ve had the opportunity to be part of a couple of Nashville highgrowth companies over the past five years and have had a couple of key takeaways for the back-end, more administrative side. One key challenge is on the revenue and capital side.

Early-stage companies spend a lot of capital getting that initial product or revenue line to market. The problem is, many times, you realize the big opportunity for the business is in a little bit of pivot. Health care sometimes can be a little bit of a Whack-A-Mole game of trying to shift and chase the opportunity.

So in an early-stage company, there’s always this idea of balancing revenue in your original product and spending a lot of capital to get to market and then also shifting at the same point to wherever the big gain could be. And so you have to make some tough decisions on that original product. You are either going to cut ties or minimize spending or you’re going to double down on it. Either way, you’re probably going to be raising more capital.

Marketing and sales is the other thing I have seen. You have to bring into an early-stage company a marketing sales guy who knows the industry, knows the network, has the contacts, has the team that can probably

NASHVILLEPOST.COM | WINTER 2019

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VITALS

bring into business. Or else you will spin your wheels and not get any traction.

And with that same thought, you need a financial co-pilot with that marketing leader.

Because even if they know exactly what they are doing in that industry, you’re just finding your traction. You’re going to be throwing a lot at the walls or seeing what works and you need that financial co-pilot to help assess what’s working, what’s not and taking the money away from what’s not working.

And my last thought is, the more you can get the administrative processes in place — I’m talking about HR, accounting, process flow, documentation — and running smoothly so they can be scaled without a lot of extra work is key. I came from a large organization before and what I never thought would work very well was outsourcing a lot of that. But it actually works very well. One, it’s very cost-efficient, and two, they have a lot of those protocols, systems, policies, procedures, employee handbooks — a lot of those basic building blocks — already done.

Then you can take those and adjust them as you need to for your business.

Those are three building-block pieces I’ve seen that have been key for when things heat up on for these hyper-growth young companies.

DE LOMBAERDE: You talk about bringing in help. As an entrepreneur, it’s your company, it’s your idea and you got it rolling. So you’re the best salesperson, right? But you may not be the best marketing exec. How do you figure out where to spend your time when your company grows to its next stage?

FETHERLING: Well, I did get my degree from the University of Tennessee in marketing so I take a little offense to that last part about marketing. But you are spot on.

It’s knowing what your skill sets are, what you can do, and surrounding yourself when you need to. The financial side is probably the most important. We also outsource HR and accounting and have had a lot of success with that over multiple ventures. So, I would recommend that in the early stages for sure.

You do get to a tipping point of 50 or 100 employees where you want to control that process from a culture standpoint.

And I think on the sales side, what I have learned over the years is really trying to find the

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WINTER 2019 | NASHVILLEPOST.COM

two months later to Fox, half the company. We had a plan they wanted and we executed the first month. It doesn’t happen like that often.

Today, I would say our company literally has the smartest people I have ever worked with — and no offense to a lot of former employees out here. The IQ on the team is challenging at times in that I have to listen harder than I have ever had to listen to understand what they are really trying to say — and then translate to a pretty old industry all of these new techniques that are available. So I do become the translator a lot of times between the customer and our team.

DE LOMBAERDE : And that’s basically good

marketing, right?

‘I have to listen harder than I have ever had to listen […] and then translate to a pretty old industry all of these new techniques.’

TOD FETHERLING, PERCEPTION HEALTH

leverage point. Yes, I can talk a lot about health care data and go as deep as any client ever wants to go. But having the ability to bring me in at the right time is the skill set of a really good sales manager. Someone who says, “I’ll take care of 80 percent of this work but I need you here for this 20 percent of the time to do that.”

DE LOMBAERDE: You mentioned your past experiences. Do you look back and say, “I’m doing this differently than before and it’s working better or it’s not working as well this time.” Can you lean on duplicating a certain order from the past or do you have to say, “You know what, the market is regenerating itself. I have to do the same thing.”?

FETHERLING: The first three start-ups, I had a

very specific timeline and growth mode. Maybe some of that was driven by Rick Scott, I don’t know. But with The Health Network at HCA, two months after being there, we did the first live birth on the internet and then we were sold

FETHERLING: Exactly.

OPPORTUNITIES AND CHALLENGES DE LOMBAERDE: Xsolis has added a new business line in the past year, marketing its services to insurance companies as well as providers. Will you walk us through the technological aspect of that and also the management side of straddling that fence?

EVANS: Yes. Britt was talking about those transition points [of young companies]. Xsolis started life as a retrospective audit support company supporting [Recovery Audit Contractor] audits.

When that market literally almost disappeared overnight, we had to pivot and became this very data-centric organization. And for the next four years, our focus was pretty exclusively on the provider side. We were selling to hospitals.

We had a really innovative partner in East Tennessee that came to us one day and said, “Hey, we’d like you to help us improve a relationship with one of our largest payers. We think your data is so powerful that you can help us improve this relationship and actually help us impact our patient experience by improving this relationship.” And we said okay.

As smart marketers do, we like to listen to our customers from time to time and say, “Sure, we can have that conversation.”

And so, from the technology perspective, it really became about tweaking our analytics,

VITALS

GROOMES: Yeah, there is a lot of red tape. I

think the one way you do win with it is having a big advocate for your product somewhere on the inside who has a lot of power and the right pull to keep pushing it through the process.

That appears to be the main way to win.

Zach Evans

tweaking to our models to see how we could leverage the same data to also meet the needs of payers and to carve out that kind of neutral ground. So, as Elliott mentioned about his board room, we get to play the role of Switzerland in that relationship.

We had a lot of our customers who said, “That will never work. You’ll never get the provider and the payer to agree on a common data set.” Almost a year ago this week, we unveiled a joint presentation where our senior client leader from Covenant Health and the senior leader from Humana sat at the same table and literally hugged it out. And then they proceeded to say, “Our relationship is so much better than it ever was because we have taken out the variability of this process by leveraging this technology, by leveraging the actionable data.”

We’re able to say that we let the data speak for itself and the provider and the payer accept without exception what the data is pointing to. That has been a powerful statement in the marketplace. It’s a model that — not to get all touchy-feely — but it actually makes you feel really good that it does not have to be an adversary relationship in the marketplace. Using data to make the best decision for the patient allows the reimbursements to flow correctly.

DE LOMBAERDE: Trusting in the data, that

was one of the first things you all talked about this morning; the idea of getting people to open their eyes a little bit to the possibilities in technology within or on top of traditional models.

That’s a good way to circle back to that.

I’m going to start wrapping up here with this question: What is the hardest thing for you in your day-to-day work? And is it different than it was three or four years ago?

GROOMES: A lot of my day-to-day, I’m doing

the back end of construction, of building out, so that’s the easier part. The harder part that I’m doing now is we’re opening the enterprise chapter of EvidenceCare by getting validated in Cerner’s and Epic’s app stores. We’re going directly and selling to the hospital networks.

Dealing with the red tape of the hospital networks is probably my new biggest challenge.

We have a lot of hospital networks who are very interested. We get the process started but then getting through the contracting and legal process is a challenge. It’s somewhat of a black hole.

DE LOMBAERDE: Because they all want to

do things just so and it’s not the same way across the board?

FETHERLING: On a personal level, it’s certainly time management. If anybody has a private jet that you’d like to let me borrow, I would really appreciate it over the next three weeks. I need to be in multiple cities on the same day so I don’t know how that is going to happen. But I guess we’ll figure that out.

From a company perspective, it’s really about training the industry on predictive analytics without being too Minority Report. I see scared looks on faces of doctors in the morning at 6 a.m. It’s that almost perplexed look of, “What is my role going to be in the future? Are you going to take the patient communication away from me?”

These are some scary times for the industry, and the ability to effectively communicate how this should work in an optimized way [is key]. I got into health care because I wanted to help save lives. I have seen through data information and technology where you can do that.

But it is also the hardest thing to figure out.

EVANS: Our leadership team’s theme for the fourth quarter is “purposeful growth.” On a personal level, that involves empowering teams and letting go. We talk about big-boy pants a lot in the company, about how the leadership team can’t always be the ones who go and take care of things.

The other big challenge we have is that we’re sitting here with the holidays right around the corner. We will have 29 hospitals go live between today and Dec. 31. And so we may have to borrow a private jet as well. With implementations, with go-lives and with client training, it’s a lot of coordination. It’s a lot of hard work at a time where you’re trying to wrap up the year. And you don’t want to say, “Oh by the way, you get to take a breath in January.” Because there are another 40-some implementations that are coming in the first quarter.

So our focus for the rest of this year is how we manage that, how we build the team the right way, how we give them the resources they need, whether that’s people or processes or technology.

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VITALS

‘It’s very challenging to have conversations with people who have been very loyal to your business and there may not be a seat for them anymore.’

ELLIOT T WOOD, MEDALOGIX

WOOD: I have a two-part answer. The first is going back to the analogy of Big. Much of the big problem itself is inherently the people and trying to figure out how to scale as a company. How do you make those adjustments and not kill your culture?

In some cases, you have people that have been with you from the beginning that may not need to be with you moving forward. Or they may need to take a different role. This is especially so in a start-up culture, where things are highly, highly emotional and that probably never goes away, right? But it’s very challenging to have those conversations with people who have been very loyal to your business and there may not be a seat for them anymore. So, that’s challenge one.

Challenge two for us is that we have very similar conversations to what Zach is talking about, where the data can be a major part of what brings plans and providers together in a good way. The home health industry was very slow to adopt predictive analytics.

What we are finding is we’re having more trouble getting plans to move. So the challenge for me is that we have these huge ideas and these huge opportunities but in health care, it just takes a long time. It takes time for adoption to demonstrate that this is working and there is a return. So we’re trying to balance the expectations of the private equity firm with the reality in health care and adopting technology.

DE LOMBAERDE: Alright, one last question to wrap up. Talk to us about hiring for growth. Can you share your best secret for finding good people — or at least give us your second-best secret and keep the best one for yourself?

FETHERLING: I can. I’ve invested the last 19 years

in being a part of this Nashville community. The best thing you can do is show up. Get involved in your community. Our last five hires have all been people

that have proactively come to us because of what we’ve done the last 19 years. That’s the No. 1 recruiting tip. Go to Nashville Post events, the NTC, Tennessee HIMSS and the Health Care Council. That’s where you’re going to find your next opportunity.

GROOMES: I think it was mentioned earlier: Strong

leaders attract other strong players. As you’re hiring the managers and the functional leaders, as you continue to grow, many times they can bring a network of people with them. That can be pretty crucial.

EVANS: Certainly for technical roles. We hire a lot on potential. You may not even know what case management is. That’s OK. If you have the technical skills, I can teach you the business side of it. Sometimes, those are the best candidates because they are hungry to learn.

WOOD: It’s a lot harder to teach someone how to do the job — especially when you’re at a very fast-paced, fast-growing company and a lot of your leaders are still working. They are still carrying a bag themselves and so a lot of the mentorship is a challenge.

A second idea is that A players attract A players.

When we’re out in the market talking to high-caliber talent and they come and interview, they are constantly telling us part of the reason why they chose to join Medalogix was because of the people and the culture. And that’s just something that high-caliber talent looks for: Are they going to be working with people who can run as fast as they can?

DE LOMBAERDE: Excellent points and that’s a

good place to end things. Terrific insights and terrific advice — and a clear need for private jets. Britt, Tod, Zach and Elliott, thank you very much. We really appreciate it.

STOCKS

Letting it ride aking a true buy-and-hold approach to Middle Tennessee stocks at the end of 2009 would’ve paid off pretty decently. This table shows that, using adjusted closing prices, nine of the area companies that are still around and publicly traded have outperformed the Vanguard 500 Index Fund Investor Shares in the 2010s — a handful of them by more than double. Then again, a number of well-known local names have either trailed the market or are on track to end the 10-year period deeply in the red. > GEERT DE LOMBAERDE

T

COMPANY

MARKET CAP ($M)

CLOSING PRICES 11/1/19 12/31/09

CHANGE

Tractor Supply

11,423

95.78

11.94

Delek US Holdings

3,029

40.21

5.20

673%

Dollar General

41,105

159.90

21.20

654%

Ryman Hospitality Properties

4,420

85.92

11.59

641%

905

27.96

3.79

638%

HealthStream

702%

Cracker Barrel Old Country Store

3,752

155.93

25.88

503%

Pinnacle Financial Partners

4,603

60.01

13.36

349%

Louisiana-Pacific

3,560

29.87

6.73

344%

National Health Investors

3,701

85.36

22.02

288%

Vanguard 500 Index Fund

493,910

283.37

85.21

233%

National HealthCare Corp.

1,265

82.56

27.11

205%

First Advantage Bancorp

110

28.50

10.58

169%

4,493

34.76

13.52

157%

Genesco

583

38.84

27.46

41%

CoreCivic

1,871

15.71

12.05

30%

Tivity Health

806

16.85

18.34

-8%

18

2.71

5.84

-54%

Healthare Realty Trust

Diversicare Healthcare Services Brookdale Senior Living

1,395

7.52

18.19

-59%

Cumberland Pharmaceuticals

85

5.56

13.59

-59%

Community Health Systems

377

3.20

29.18

-89%

Kirkland's

21

1.54

16.40

-91%

Source: Yahoo! Finance

LEADERS

THREE QUESTIONS

Zulfat Suara New Metro Councilmember is focused on education, wages and the city budget

Zulfat Suara became the first Muslim elected to public office in Nashville (and by some accounts, in the whole state) when she won one of five countywide seats on the Metro Council in September. Suara — a Nigerian immigrant, accountant and Metro schools parent — spoke to the Post about settling into her new role, her goals for her four-year term and more.

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WINTER 2019 | NASHVILLEPOST.COM

DANIEL MEIGS

LEADERS

What motivated you want to run for office?

One is that I want to give back to Nashville. I had a point in my life where my husband and I were without a job for six months and it was people in town who rallied around and helped me. I always say that was a turning point in our life. We could have been on the streets, but people helped us. I wouldn’t be here if that didn’t happen, so that was a big part of it.

The second thing is the budget, because I’m a CPA, and we’ve been talking about the budget for the last couple of years. I figured if I’m going to give back, this is an area that I know about. This is my area of expertise, so I can give back that way.

And then the schools is a big one. My daughter goes to a school that doesn’t have enough textbooks, that doesn’t have enough computers. If as a city we want to grow, we want to develop, education is very important, so we need to do something.

What do you hope to have accomplished by the end of your four-year term?

How do we make sure that we’re equitably funding our schools, regardless of the ZIP

code? When I say that, I always clarify that I’m not just talking about education. I’m talking about social-emotional learning.

Each school is different. I know we don’t budget each school, but we determine the lump sum that goes to the school board. If the school board does not have it, they cannot spend it, so it’s important for us to have an understanding of what the needs are. That would be big for me: If we can make sure that our kids’ education is taken care of — that we’ve moved the needle — and that every kid has access to what they need.

Another is community-based budgeting. I really do believe that our budgeting process has to get more people involved, more communication with the people so people know what’s going on. I hope that we can do a better job of that. Not just a quick three-month process. I think it should be more than that and I think we should get more input from the community. If we can get to that, that would be great.

I campaigned on a livable wage. With all the growth that is happening in Nashville, there are a lot of people that are not feeling that

growth. We want to make sure that we’re taking care of our own people, the people that are building the city.

If we can move the needle, so people feel like, “Oh yeah, this is our city. We’re all vested, we all belong, we’re all thriving,” I think we will have done a good job.

What lessons have you learned in your first weeks in office? What have been the most challenging parts?

Before we have the meeting, we have all the information, and you want to go through it, you want to look at it, you want to make sure that you’re at least familiar with everything that has been put in front of you. The incumbents have taken us under their wings. The vice mayor did orientation for the new members.

All of them are trying to make sure that we get the feel of things, so that’s been very good.

There’s also a good rapport between almost all of us. It was a long campaign, you see a lot of people along the way, so that’s been very good.

Staying on top of it, it’s a big challenge, but I think it’s just a question of figuring out how to do it.

Caring for your business across the continuum High quality healthcare takes a team approach, both clinically and operationally. As a management services organization (MSO), LBMC offers solutions in human resources, finance and accounting, physician office solutions, and technology to keep clients compliant, efficient, effective, and profitable.

615.377.4600 | www.lbmc.com/healthcare

Embracing the MLS challenge Former Liverpool CEO Ian Ayre pulls back the curtain on ‘the size and weight’ of what’s ahead

BY MICHAEL GALLAGHER

ashville Soccer Club CEO Ian Ayre’s resume is second to none. One of the most distinguished business names in the global soccer community, Ayre came to Nashville in 2018 after several years in the

N

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WINTER 2019 | NASHVILLEPOST.COM

Premier League at the helm of Liverpool FC, where he was named CEO of the Year in 2017.

Less than two years later, the 55-year-old Ayre leads Nashville SC’s off-the-field team as it prepares to transition from a record-breaking club in the United Soccer League — it sold more inaugural-year season tickets than any other franchise in the league’s history — to a 2020 expansion franchise in Major League Soccer. With recent MLS entrants such as Atlanta United and LAFC making their mark quickly — the former averaged more than 52,000 per home game this year, the latter set an MLS points record in its second season — the bar has been set high.

But over the course of his career, Ayre has shown he’s not one to shy away from making bold decisions. During his tenure with Liverpool, he spearheaded a financial revitalization that included landmark sponsorship deals with Warrior Sports, global bank Standard

Chartered and others and oversaw a $160 million stadium expansion. The moves have helped Liverpool’s value grow to nearly $2.2 billion, per Forbes — up from $1.5 billion in 2017 and “just” $982 million in 2015.

Ayre has the expertise to not only cater to different audiences — fans who are already following soccer as well as those newer to the game — and build a strong soccer brand, but to then also turn that into revenue streams. The latter is a big part of his work in Nashville.

“At the base level, all soccer clubs are very similar in what matters in terms of where you make revenue and expand costs,” Ayre says.

“So it’s about building it smartly and efficiently but also making it uniquely Nashville.”

While much of Ayre’s job focuses on marketing and brand awareness — following the news in September of Renasant Bank coming aboard as the club’s first MLS jersey sponsor, he teased many more such announcements —

ERIC ENGLAND

LEADERS

MAJOR-LEAGUE REFERENCE POINTS The average MLS team ended its 2018 season worth $240 million, which was an increase of nearly 7 percent from the mark of the year before. (By comparison, the average NHL franchise value last year was $630 million.) Several of the league’s younger franchises are among the most valuable.

‘There’s no point in building that thing if you don’t think you’ll fill it eventually.’

IAN AYRE, NASHVILLE SC

his responsibilities run much deeper and these days include overseeing the construction of what will be the largest soccer-only stadium in the country. Early this year, he overhauled the club’s first stadium plan for its Fairgrounds site and delayed its move to the new 30,000-seat facility to 2022.

“In its sense and size, [it] makes a huge statement about the ambition for soccer in Nashville,” Ayre says. “There’s no point in building that thing if you don’t think you’ll fill it eventually.”

And once the club settles in at the Fairgrounds — it will spend the next two seasons at Nissan Stadium — Ayre’s work will take on a new set of dimensions.

“A lot of people don’t really grasp the size and the weight of a soccer team,” he says.

“We’ll attempt to feed 30,000 people at every game. That’s a pretty significant restaurant business. We’ll sell merchandise to thousands and thousands of people, so we’re a retail business. We’ll run our own creative content, running websites, social channels, producing a broadcast output for our games. That’s a big media business.”

Tasked with building and growing the Nashville SC brand, Ayre isn’t flying solo. Since be-

ing hired, the NSC front office staff has grown to around 75 members, and he expects that number to grow closer to 100 by the time the club enters MLS early next year.

“I don’t think I spend more time on one area than any other,” Ayre says. “Your job as the CEO is to hire great people and hire the best people you can in any of those categories. Your job is to oversee that to make sure it gets done.

It’s a massive operation.”

Having been on the job for a little over a year and a half, Ayre has done his due diligence on the passion and desire of Nashville for MLS. And if he has learned anything from his short time in Music City — especially with the Nashville Predators right down the street — it’s that growing a sport in an area where it could be considered non-traditional may be challenging, but if approached correctly, far from impossible.

“What makes Nashville a great market for soccer and for sports is people really care and they’re really passionate about their city,” he says. “Getting people to realize this is our city, our MLS team and come out to support Nashville… It’s about supporting your city in this major-league sport.”

Atlanta United

$330M

LA Galaxy

$320M

Seattle Sounders

$310M

LAFC

$305M

Toronto FC

$290M

Portland Timbers

$280M

NYC FC

$278M

Orlando City

$275M

Sporting Kansas City

$270M

D.C. United

$265M

Source: Forbes

Playing primarily at First Horizon Park, Nashville SC drew an average crowd of 7,000 people for the 2019 season, which ranked sixth in the USL Championship. MLS’ average regular-season attendance this year was more than 21,000, and only Chicago drew fewer than 14,000 people on average. Here are the big league’s top 10.

Atlanta United

52,510

Seattle Sounders

40,247

FC Cincinnati

27,336

Portland Timbers

25,218

Toronto FC

25,048

LA Galaxy

23,205

Orlando City

22,761

LAFC

22,251

NYC FC

21,207

Minnesota United

19,723

Source: Soccer Stadium Digest

NASHVILLEPOST.COM | WINTER 2019

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LEADERS

LEADERS

Building for Day 10,000 Studio Bank CEO Aaron Dorn on how his job is changing after Year 1 bout a year after opening its doors in The Gulch in late summer 2018, Studio Bank had amassed roughly $130 million in loans and more than $150 million in deposits — ahead of the projections Chairman, President and CEO Aaron Dorn and his team had mapped out. Post Editor Geert De Lombaerde talked with Dorn shortly after Studio’s first anniversary about what lays ahead and how his management priorities are shifting.

A

When you took stock this summer after a year in business, what was your overriding thought? The bank is positioned very well to benefit from the expansion of this region. A big lesson I took away is that the core initial team did a great job in getting the culture and trajectory right coming in. We set high expectations and, if anything, we’ve overachieved. We spent a lot of time in the founding stages absolutely ensuring that we were able to execute on the plan we devised.

It was a plan that helped us raise nearly $50 million and earned us regulatory approval.

First and foremost, we’ve created a wonderful company that happens to be a bank. When you’re starting something like this, everything is stressful but the team gelled in a way that’s hard to describe. In the military, we call it esprit de corps. One indicator of that is that, in our first year, we earned a best-place-to-work award. Secondly, we grew faster than we had anticipated. We grew loans 18 percent faster than we had expected and deposits 20 percent faster. A third thing is that our ability to serve

DANIEL MEIGS

clients in an extraordinary way is even better than we expected; our technology stack is a significant advantage versus our competitors and the flexibility and nimbleness of our processes is even better than I had anticipated.

Now it’s about pivoting to the next five years for me as CEO. A leader has to grow with his or her organization and that’s true of the broader leadership team as well. We’ve been planning for this and asking for feedback on how to best do that. Even though we’re a new company, we have planned for the best practices even a $1 billion bank would have in place, to operate the company in a very sophisticated manner. Many of us came from a $1 billion bank, and we set the company up to run like that from the very beginning. That has laid the groundwork for how we’ll grow as a team in the next five years.

You mentioned getting feedback.

Who are you turning to and what are you looking for? We are constantly meeting with other banks and advisors and looking for best practices of banks that are three times our size. Part of our process in launching was studying other banks that had started in this market and grown to $1 billion or more in assets. Some of those advisors included audit partners, investment bankers and some of our regulators, who have experience with literally thousands of banks.

As it relates to our team, that future growth really comes down to organizational development and being intentional about how we develop leaders across the organization so that they can lead the company when we do arrive at that point years from now when we are three times or five times larger — or more. It’s probably a weekly or monthly conversation.

There is a daily cognizance of the fact that we may be this size now but we will be much bigger in the future. We know we will need to be ready for the larger organization when the time comes. It means going to conferences and interacting with experts in a number of subjects — particularly when the topic is one bigger banks have to consider. It’s a collective awareness of what the future looks like and a consideration in almost every decision we make.

For you personally, how have your priorities evolved? For me, it’s about being in the trenches but also being the one sticking my head above the trenches. Launching and open-

ing a bank sometimes is about taking things hour by hour. There are just so many things to take care of. We’ve done that but we’re still an early-stage company. There’s still an element of me being in the trenches with everyone.

At the same time, the focus now is on getting us successfully to the next stage, which is truly being a growth company. That certainly involves me lifting my head above the trenches quite a bit. Rather than me specifically helping execute on certain projects, my focus is on making sure my team is working on the right projects to get us where we want to go. It’s certainly focused on strategic planning. That includes continuing to deliver on an exceptional, compelling value proposition while also delivering growth.

So instead of nine people working in the trenches on massive projects, it’s about making 51 people row in the right direction and building on key growth initiatives while building a culture where everyone is thriving. And at the end of the day, that means making sure we are having a positive impact on Nashville.

We’re here to empower people who are creating things — whether that’s a better life for their family by buying a house or building a business or a new office project or someone who’s creating music or creating life through the health care industry.

It sounds like your priority is to have your team take that big-picture, strategic journey with you. Yes, and I’ve been able to use my skills learned at Avenue and in the military to help do that. So in a sense, it’s back to normal for me. It’s less about the regulatory applications to become a business and more about the strategy of building a company. Even in the midst of the trenches of going through a capital raise and an extensive, multithousand-page regulatory application and all the recruiting — all the things to simply open on Day 1 — we still devoted significant time as a leadership team to vision and culture and strategy. We wanted to ensure the decisions we were making would also serve us on Day 1,000 and then again on Day 10,000.

We are now building it in a much more concrete way and reaffirming it in very concerted, material ways. We have a very cohesive leadership team and that’s essential to having not only a plan but also delivering on it. The team has a great sense of the intangibles, the things that are the glue of the company now.

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THREE QUESTIONS

John Mark McDougal LBMC’s audit and advisory leader lays out the case for the firm’s recent analytics acquisition BRENTWOOD ACCOUNTING and business advisory firm LBMC this summer said it had acquired Think Data Insights, a local data analytics company specializing in business intelligence for companies in health care, manufacturing and a few other sectors. John Mark McDougal, an LBMC shareholder and leader of the firm’s accounting and assurance practice, spoke to the Post’s Geert De Lombaerde following the deal’s announcement to talk about using AI in management decisions. Here are excerpts of their conversation.

Walk me through the business case for analytics in accounting and auditing.

When bots and AI and machine learning first got started, the reaction from a lot of people was that accountants weren’t going to have jobs in five years. But people have realized that AI does a lot of what was going on before in bringing together various types of information; we just didn’t know what to call it. It’s like in manufacturing: People conjure up an image of automation eliminating jobs but there are still a massive number of jobs. Human hands just aren’t touching as many parts.

Here’s how we’re talking now about AI: It’s about how we use data to see predictive patterns, to see that things are OK and that there are no anomalies. A lot of people think they can build the perfect app to do that on its own but I haven’t seen it yet. You can’t press a button and eliminate 300 hours of work, have the bank accept your report and be done with it.

We’re generally not creating new data. A lot of what we do and TDI does is search, filter, organize and ultimately report information in a format to someone who can use it. For instance, “Here’s info about your customers.

And here’s another 10 layers of data on some specific customers.”

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Is there a risk of flooding your clients with data that may not be useful? Do you have to educate them on how to filter it?

Maybe, but a lot of people just don’t know where to start. They don’t know what they don’t know. Our goal is to ensure we bring value to our clients and not just “flood” them with useless data. They are getting overwhelmed with volumes of data that lack key takeaways and insights into how they can better serve their customers, drive efficiencies and revenue.

The new data experts are helping educate them on how to filter data, what to look for and how to use it. We listen, we ask questions and then we build models to bring together things that aren’t naturally together.

But you have to know the business to do that. You have to build the right questions. And analytics assumes volumes of information that give you predictive capacity to then answer those questions.

How do you pitch and sell services such as this to clients? Not as a stand-alone product, I would assume.

Right. It’s naturally part of the business, part of everything else we bring to the table. We use CRM systems as an example. Those don’t just give information about the customer; they put the right info into the right people’s hands to generate sales. People don’t say, “I can’t believe I spent that much money on this project.”

Instead, when it works, they say, “How did I ever make it without this information?”

There’s a consulting piece to the data but, yes, it’s a little nebulous. I was at an AICPA conference earlier this year and there was a panel on AI. It was 30 minutes and intense but I’m not sure I knew more afterward. There’s a little bit of, “You know it when you see it” to this. When you start asking questions and forcing people to ask questions they hadn’t thought about, that’s when you’re able to move the needle.

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TECHIE

‘Comfortable in not knowing’ Health care tech companies can improvise to spark innovation

BY KARA HARTNETT

mployee personalities and individual traits are slow to creep outside the four walls of their homes and into the workplace, oftentimes throwing a wrench in effective communication and collaboration between employees.

In these conditions, innovation simply cannot thrive.

For some, being thrust into unexpected social situations in a professional setting can occasionally yield the feeling that their brains are disconnected from their mouths — and their ability to articulate is often thwarted by an inability to think of any words.

But, as we all know, there is always more to say. Always more to collaborate on, listen to, innovate with and, overall, work in rapport while solving problems.

That’s why improv has proven to be such a great professional development tool. And it’s taking off in the technology world, where a generally creative and perhaps introverted industry is

E

catalyzing innovation and collaboration through improv training — and seeing results.

Silicon Valley tech executive Busy Burr describes improv as the ability to let go and discover. In a 2018 piece for Business Insider, Burr wrote, “The key is to become comfortable in not knowing. Being on stage with no script, no props, and a promise to create something is a scary ride, but it’s one that I love.”

That positioning — making something out of nothing in real time — is a reality Nashville’s tech scene is all too familiar with.

Along with the rise of health-tech startups and unprecedented capital funding volumes, the industry faces a labor deficit, the pressure to create is as high as ever.

Nashville-based Stratasan knows that pressure well. And last year, as officials with the health care technology company began testing a market for further product development, that pressure turned to the promise of improv to spark innovation.

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“We had just launched our efforts with a dedication toward innovation, and not just product development but kind of pushing the envelope on more exploratory projects rather than things that we knew we needed to develop that our clients were asking for. But really more an exploration,” Stratasan CEO Jason Moore says.

Stratasan had just landed a partnership with the Texas Hospital Association to give that group’s member hospitals access to the company’s visual intelligence platform Launch Pathway through the association’s data program. That partnership inspired the idea for Stratasan’s newest platform — Star, a statewide claims data aggregation tool that launched last month. The company also last July closed a $26 million funding round, some of which it used to launch Star, and much of which it will use to bolster its sales and marketing departments.

It’s safe to say Stratasan had a busy year.

And at the beginning of that, Moore was prepping his team to be successful through the growing pains. What his co-workers got out of the training, he says, was learning to build upon each other’s creativity and ideas, rather than dismiss them.

“It was a team building exercise to some degree, but if you could point to one particular thing as we worked through product development and product life cycle from the newer innovation pieces that are more exploratory and less defined, we were looking to improve our collective responses to new ideas rather than looking at the reasons why something may not work,” Moore says.

For their training, Stratasan tapped Dave Delaney, a Nashville-based self-proclaimed communication connoisseur. He teaches communication mastery workshops to fast-growing companies designed after his experience performing improv. Familiar with the local tech scene, Delaney combines his knowledge of the industry and love for communication and relationship-building to distinctively develop his workshops around what sort of problems companies are looking to solve. For Nashville’s tech sector, Delaney says, company culture is a key factor when it comes to growing pains.

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COURTESY OF DAVE DELANEY

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‘The key is to become comfortable in not knowing.

Being on stage with no script, no props, and a promise to create something is a scary ride, but it’s one that I love.’

BUSY BURR

“One thing I have experienced firsthand in working with fast-growing tech companies is their culture starts to take a bit of a hit as they grow, in part because they are growing so rapidly that the employees or team members don’t know each other anymore,” Delaney says. “Part of my goal with this workshop is to bring team members together so that they can learn about each other’s talents and get to know each other better.”

Delaney has presented workshops and keynotes across the country, including at industry giants like Google, LinkedIn, HealthStream and HCA. He has authored books on friendly networking, runs a website called “Networking for Nice People” and has jump-started several key networking initiatives in the local tech space. The man loves communicating.

And through improv’s “Yes, and” approach, he’s sharing the collaborative spirit with any-

one who dares step outside her or his comfort zone and into the world of the unknown.

“The main goal of this workshop is to bring team members together to teach them how to listen more effectively, to actively listen, to lead with acceptance and to be more accepting to one another,” Delaney says.

“This also leads to being more empathetic as well. Finally, really letting your hair down and having fun.”

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TECHIE

Data-driven In an ocean of growth, a promising local tech company’s lighthouse remains unchanged

BY FELICIA BONANNO

he leaders of XOi Technologies, which develops communications services for workers in field service sectors such as HVAC and plumbing, have focused on two major aspects since securing $11M in Series C financing this summer: growing their team and improving their product.

Since August, when the Nashville-based company announced it had landed the capital from an investor group that includes the Nashville Capital Network, XOi has added more than 15 employees and plans to keep growing.

More work and additional team members are to be expected with any infusion of growth capital, but the difference this round is that the company is bringing on more leaders, says CEO Aaron Salow.

“It has been an interesting transition as a founder to go to from managing a small team you see every day to managing managers.

It’s something you have to do if you want to grow,” Salow says. “This growth has been an opportunity for me and my team to continue cultivating the strong culture we have built at this point, which is about serving the technician in the field. And for me, it has been about stepping back from the day-to-day to allow the leadership team to grow their own team.”

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The new leaders have been hired in sales and marketing, customer success and engineering.

One of them is Paige Collins, vice president of customer success, who was brought on in July.

“My team had two [customer service managers] when I started, and we are now at six, with the plan to add another support person and to continue growing into the new year,” she says.

With more employees comes the new challenge of ensuring everyone is swimming in the same direction, especially as the company plans to scale even larger in 2020, says

Collins. Salow agrees: “Our long-term vision, our lighthouse, has always been about solving problems for our technicians and our companies. That’s really key. […] It’s part of my responsibility to ensure that our ultimate goal never changes.”

Prioritizing investments in relationships and partnerships in a more strategic manner is one way the XOi is working on that, he says.

XOi signed two Fortune 500 companies this year and now has a footprint in Europe, Australia and Canada.

DANIEL MEIGS

TECHIE

Nashville Capital Network’s co-investment in XOi earlier this year is one of seven the local investment group has made from its NCN Partners Fund. Here is a snapshot of the other six.

• Ambition Solutions of Chattanooga, a cloud-based software platform to help improve sales productivity. Former Emma CEO Clint Smith and Shannon Terry of 247Sports and Rivals.com invested alongside NCN. • Bellhops, also of Chattanooga, a tech-enabled moving company that promises “unprecedented quality, growth and margin.” The $31 million round in which NCN took part was the largest ever for a Chattanooga startup.

• CareHarmony, a four-yearold Brentwood company that markets population health and care coordination software to accountable care organizations, health systems and hospitals. A number of local health care executives invested alongside NCN. • JumpCrew, the booming tech-enabled sales, marketing and publishing venture that helps businesses cut through digital clutter. NCN joined existing investor Hinsdale Capital in the company’s Series B ahead of its HQ move to MetroCenter.

• Trilliant Health, the locally based holding company for health care tech and analytics ventures that help hospitals grow revenues and profits. NCN last year joined with Martin Ventures and others to give the company a boost.

• Upfront Healthcare of Chicago, a patient experience play marketing a tech platform that helps large physician practices attract and keep customers. NCN led the venture’s 2017 Series A and late last year returned alongside Martin Ventures and two other firms.

“We are definitely excited about that and are certainly allowing those strategic relationships to help guide our expansion,” says Salow, although he points out that the company’s primary focus will continue to be in North America.

Collins emphasizes that her team is using data-driven metrics ever more — even as it adds more people.

“We are really using that capital to build these customer-facing teams so that we can proactively support and manage our clients,” she says. “Rather than having a feeling that a client isn’t adopting as well, we instead get in front of that before they call us. We say, ‘Let’s look at the data and see if they are actually adopting the product, and if not, let’s create a plan before they even reach out or have to say anything to us so that we can get our client into a better place.’”

techs might have had to diagnose problems via hopeful Google searches, a phone call to a buddy, boss or supervisor or to a distributor where they would have to potentially wait on hold. Now, the process can be accomplished in just a few minutes, with all the information stored in one location.

“There is a lot of data that needs to be at their fingertips, and we are excited about the path our team is taking to get there. We are working on a first big step toward a single source of truth, and we are always building on it,” says Salow.

The newly developed platform also lets XOi play a more meaningful role in the workforce development efforts of clients, many of whom struggle to find qualified field workers. Recommendations, diagnostic help and trend analysis that previously took years

‘We are working on a first big step toward a single source of truth.’

AARON SALOW, XOI

Recently, that better place has included the unveiling of a revamped 2.0 version of the XOi Vision platform. As of October, 70 percent of the company’s clients had moved to the updated version, with the rest in line to be ushered along by year’s end. It’s a big change from years prior, when the company was focused on building Vision and proving the value and effectiveness of artificial intelligence in the field service industry.

“Now, we are scaling that capability and attacking increasingly larger and more significant problems,” says CTO Adam Jaggers.

XOi’s data scientists have developed new technology that will allow technicians to take a photo of a data plate on a piece of equipment and have XOi Vision automatically pull up manuals, wiring diagrams or training videos relevant to that equipment. In the past,

of experience to gain is now at a technician’s fingertips, making junior techs more hirable.

That’s a potentially massive value-add in the field service sector: A 2018 study by Blumberg Advisory Group and Field Service Insights showed that the sector — which employs about 12.6 million people now — will need another 2 million workers by 2021 to meet the retirements of senior workers as well as growth expectations.

“We are creating this great software solution, but really we are also helping blue-collar businesses scale and providing an educational and workforce opportunity that would otherwise not be available to them,” says Jaggers. “If you think about the industry today, if you need a mid-level tech, you simply can’t hire a junior tech. But we are enabling the junior techs to be more effective and more employable.”

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Nathan Lyons Developer focused on adaptive reuse projects talks neighborhoods, partnerships

NATHAN LYONS is president of Vintage South, which he founded in 2011. A University of Mississippi graduate, he started the company with a focuses on single-family residential development and older home restoration. However, and within the past five years or so, Lyons has turned his focus toward the adaptive reuse of existing industrial buildings — including Stocking 51 in The Nations — giving them new life with retail, restaurant and creative office spaces. Lyons spoke recently with Post Managing Editor William Williams.

What has been the single-great challenge related to Stocking 51? Relatedly, what has been the main positive surprise to come from that effort?

Also, how is phase two progressing?

There were many challenges along the way. The greatest challenge, was initially, when I decided to buy the old stocking mill. I learned very quickly the commercial development world is much different than residential development. I’m a big believer in working with like-minded partners. Our team members — Gina Emmanuel with Centric Architecture, civil engineer Jay Fulmer with Fulmer Engineering, and broker Trent Yates with Sagemont Real Estate — were instrumental in seeing this project get off the ground. It’s been a great learning experience for us. These experiences will only make our future developments better.

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DANIEL MEIGS

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The phase two of Stocking 51 has progressed nicely. We are tracking on schedule, which is challenging in today’s climate.

Our general contractor, Chris Parker with City Construction, has done an excellent job. We’ve had great activity and are approaching 50 percent pre-leased.

Trent has handled all leasing for Stocking 51. He’s done a phenomenal job with our tenant mix and will handle the leasing at Highland Yards and our East Nashville church site.

How will Highland Yards — the former Vaughn Manufacturing stie — and the Hobson United Methodist Church project be similar and different compared to your Stocking 51 effort?

The Vaughn Manufacturing facility in East Nashville, which we’ve named Highland Yards, will be very similar to Stocking 51.

Vaughn Manufacturing is a great American story dating back to the late 1920s. While so many factories have closed over the years, Vaughn still operates today and relocated to another facility. We feel very fortunate to reinvent the factory as creative space.

With Highland Yards, our goal is for it to become an important, vibrant part of the neighborhood.

We feel we’ve done this with Stocking 51 in The Nations. Highland Yards is conveniently located on Douglas Avenue, which is a connector to Gallatin Avenue and Dickerson Pike, and right off Ellington Parkway. We will offer space for office, retail, wellness, and food and beverage tenants.

While plans have yet to be finalized for the East Nashville church site, once again, our goal is to provide the neighbor-

hood new life to a 168-year old place of congregation. We work to make our projects walkable, and our hope is these projects fit seamlessly within their respective neighborhoods.

Why adaptive reuse projects?

And are there other parts of the city you are eyeing for similar efforts?

Whether it’s a historic home or building, I’ve always been drawn to revitalization. It’s a passion of mine. I feel very fortunate I’m able to chase my dreams and follow my passions. I’ve always been a ‘why not me?’ kind of guy, and my hope is that the passion can be seen through our work. Adaptive reuse projects provide natural character and charm that’s hard to replicate with new construction. Our Stocking 51 phase two project is actually all new construction, but built around old silos that provide a landmark for the development. Many would have simply removed the silos and added more usable space, but I saw it as an opportunity to create something distinctive and different. Where else in Nashville will there be new mixed-use buildings interacting with old silos?

As to the second part of the question, we are actively pursuing opportunities throughout Nashville and beyond. Adaptive reuse opportunities in Nashville are challenging to find, so we will look anywhere. We are also expanding our work to other markets, and will soon announce our first out-of-state project. But, getting in a neighborhood “early” is key. So we prefer to keep the identities of the neighborhoods and cities in our searches close to the vest.

Matt Lackey Project Manager, P.E., LEED AP “Our maturing population will only increase pressure on today’s healthcare systems.

Understanding how to deliver care efficiently, effectively, and intentionally is essential to Medical Campus design. It is imperative as designers to work in an integrated, collaborative manner with providers and contractors to maximize value and optimize the end user experience.”

Most importantly, it’s about the patient.

ragansmith.com | 615.244.8591

BOOM

Street cred Eighth Avenue has changed significantly the past five years, now faces interesting future

BY WILLIAM WILLIAMS

ashville’s post-Great Recession boom has rendered many streets and urban districts vastly different in form and function than their previous iterations.

Places like Germantown, The Nations and 12South and thoroughfares such as Main Street on the city’s east side and Charlotte Avenue on the west offer a more lively and urban vibe than was the case in 2010.

But perhaps no street segment in the city combines robust recent change with continued concerns and limitations than the approximately 2.3-mile stretch of Eighth Avenue South spanning Nashville’s inner-interstate loop on the north to I-440 on the south.

Countering the eight large-scale buildings opened and located on (or near) Eighth since late 2014 are about 50 surface parking lots with 10 spaces or more. And the excitement of all the interesting and distinctive businesses that have opened during the past five years is tempered somewhat by large swaths of the street remaining either unsafe or uninteresting for pedestrians.

So even though this segment of Eighth offers multiple ingredients needed for a quality linear mixed-use corridor — including a park (Reservoir Park), a major cross street (Wedgewood Avenue), two wonderful historic residential districts (Woodland-in-Waverly and Waverly-Belmont), easy access to an interstate (Interstate 65) and a charming, old-school commercial district (Douglas Corner) — the street has yet to fulfill its robust potential.

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Joe Baker, the veteran manager of the City of Berry Hill (a part of which includes Eighth), knows Eighth intimately.

“We had no idea the corridor would change as quickly as it has,” Baker says of the past five years. “It has transitioned from primarily a highway business district, with multiple car lots, auto repair businesses and fast food drive-thrus, to a true mixed-use community, where people live, work and play. All of the large tracts on our segment of the street have redeveloped over the last several years.”

And as to the next five years?

“We don’t think the pace of redevelopment will necessarily slow down, but the scale of the developments will probably be smaller,” Baker predicts.

Clearly, Eighth has a lot to offer. But it’s also missing some key elements, Baker says.

“A mixed-use building with office space over retail would be very nice,” he says. “[The Berry

Hill] segment of Eighth Avenue has been blessed with more residential growth than we could have hoped for, so we’d like to see some more retail and office growth to round things out.

“And with the hotel building boom over the last few years, I’m also a little surprised there’s not a hotel on Eighth Avenue and south of the downtown loop,” Baker observes.

The hotel and office components could be addressed soon, however, as an investor group led by Moni Advani is eyeing a mixed-use development for 3.1 acres where Eighth and South Street T-intersect in the shadow of downtown.

Mark Hollingsworth, president of the Nashville chapter of placemaking online message board urbanplanet.org, agrees with Baker regarding office and hotel space.

“Currently, there are zero restaurants along the first mile of the avenue between the inner-interstate loop and Wedgewood,” says Hollingsworth, who ranks among the city’s most knowl-

ERIC ENGLAND

‘We had no idea the corridor would change as quickly as it has.’

JOE BAKER, CIT Y OF BERRY HILL

edgeable manmade environment enthusiasts (he has visited about 50 countries and almost every one of the United States’ 53 metropolitan statistical areas). “It would seem that with additional residential density building up along that stretch that a few more dining options might become available. Combine those with the six residential complexes south of Wedgwood that have opened in the past half-decade and that collectively offer about 1,300 units, and there is significant density. But more could certainly be forthcoming as there are sites to be had.”

Hollingsworth notes the need for installing sidewalks on the span of the street south of Bradford Avenue.

Baker says improvements are on the way.

“We are beginning a project to fill in the sidewalk gaps on the east side of Eighth,” he says. “That is a priority for us and overdue.

We would hope to move on to the west side as soon as the east side project is complete.

We also have a project to improve some of the intersections with better pedestrian crossings and synchronized traffic signals. That should

be constructed next year. Another goal is to have a limited number of crosswalks on Eighth at non-signalized intersections, which would be a real pedestrian-safety improvement.”

About two years ago, Berry Hill and Metro Planning Department staffers sought public input about a possible reconfiguration of the street. One possible alteration — changing the busy thoroughfare from four lanes to three and adding buffered bike lanes and a center turn lane — fueled a lively debate.

Eventually, any major reconfigurations were scrapped. And worth noting: Eighth is a state highway, so the Tennessee Department of Transportation will need to be involved in any future upgrades.

“Given recent developments — such as the prospective MLS stadium at the Fairgrounds Nashville and concerns about maintaining Eighth as an alternate route for I-65 — we are not pursuing a change in vehicle travel

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lanes, but are still focused on making pedestrian improvements,” Baker says. “The studies that were performed [in 2017] also addressed possible improvements to the Wedgewood/ Eighth intersection and the I-65 on-ramps east of Eighth that could help relieve traffic congestion in the area. I think they may still be under further study or consideration.”

Five years ago, the Post published an article regarding Eighth Avenue’s strong potential. Since then a new “epicenter” of sorts has emerged: the T-intersection at Eighth and Craighead Street.

Within two blocks to either the north or the south of that intersection are large-scale residential buildings (some with retail) 23Hundred at Berry Hill, Octave, IMT 8South and Eighth South. Under construction is a building to house a Publix grocery store.

Hollingsworth notes a glaring omission for Eighth.

“As more retail and restaurants populate the stretch, there will need to be some concerted thought put into having parking garages at key junctures,” he says.

Perhaps key, Eighth (which had been called Franklin Pike starting at Melpark Avenue and moving south before a name change in early 2017) has no low-income housing lining either of its sides — as such buildings often deter would-be developers from reinventing nearby sites. Relatedly, the street snakes southward into some of Davidson County’s wealthiest suburban neighborhoods. As such, the aforementioned segment of Eighth serves as an effective “middle-section,” connecting high-dollar residential enclaves on the south to a vibrant downtown on the north.

For comparison, Nashville offers only two street segments located outside its inner-interstate loop (Broadway/21st Avenue/ Hillsboro Road and West End Avenue/Harding Pike) that most local urban placemaking experts would describe as superior. Some would argue the Eighth Avenue stretch has as much long-term potential as the segment of Charlotte Avenue spanning the inner-interstate loop on the east to White Bridge Road on the west.

With that in mind, Hollingsworth offers a few thoughts.

“From Wedgwood heading south to I-440, there are 26 eateries, but only a few could be considered fine dining,” he says.

“So there is a vacuum to be filled.

And as it stands now, there is only a single coffeehouse along the entire two to 2.5-mile stretch (8th & Roast), so more café options ought to be forthcoming.”

Lindsey Ganson, director of advocacy and communications for nonprofit Walk Bike Nashville, says Eighth lacks “safe street design.”

“Eighth Avenue is a pretty typical [arterial] road in Nashville,” she says. “It functioned well for many years to move people quickly into and out of downtown. And though more retail, restaurants and apartments have been added, what hasn’t changed is the street design.

Eighth Avenue, with all the new development, can no longer function as a shortcut to downtown.

It can no longer move people in their cars quickly. Vehicle speeds need to remain at a safe speed for pedestrians. Infrastructure is needed to ensure drivers travel at safe speeds and people walking can do so safely. A more walkable Eighth Avenue will ultimately be a friendlier and safer community space for everyone.”

BOOM

Preaching a different sermon Local real estate pros give former church buildings new uses

BY WILLIAM WILLIAMS

ashville’s urban placemaking enthusiasts who treasure non-residential buildings designed in a traditional manner face a humbling reality.

If a historic church building located within one of the city’s urban areas is demolished, that is one fewer traditional religious structure — with all its charming, beautiful and sometimes even grand architectural features — that local citizens can admire.

And the reason is simple (and seen in most other U.S. cities, too): Nationwide, the overwhelming percentage of church building construction is taking place in suburbia, and many of those places of worship eschew stately and timeless exterior and interior designs for practical purposes related to energy consumption, access for mobility-limited worshipers and (in the case of many mega-churches) massive surface parking lots (which old-school urban churches rarely offer). And, of course, there are cost considerations, as building a grand church with two soaring steeples is much more expensive than opting for a more utilitarian structure.

And this reality renders all the more important the need to see Nashville’s remaining gorgeous religious buildings remain.

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RYAN M C CLEMORE

The Russell

Fortunately, there are Nashvillians who are reinventing churches with new uses, updating their spaces, and — in the process — often introducing thousands of Nashvillians to sample historical buildings they would otherwise never have visited.

“Unfortunately, there are more churches closing than opening these days,” says Micah Lacher, president of Nashville-based Anchor Investments. “[Many] churches are beautiful structures and need to be saved from the bulldozer.”

Lacher spared — and tastefully so — the former Russell Street Church of Christ in Historic Edgefield. Today, the East Nashville building that once housed sermon-giving pastors serves as The Russell, a 23-room boutique hotel located at 819 Russell St. in the heart of one of Nashville’s most architecturally noteworthy neighborhoods. The overhaul has been nothing short of stunning, winning praise from both advocates of historic preservation and guests who seek a distinctive hotel experience.

“We loved repurposing the building, and it has been fun to see former church members come by and tell us how happy they are that we saved the [structure] from getting torn down,” Lacher says.

Next up for Lacher and his team: an updating of the East Nashville building last home to Eastside Church of Christ. In June, Lacher paid $3 million for the property, located at 2518 Gallatin Ave. Though the site’s building is nowhere near as grand and detailed as the structure now home to The Russell, it offers an understated elegance that justifies it being worthy of a new life, Lacher says.

“It is very rewarding to repurpose a building that is deteriorating,” he notes. “If we do not bring these buildings back to life, they will most likely be demolished and that piece of history will be gone forever.”

Of course, updating aging structures that lack desirable contemporary design offerings is no inexpensive task.

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BOOM

Clementine

“It is always difficult to estimate all of the costs it will take to renovate the properties, due to the age and all of the unknown factors,” Lacher says.

“We have to put in a healthy contingency as we will inevitably end up needing it.”

And cost considerations can dissuade otherwise interested parties from pursuing adaptive reuses of ex-church structures.

For example, in 2013, the owners of the former Charlotte Avenue Church of Christ — then located at the northeast corner of Charlotte and 46th avenues — offered the property for sale. At least one entity interested in possibly giving the building a new use considered purchasing. But the church eventually sold for about $1.86 million to a development company that razed the building and replaced it with a multi-floor apartment structure.

Dan Cook, who in 2018 converted a former church building located nearby at 4708 Charlotte Ave. to event space Clementine, said the loss of the church building at Charlotte and 46th was noteworthy.

“We still mourn the demolition of the Charlotte Avenue Church of Christ,” he says.

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‘If we do not bring these buildings back to life, they will most like be demolished and that piece of history will be gone forever.’

MICAH L ACHER, ANCHOR INVESTMENTS

The original portion from which Clementine operates was constructed in 1889, with the building sitting on a 0.45-acre site. It is a similar building, in many ways, to Cook’s Ruby, which opened in 2011 as one of the first post2000 church space conversions in the city.

Of note, Cook is one of the few local real estate investors who has experience converting two former local church buildings.

“The challenges were different between the two,” he says. “For Ruby, working with the Metro Parks Department and the neighborhood was a challenge, but a rewarding one. For Clementine, working with the city was the biggest challenge — and far less rewarding.”

Interestingly, Cook is a strong advocate of urban placemaking, a man who embraces adaptive reuse projects, mixed-use buildings and building/people density. However, and unlike some more hard-core urban proponents, Cook does not necessarily feel every historic ex-church space can be used for events — or even re-used period.

“It is amusing that many people think that all churches are suitable for conversion to [event

ERIC ENGLAND

BOOM

space],” says Cook, who has been assisted with both projects by his wife Brenda. “We suppose on some level that is flattering.”

In 2014, Cook purchased the former Riverside Drive Church of Christ building at 1530 Riverside Drive in East Nashville and considered repurposing it as an events space. The building was to have been renamed Haesel (pronounced like the name “Hazel”).

However, Cook eventually decided to pass on that effort, selling the site a year later for about twice what he paid for it.

Cook says church building conversion is suitable for a small percentage of developers and investors. But for those who enjoy history and the challenge of reconfiguring what typically are very distinctive interior spaces, the rewards can be significant.

“Seeing how our clients respond to the repurposed spaces is satisfying,” he notes. “Everyone interprets them differently — and often in a very personal way.”

On the city’s west side, veteran real estate investor Jeff Estepp owns a modernist church in The Nations located at 4909 Indiana Ave. and home to Brightside Bakeshop. Eventually the building will house cosmetic dermatology practice Indie Aesthetics and craft beer business Czann’s Brewing Co. Estepp also owns a former church building, also in The Nations, located on 51st Avenue North and accommodating neighborhood watering hole Corner Pub. “As a result of land values rapidly increasing and church attendance steadily declining over the years, the smaller neighborhood churches built in the mid-1900s are becoming a thing of the past,” Estepp says. “The church on Indiana was down to 13 members and the church on 51st Ave was down to around 20. Neither

could afford to keep their power turned on, so they were forced to sell. My options at that point were to 1. sell the properties; 2. keep the buildings in place and find a tenant other than a church; and 3. tear them down and start from scratch.”

Estepp faced some restrictions with the Indiana Avenue building.

“Starting from scratch would mean replacing the Indiana Avenue building with six new houses, due to zoning restrictions in place,” he explains. “Or I could seek a neighborhood landmark overlay that would allow limited development of the existing structure. Mary Carolyn Roberts, our district councilwoman, was the one that suggested the overlay and was extremely helpful in guiding me through the process.”

Similarly, Estepp says razing the 51st Avenue building would mean less parking and a smaller replacement building due to zoning restrictions and would have been “extremely cost-prohibitive.”

“Faced with both buildings being unoccupied for three-plus years, I decided that it was best for me to repurpose the properties,” he says. “Since they were former neighborhood churches, I wanted to make sure the new tenants would be able to service the local residents.”

For Lacher, repurposing churches is helpful not only from the standpoint of preserving important historic architecture. It also provides a sense of community.

“We give away a significant portion of our revenues from our hotels to support Nashville’s underserved communities,” he says. “It is fun to think that these churches did ministry in their neighborhoods for years and they are still doing ministry by people staying with us and us being able to give money away to support those most in need.”

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N A S H V I L L E P O S T. C O M

CREATE

Cultivating a community CreativeMornings Nashville wants to connect, inspire and be ‘fully honest’

BY MEGAN SELING

f you’ve ever worked from home, you know the struggle. Suddenly — no matter how many deadlines or emails might be pinging your inbox — the dishes need scrubbing and the laundry needs folding. Work can wait, you need to clean.

It’s called “productive procrastination” and it is a real thing, coined by University of Calgary psychologist Piers Steel in 2011. Even worse than a house full of procrastination traps, though, is the isolation that can come with remote and freelance work. Working from home is on the rise: According to data from the U.S. Census, the Bureau of Labor Statistics, Global Workplace Analytics and FlexJobs, remote work has increased 159 percent since 2005 and 4.7 million people in the United States now telecommute. In 2017, Forbes reported that if freelance work continues to climb at the current pace, more than half of the U.S. population will be freelancing by 2027.

We’ve seen this trend grow in Nashville, too.

The city is booming with ticketed networking events and co-working spaces — Center 615, Industrious, Deavor, Refinery Nashville, WeWork — aimed at individuals and small remote teams who are craving a sense of community (or at least a temporary escape from Hulu’s gravitational pull).

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Colin Pigott

There’s a global group less focused on making money off this evolving workforce and more interested in inspiring it. CreativeMornings is a free global breakfast and lecture series that started in New York in 2008. An estimated 20,000 attendees now gather each month in more than 200 cities across 65 countries — Amsterdam, Warsaw, Guadalajara, Bangalore and, yes, Nashville — and they’re all there to fill up on free coffee and breakfast and hear short presentations from some of their regions’ most creative thinkers.

“The main two goals of CreativeMornings Nashville are to provide some community for people and a dose of inspiration,” says Colin Pigott, CM Nashville’s host. “[We want people to] leave the event and feel like they can go and do their best work and be a better version of themselves.”

Pigott is a Nashville native who works in advertising by day. Every month, he and about 20 volunteers book speakers, secure an event space and arrange for coffee and donuts so that Nashville’s creative community can come

together for a few hours and hang out without pressure or expectation. And it’s no surprise that, according to Pigott, the majority of CM attendees are remote workers and freelancers.

“I think our No. 1 job among the attendees is graphic designer or designer of some kind.

Up there is marketing, and then we have people who work at agencies, advertising folks and people who are artists of some kind,” he says.

“When we offer programming around freelance stuff, like how to manage your time or your life or your portfolio, it’s really popular.”

But CreativeMornings isn’t a networking event for folks looking to beef up their client base (although Pigott says dozens of people have gotten jobs and even built their own businesses based on the connections they’ve made through the group). Pigott and his colleagues go out of their way to ensure Nashville’s installment feels more genuine and personal than the usual hour or two of drinks and mingling.

“I always challenge people on labeling it a networking event,” he says. “I think it’s ac-

DANIEL MEIGS

CREATE

curate to say that, but […] you don’t tend to see a lot of business cards being exchanged. It doesn’t feel transactional.”

It helps set a more personal tone when one of the first things you do when you arrive is fill out a nametag with a sometimes very personal question on it. Pigott laughs when asked about the creative prompts — every month features a different, almost invasive question such as, “What’s the last thing you cooked?” “What three words best describe you?” or “What’s something that was hard for you this month?”

It can throw off new visitors, especially early in the day when the coffee hasn’t quite kicked in.

“We specifically try to encourage people — and really, to force people — to have conversations about things other than what they do for a living,” says Pigott. “There’s way more value in people being their complete selves. They’ll make more genuine and lasting connections that way and our community will move forward in better, new, different, unexpected directions because of that.”

The same appreciation of authenticity is also considered when booking monthly speakers. Pigott and his fellow volunteers look for people who can challenge the audience.

“With all the challenges that we have as a culture — the ways we need to make our society a better place that works for more people — we can’t afford to put people on the stage at CreativeMornings who are just going to go up there and tell everybody that it’s all OK and that everything is fine,” he says. “Because that’s too much of a missed opportunity and it’s not fully honest.”

At October’s event, business and leadership coach Kacey Cardin had the room of about 200 attendees shouting out their insecurities and aligning their chakras. At another talk over the summer, local food blogger and podcast host Hannah Messinger spoke openly about having to re-establish herself both personally and professionally after loss and heartache.

Other recent speakers include Metro Councilmember Zulfat Suara, who talked about how

to create positive change in the face of injustice, and author Meera Lee Patel, who shared what she learned about herself after she started to embrace her fears. This isn’t your usual “How to Be Successful” motivational nonsense.

“The reason that I encourage people to talk about stuff other than work and the reason that I’m personally involved in something that is free and volunteer-based and is just for fun, is that I think that that’s the Nashville I always thought I lived in, and I hope I continue to live in,” says Pigott. “What I’m trying to do is help people collaborate, even if there’s no point to it, if there’s no profit motive or expected outcome.

If we do things together, if we get in the same room together and we have conversations about what we actually think and care about, I believe good things will happen.”

Learn more about CreativeMornings Nashville at creativemornings.com/nsh or on Twitter and Instagram at @Nashville_CM

NASHVILLEPOST.COM | WINTER 2019

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INDEX

A-J

HealthStream 33, 45

Ruby 54

Highland Yards 49

Sagemont Real Estate 48

Ian Ayre 36

Saint Thomas Health 24

2bPrecise 16

Industrious 56

Saint Thomas West 24

Aaron Dorn 39

Jason Moore 44

Sarah Tanksley 13

Aaron Salow 46

Jay Fulmer 48

Shearwater Health 25

Adam Jaggers 47

J.D. Thomas 22

Stocking 51 48

AMN Healthcare 25

Jeff Estepp 55

Stratasan 43

Anchor Investments 53

J. Kline 60

Studio Bank 39

Ascension 24

Joe Baer 50

Bill Lee 12

John Mark McDougal 40

Britt Groomes 26

Josh Denny 18

Busy Burr 43

JumpCrew 47

CareHarmony 47

LBMC 40

TennCare 12, 19

Center 615 56

Lindsey Ganson 52

Tennessee Department of Transportation 51

M-S

The GetPreCiSe Center 20

Center on Budget and Policy Priorities 12, 19 Centric Architecture 48 Charlotte Avenue Church of Christ 54 Chris Parker 49 City Construction 49 Clementine 54 Colin Pigott 56 Consuelo Wilkins 16 CreativeMornings Nashville 56 Dan Cook 54 Daniel Stein 8 Dave Delaney 44 Deavor 56 Eighth Avenue South 50 Ellen Clayton 20 Elliott Wood 26 Embold Health 8 EvidenceCare 26 Fulmer Engineering 48 Gabe Roberts 12 Gina Emmanuel 48 Hannah Katch 12, 19 HCA Healthcare 25, 29, 45

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WINTER 2019 | NASHVILLEPOST.COM

Major League Soccer 36 Mark Hollingsworth 50 Medalogix 26, 32 Meharry Medical College 16 Metro Council 34 Metro Planning Department 51 Micah Lacher 53 Michelle Robertson 24 Murfreesboro Medical Clinic 16

T-Z The Nations 48, 55 Think Data Insights 40 Tod Fetherling 26 Tom Dent 10 Trent Yates 48 Trilliant Health 47 United Soccer League 36 Urgent Team 10 Vanderbilt University 13, 14 Vanderbilt University Medical Center 13

Nashville Capital Network 46

Vanderbilt University School of Medicine 16

Nashville General Hospital 23

Vintage South 48

Nashville SC 26

Walk Bike Nashville 52

Nathan King 25

Watkins College of Art 60

Nathan Lyons 48

WeWork 56

Nicholas Cote 16

XOi Technologies 46

Paige Collins 46

Xsolis 26

Perception Health 26

Zach Evans 26

Ralph Henderson 25

Zulfat Suara 34, 57

Refinery Nashville 56 Renasant Bank 36

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CHARGE

Submit your nomination at InCharge@NashvillePost.com N OM I NAT I O NS C LO S E DEC E MBE R 6, 2 0 1 9

FAVORITES

MY FAVORITE PLACE TO SPOIL A GOOD WALK WATKINS PRESIDENT J. KLINE STAYS CLOSE TO TOWN FOR A GOOD GOLFING CHALLENGE

SHELBY GOLF COURSE in East Nashville is a short but narrow, “hilly” track that requires exceptional course management, prudence, intuition and superior ball-striking ability. I possess none of these qualities. To the dismay of my playing partners, I always choose to walk the course. There are two reasons: I can save a few bucks (although the rates are so low that when I achieve senior status, they will actually have to pay me) and everyone can use the exercise. (Although sports one can play while smoking cigars should hardly count as “sport.”)

I remediate my partners’ fears of slow play by gleefully swinging away whenever ready and so long as they are somewhere within the fairway, they are safe from harm. As a consequence of design cruelty, the back nine has two par 5 holes in a row.

These occur over mountainous terrain that would make a Navy Seal reconsider his career choices.

After mastering these challenges — and pretty much looking like T.E. Lawrence emerging from the desert had the desert been twice as broad — I make sure to hook my approach on 18 onto the clubhouse roof. That strategically places me adjacent to the Gatorade cooler, content with a full day of activity and most probably having caused no fatalities. It’s an experience not to be missed!

ERIC ENGLAND

SEPTEMBER 12 JE Dunn | 5:30-8 PM

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