1. Develop a Simple Framework for Strategy. There are several different frameworks that can be used to build a strategy. One concept as to strategic approach proclaims that an organization should assess (1) whether an enterprise wants to be a cost leader, (2) whether it wants to be the most dominant in a specific niche, or (3) whether it wants to be the most customer centric enterprise. Michael Porter, the noted author of Competitive Strategy, uses a similar framework and group’s strategies into 3 generic strategies (i.e. strategies that are applicable across industries): cost leadership, differentiation, and focus. Michael Porter argued that to be successful over the long-term, a firm must select only one of these three generic strategies. Otherwise, with more than one single generic strategy the firm will be "stuck in the middle" and will not achieve a competitive advantage.
He also states, "These generic strategies are not necessarily compatible with one another. If a firm attempts to achieve an advantage on all fronts, in this attempt it may achieve no advantage at all. For example, if a firm differentiates itself by supplying very high quality products, it risks undermining that quality if it seeks to become a cost leader. Even if the quality did not suffer, the firm would risk projecting a confusing image."
An orthopedic group may decide to be the absolute lowest cost provider, or it can attempt to be so good in specific areas within their geographic region or nationally and within a specific area of care that it is a magnet for patients, payors and the most sought after residents. I.e., it has established dominance in a niche. This dominance also can discourage competitors’ efforts in such areas. For example, it can be the dominant 80 physician orthopedic group in an area where all other groups are five doctors or less. Alternatively, it can be the very best in a service line area such as sports medicine, hand surgery or spine where there can be a sustainable advantage.
Finally, a practice may choose to be the most customer centric enterprise. Here, the practice may see as its customer, either a hospital, patients generally, or specific payors and try and develop an extremely close relationship or working relationship with such party. For example, a group my decide it wants to develop a very close and customized relationship with the lead payor and be willing to sit down with the payor and try new risk offerings or recruit to fill gaps in the payors' coverage. Alternatively, a group may endeavor to develop a relationship with a hospital where it becomes the go to group to fill all hospital needs and positions. This may in turn allow the group to maintain the flow of referrals, reduce competitive recruiting, obtain compensation and realize other benefits. There, its essential mission will be to do anything it can for that customer base.
Looking at strategies through this prism, we tend to believe that it is likely not profitable nor fun or fulfilling to be the Walmart of orthopedic care. The Stanford Hospital Chief of Staff, Brian Bohman, M.D. states this well. He states, "We are not a low cost hospital and not likely to be one in the near future." To become a low cost provider, one could envision an orthopedic practice with a very high physician assistant to physician ratio or similar coverage model. Assuming one is not focused on being a cost leader, the concept becomes that one has to normalize costs but can’t view its absolute goal as being the absolute cost leader. It may be a more profitable strategic alternative to aim to become great and dominant in an area or to become so customer focused and thus spend a huge percentage of time and efforts focusing the organization around those efforts.
In assessing strategy, we are big believers in exploiting existing strengths of the practice first. For example, you might add existing depth and strength to your most dominant geographic or specialty area first. If a practice has great or leading knee specialists and/or sports medicine program, or a leading business site or unit, it should generally invest first in marketing, equipment and recruiting for these strengths. A goal would be to be truly dominant in an area and not to sprinkle resources. E.g., if the group has a great hand surgeon, it may add to this area and both strengthen itself and discourage competition and invest here. Likewise, if the group is doing well with spine, it might make sense to attempt to develop a more dominant position in spine and add revenue there. This also, as a group develops critical mass, can discourage competition from attempting to allocate dollars to compete in such areas. Second, the group may diversify in an area that can be high growth areas and where the group has had some success to date. Here, another core tool that can be used for evaluating practice options for growth is the BCG matrix, a tool developed by the Boston Consulting Group essentially divides an entities’ offerings into four areas – stars, cash cows, dogs and question marks. See, e.g., www.BCGMatrix.com.
Here, in assessing growth options, a practice may examine first the areas that are immediately adjacent to its strongest areas. This concept of building out from adjacent strengths is a theory developed by Bain & Company, Inc. in a well noted book titled Profit from the Core authored by Chris Zook. Bain and Zook note that successful companies focus on 1. Reaching full potential in the core business. 2. Expanding into logical adjacent business surrounding that core. 3. Preemptively redefining the core business in response to market turbulence. Instead of focusing on taking advantage of the next "hot industry", Bain directors recommend that companies focus on strategy, competitive position, reinvestment rates, and execution. They cite the example that the most successful sustained growth companies specialize in goods with lower growth, such as energy (Enron), beverages (Starbucks), and athletic gear (Nike).
In sum, a practice must first decide, with thorough examination of its current business and opportunities, what it desires to excel in and then dedicate a great majority of resources to such efforts.
2. Understand Where Your Revenues Are Coming From. On a macro level, it is critical for a group to understand by service line — both by area of care and often by referral source or generator of business — what are the key sources of business. Here, if a practice has four service lines that comprise 85% of the business, a first goal of management is to align resources to focus efforts on those four service lines. Often this means deepening the strength in those areas and continuing to grow those areas. At the same time with the knowledge that the profitability of service lines changes over time, leadership also needs to have a keen eye on which areas are potential growth areas and then pick and determine a few of those areas to really concentrate a second set of resources on. Finally, there is a school of thought that essentially says a management team wants to spend zero or very little time on those areas that are true weaknesses and/or low growth and low revenue areas and to not divert its time from its core cash flow generating activities and high growth potential areas. Jim Collins in his noted book Good to Great states, "In a good-to-great transformation, budgeting is a discipline to decide which arenas should be funded and which should not be funded at all. In other words, the budget process is not about figuring out how much each activity gets, but about determining which activities best support the Hedgehog Concept and should be fully strengthened and which should be eliminated entirely." See also BCG matrix as to a similar concept as to dogs. This kind of discipline can be hard to manage in practice where you see leadership focus on ancillary outside efforts such as a market 30 to 50 miles away from a group’s home base or a specialty with very little revenue potential for the system but that seemingly somebody cannot help themselves but be focused on. However, the results that come from such efforts are not nearly worth the cost and time that would have been better spent on the cash generating activities of the organization and the potential high growth areas for the organization. As an example, if a group regularly loses money in a specialty or site or with a payor, the smart move is to often wholly abandon that payor, specialty or site and allocate time and resources to the group’s winners.
3. Normalize Costs. Even if a group does not intend to be the cost leader, it is generally always a good time to assure that costs are minimized. Are staffing costs in line? Is the group cautious about long term additional buying of equipment, expanding real estate or taking on costs that will be "forever" costs? It is a great concept to consider in hiring that when you hire, you should not look at the new employee as simply a $40,000 to $200,000 a year cost but really you need to look at it as 10 years times that cost in that it is unlikely that once you hire a person, that you will quickly dispose of the person if economics change. In essence, to look at every hire not on a per annum basis but as a long term cost basis. Here, the message is not to necessary be the low cost leader but to look very carefully at any significant expenses and to bench mark costs against the published data from MGMA, AAOS and other organizations.
4. Investing in Technology. A group need not be a technology leader unless this is their key strategy. At that same time, it must have sufficient technology so it does not become a hindrance to either patient care or becoming dominant in a particular type of area. A group needs to have a minimum level or technology investment simply to be able to practice and thrive. Dr. Ken Austin of Rockland Orthopaedics & Sports Medicine said that coordinating an EMR with his practice's scheduling and billing components has significantly increased efficiencies by reducing the number of hours spent entering information into a separate system. With the increasing prevalence of EMRs, this kind of technology becomes essential for a practice to provide efficient, state-of-the-art care.
5. Maximize Ancillary Income. While a group must fully stay within all legal and regulatory bounds, as practice professional income shrinks, it becomes more important than ever to maximize ancillary income in a safe and smart way. Here, in looking at ambulatory surgery centers, imaging, physical therapy, and other areas, a core concept is to look at which areas have the least risk and can provide the maximum amount of return. This may include physician therapy, pain management, and imaging. Brent Lambert, MD, president and co-founder of ASCOA, says that the addition of a surgery center to an orthopedic practice can augment annual practice income by 15-20 percent. In an interview with Becker's Orthopedic & Spine Review, CEO of GO Partners Gina Volmert said physical therapy can be very profitable if done right. She said while five physicians might be able to support physical therapy services, a practice of ten doctors or more will reap the maximum profits. Invest first in ancillaries with relatively reasonable investment amounts and relatively strong prospects for income. This may guide against an investment in a $10,000,000 building enterprise or more that will return less than a few percent per year?
6. Determine Areas of Greatness. We are very familiar with a leading group that at one point in its life cycle career decided that it would really focus on doing solely four procedures and spend all its time marketing and focusing on doing those four procedures. The group decided that it was going to be the absolute leader in those procedures. If a group can take leadership or focus in such a manner and then aggressively market that expertise and both internally and externally, both to the general public and to the medical community, there are often excess profits to be made through such leadership.
7. Adopt a Marketing Strategy. A practice should adopt a marketing strategy that keeps it less vulnerable to changes in hospital attitudes. Orthopedic practices often draw patients from the general public as well as from typical referral sources such as primary care physicians and hospital emergency rooms. The more diversified the referral source, the more stable the group is. One of the great providers of strategies and services for marketing a healthcare practices is Healthcare Success Strategies. A separate firm that works closely with healthcare businesses that is extremely smart in targeting messages and the use of different types of resources is CCO Partners.
8. Hospital Relations: Keep One Foot With the Hospital Relationship. In orthopedics, professional reimbursement is holding reasonably stable. At the same time, in certain specialties professional reimbursement has been decimated. Those specialties have found themselves absolutely needing to find a way to become employees of or otherwise partner with hospitals. Here, while orthopedics is not at this point right now, it is generally smart to maintain close relationships with the hospitals in both building brands, reducing external competition, and keeping the door open for further relationships and alignments.
9. Call Coverage. If providing call coverage, seek to look to see if there is an ability to earn compensation for providing such call coverage. In many markets, being paid for call coverage has become absolutely the norm. The Sullivan, Cotter and Associates' 2009 Physician On-Call Pay Survey Report states that 82 percent of the survey respondents currently provide compensation to non-employed physicians for call coverage.
10. Billing and Collecting. One of the typical ways in which an orthopedic group can improve their results almost immediately is to spend more time on improving their billing and collecting. Often this means outsourcing billing and collecting to a great firm or making that a core strength within the group. The larger the group is the easier it is to make this an absolute core competency within the group. Excellence in billing and collecting can add 5 to 10% of revenues per year which has a huge impact on the ultimate profitability for the practice.
11. Use Outstanding Managed Care Experts. Most groups cannot afford to internally retain outstanding managed care experts. More often than not, a group should hire outside managed care resources that excel in handling managed care contracts for orthopedic practices. William Pupkis, CEO of Capital Region Orthopedics, told Becker's practices should consider their managed care contracts an "investment portfolio." He says, "Both provide economic returns, and the more diverse they are, the better. Both demand careful management." There are certain firms that really specialize in this for surgery centers and there are firms that specialize in this for orthopedic and spine practices. The difference in using an experienced managed care negotiator (a business person, not a lawyer) can be a huge determination in practice profits over the long run.
12. Ancillary Services In House. Determine whether or not to bring certain ancillary services in house. This may include, e.g., physician therapy, pain management, and imaging. Practices with financial constraints can consider cheaper alternatives to expensive services. For example, new MRI equipment requires a $750,000-$1 million investment, a sum that is greatly reduced if the practice purchases used or refurbished equipment. Services such as electromyography can be offered for an investment of only $5,000. An equation to examine is can a group make a relatively reasonable investment and can it be paid off within 12 to 24 months. In order to decrease costs and increase efficiency, Jerry Magone of Orthopaedic Sports & Medicine Consultants upgraded his practice's MRI to a green machine, lowering his electrical bill and shortening the per-scan time to allow more patients through the scanner. The group also needs to examine the long term prognosis for reimbursement in the area. That stated, if the total cost to add ancillary services is reasonable, one might simply assess the fact that over time it may or may not be a profitable area but can excess profits be made in the short term. In some ways, groups have to be willing to surf from opportunity to opportunity and have a great team in place to be able to pursue and implement opportunities and retain a reasonable the debt and cost structure that allows them the reasonable ability to invest in new opportunities.
13. Build an Outstanding Team and Retain Great Leaders. There are two great concepts in business. First, define a clear strategy. Second, retain and recruit the best people. If the group views as a core part of its overall vision to have the best people in place at every level, it is often the case that it can withstand and remain strong and be flexible and excel regardless of exact strategy and outside forces. Jim Collins in Good to Great notes as to people and their importance, "Those who build great companies understand that the ultimate throttle on growth for any great company is not markets, or technology, or competition, or products. It is one thing above all others: the ability to get and keep enough of the right people." Periodically, a party can end up in such a challenging market that regardless of the people in place, the business can be a debacle. However, in almost all situations, having the best people in place, intelligence, achievement orientation, and integrity, is the best single determinant of success outside of the total macro conditions for an area.
He also states, "These generic strategies are not necessarily compatible with one another. If a firm attempts to achieve an advantage on all fronts, in this attempt it may achieve no advantage at all. For example, if a firm differentiates itself by supplying very high quality products, it risks undermining that quality if it seeks to become a cost leader. Even if the quality did not suffer, the firm would risk projecting a confusing image."
An orthopedic group may decide to be the absolute lowest cost provider, or it can attempt to be so good in specific areas within their geographic region or nationally and within a specific area of care that it is a magnet for patients, payors and the most sought after residents. I.e., it has established dominance in a niche. This dominance also can discourage competitors’ efforts in such areas. For example, it can be the dominant 80 physician orthopedic group in an area where all other groups are five doctors or less. Alternatively, it can be the very best in a service line area such as sports medicine, hand surgery or spine where there can be a sustainable advantage.
Finally, a practice may choose to be the most customer centric enterprise. Here, the practice may see as its customer, either a hospital, patients generally, or specific payors and try and develop an extremely close relationship or working relationship with such party. For example, a group my decide it wants to develop a very close and customized relationship with the lead payor and be willing to sit down with the payor and try new risk offerings or recruit to fill gaps in the payors' coverage. Alternatively, a group may endeavor to develop a relationship with a hospital where it becomes the go to group to fill all hospital needs and positions. This may in turn allow the group to maintain the flow of referrals, reduce competitive recruiting, obtain compensation and realize other benefits. There, its essential mission will be to do anything it can for that customer base.
Looking at strategies through this prism, we tend to believe that it is likely not profitable nor fun or fulfilling to be the Walmart of orthopedic care. The Stanford Hospital Chief of Staff, Brian Bohman, M.D. states this well. He states, "We are not a low cost hospital and not likely to be one in the near future." To become a low cost provider, one could envision an orthopedic practice with a very high physician assistant to physician ratio or similar coverage model. Assuming one is not focused on being a cost leader, the concept becomes that one has to normalize costs but can’t view its absolute goal as being the absolute cost leader. It may be a more profitable strategic alternative to aim to become great and dominant in an area or to become so customer focused and thus spend a huge percentage of time and efforts focusing the organization around those efforts.
In assessing strategy, we are big believers in exploiting existing strengths of the practice first. For example, you might add existing depth and strength to your most dominant geographic or specialty area first. If a practice has great or leading knee specialists and/or sports medicine program, or a leading business site or unit, it should generally invest first in marketing, equipment and recruiting for these strengths. A goal would be to be truly dominant in an area and not to sprinkle resources. E.g., if the group has a great hand surgeon, it may add to this area and both strengthen itself and discourage competition and invest here. Likewise, if the group is doing well with spine, it might make sense to attempt to develop a more dominant position in spine and add revenue there. This also, as a group develops critical mass, can discourage competition from attempting to allocate dollars to compete in such areas. Second, the group may diversify in an area that can be high growth areas and where the group has had some success to date. Here, another core tool that can be used for evaluating practice options for growth is the BCG matrix, a tool developed by the Boston Consulting Group essentially divides an entities’ offerings into four areas – stars, cash cows, dogs and question marks. See, e.g., www.BCGMatrix.com.
Here, in assessing growth options, a practice may examine first the areas that are immediately adjacent to its strongest areas. This concept of building out from adjacent strengths is a theory developed by Bain & Company, Inc. in a well noted book titled Profit from the Core authored by Chris Zook. Bain and Zook note that successful companies focus on 1. Reaching full potential in the core business. 2. Expanding into logical adjacent business surrounding that core. 3. Preemptively redefining the core business in response to market turbulence. Instead of focusing on taking advantage of the next "hot industry", Bain directors recommend that companies focus on strategy, competitive position, reinvestment rates, and execution. They cite the example that the most successful sustained growth companies specialize in goods with lower growth, such as energy (Enron), beverages (Starbucks), and athletic gear (Nike).
In sum, a practice must first decide, with thorough examination of its current business and opportunities, what it desires to excel in and then dedicate a great majority of resources to such efforts.
2. Understand Where Your Revenues Are Coming From. On a macro level, it is critical for a group to understand by service line — both by area of care and often by referral source or generator of business — what are the key sources of business. Here, if a practice has four service lines that comprise 85% of the business, a first goal of management is to align resources to focus efforts on those four service lines. Often this means deepening the strength in those areas and continuing to grow those areas. At the same time with the knowledge that the profitability of service lines changes over time, leadership also needs to have a keen eye on which areas are potential growth areas and then pick and determine a few of those areas to really concentrate a second set of resources on. Finally, there is a school of thought that essentially says a management team wants to spend zero or very little time on those areas that are true weaknesses and/or low growth and low revenue areas and to not divert its time from its core cash flow generating activities and high growth potential areas. Jim Collins in his noted book Good to Great states, "In a good-to-great transformation, budgeting is a discipline to decide which arenas should be funded and which should not be funded at all. In other words, the budget process is not about figuring out how much each activity gets, but about determining which activities best support the Hedgehog Concept and should be fully strengthened and which should be eliminated entirely." See also BCG matrix as to a similar concept as to dogs. This kind of discipline can be hard to manage in practice where you see leadership focus on ancillary outside efforts such as a market 30 to 50 miles away from a group’s home base or a specialty with very little revenue potential for the system but that seemingly somebody cannot help themselves but be focused on. However, the results that come from such efforts are not nearly worth the cost and time that would have been better spent on the cash generating activities of the organization and the potential high growth areas for the organization. As an example, if a group regularly loses money in a specialty or site or with a payor, the smart move is to often wholly abandon that payor, specialty or site and allocate time and resources to the group’s winners.
3. Normalize Costs. Even if a group does not intend to be the cost leader, it is generally always a good time to assure that costs are minimized. Are staffing costs in line? Is the group cautious about long term additional buying of equipment, expanding real estate or taking on costs that will be "forever" costs? It is a great concept to consider in hiring that when you hire, you should not look at the new employee as simply a $40,000 to $200,000 a year cost but really you need to look at it as 10 years times that cost in that it is unlikely that once you hire a person, that you will quickly dispose of the person if economics change. In essence, to look at every hire not on a per annum basis but as a long term cost basis. Here, the message is not to necessary be the low cost leader but to look very carefully at any significant expenses and to bench mark costs against the published data from MGMA, AAOS and other organizations.
4. Investing in Technology. A group need not be a technology leader unless this is their key strategy. At that same time, it must have sufficient technology so it does not become a hindrance to either patient care or becoming dominant in a particular type of area. A group needs to have a minimum level or technology investment simply to be able to practice and thrive. Dr. Ken Austin of Rockland Orthopaedics & Sports Medicine said that coordinating an EMR with his practice's scheduling and billing components has significantly increased efficiencies by reducing the number of hours spent entering information into a separate system. With the increasing prevalence of EMRs, this kind of technology becomes essential for a practice to provide efficient, state-of-the-art care.
5. Maximize Ancillary Income. While a group must fully stay within all legal and regulatory bounds, as practice professional income shrinks, it becomes more important than ever to maximize ancillary income in a safe and smart way. Here, in looking at ambulatory surgery centers, imaging, physical therapy, and other areas, a core concept is to look at which areas have the least risk and can provide the maximum amount of return. This may include physician therapy, pain management, and imaging. Brent Lambert, MD, president and co-founder of ASCOA, says that the addition of a surgery center to an orthopedic practice can augment annual practice income by 15-20 percent. In an interview with Becker's Orthopedic & Spine Review, CEO of GO Partners Gina Volmert said physical therapy can be very profitable if done right. She said while five physicians might be able to support physical therapy services, a practice of ten doctors or more will reap the maximum profits. Invest first in ancillaries with relatively reasonable investment amounts and relatively strong prospects for income. This may guide against an investment in a $10,000,000 building enterprise or more that will return less than a few percent per year?
6. Determine Areas of Greatness. We are very familiar with a leading group that at one point in its life cycle career decided that it would really focus on doing solely four procedures and spend all its time marketing and focusing on doing those four procedures. The group decided that it was going to be the absolute leader in those procedures. If a group can take leadership or focus in such a manner and then aggressively market that expertise and both internally and externally, both to the general public and to the medical community, there are often excess profits to be made through such leadership.
7. Adopt a Marketing Strategy. A practice should adopt a marketing strategy that keeps it less vulnerable to changes in hospital attitudes. Orthopedic practices often draw patients from the general public as well as from typical referral sources such as primary care physicians and hospital emergency rooms. The more diversified the referral source, the more stable the group is. One of the great providers of strategies and services for marketing a healthcare practices is Healthcare Success Strategies. A separate firm that works closely with healthcare businesses that is extremely smart in targeting messages and the use of different types of resources is CCO Partners.
8. Hospital Relations: Keep One Foot With the Hospital Relationship. In orthopedics, professional reimbursement is holding reasonably stable. At the same time, in certain specialties professional reimbursement has been decimated. Those specialties have found themselves absolutely needing to find a way to become employees of or otherwise partner with hospitals. Here, while orthopedics is not at this point right now, it is generally smart to maintain close relationships with the hospitals in both building brands, reducing external competition, and keeping the door open for further relationships and alignments.
9. Call Coverage. If providing call coverage, seek to look to see if there is an ability to earn compensation for providing such call coverage. In many markets, being paid for call coverage has become absolutely the norm. The Sullivan, Cotter and Associates' 2009 Physician On-Call Pay Survey Report states that 82 percent of the survey respondents currently provide compensation to non-employed physicians for call coverage.
10. Billing and Collecting. One of the typical ways in which an orthopedic group can improve their results almost immediately is to spend more time on improving their billing and collecting. Often this means outsourcing billing and collecting to a great firm or making that a core strength within the group. The larger the group is the easier it is to make this an absolute core competency within the group. Excellence in billing and collecting can add 5 to 10% of revenues per year which has a huge impact on the ultimate profitability for the practice.
11. Use Outstanding Managed Care Experts. Most groups cannot afford to internally retain outstanding managed care experts. More often than not, a group should hire outside managed care resources that excel in handling managed care contracts for orthopedic practices. William Pupkis, CEO of Capital Region Orthopedics, told Becker's practices should consider their managed care contracts an "investment portfolio." He says, "Both provide economic returns, and the more diverse they are, the better. Both demand careful management." There are certain firms that really specialize in this for surgery centers and there are firms that specialize in this for orthopedic and spine practices. The difference in using an experienced managed care negotiator (a business person, not a lawyer) can be a huge determination in practice profits over the long run.
12. Ancillary Services In House. Determine whether or not to bring certain ancillary services in house. This may include, e.g., physician therapy, pain management, and imaging. Practices with financial constraints can consider cheaper alternatives to expensive services. For example, new MRI equipment requires a $750,000-$1 million investment, a sum that is greatly reduced if the practice purchases used or refurbished equipment. Services such as electromyography can be offered for an investment of only $5,000. An equation to examine is can a group make a relatively reasonable investment and can it be paid off within 12 to 24 months. In order to decrease costs and increase efficiency, Jerry Magone of Orthopaedic Sports & Medicine Consultants upgraded his practice's MRI to a green machine, lowering his electrical bill and shortening the per-scan time to allow more patients through the scanner. The group also needs to examine the long term prognosis for reimbursement in the area. That stated, if the total cost to add ancillary services is reasonable, one might simply assess the fact that over time it may or may not be a profitable area but can excess profits be made in the short term. In some ways, groups have to be willing to surf from opportunity to opportunity and have a great team in place to be able to pursue and implement opportunities and retain a reasonable the debt and cost structure that allows them the reasonable ability to invest in new opportunities.
13. Build an Outstanding Team and Retain Great Leaders. There are two great concepts in business. First, define a clear strategy. Second, retain and recruit the best people. If the group views as a core part of its overall vision to have the best people in place at every level, it is often the case that it can withstand and remain strong and be flexible and excel regardless of exact strategy and outside forces. Jim Collins in Good to Great notes as to people and their importance, "Those who build great companies understand that the ultimate throttle on growth for any great company is not markets, or technology, or competition, or products. It is one thing above all others: the ability to get and keep enough of the right people." Periodically, a party can end up in such a challenging market that regardless of the people in place, the business can be a debacle. However, in almost all situations, having the best people in place, intelligence, achievement orientation, and integrity, is the best single determinant of success outside of the total macro conditions for an area.