Unfortunately, I learned them by getting it wrong.

As our organization grew, so did Lane Home Medical Equipment, one of the businesses we operated. We reached the point where we believed it needed dedicated leadership, so we began looking outside the organization for someone who could take it to the next level.

Our first hire was Jonathan.

Jonathan interviewed exceptionally well. He was articulate, confident, and presented himself as someone capable of building and leading a successful business.

By every measure I knew how to evaluate at the time, he looked like exactly what we needed.

I was convinced we had found the right person.

I was wrong.

It didn’t take long before small concerns began to appear. Jonathan seemed more interested in what the position could do for him than in what he could do for the organization and the people he was leading.

Then came a relatively simple assignment.

We had leased a new location outside Portland, and one of Jonathan’s responsibilities was arranging permanent signage for the building.

When problems developed, the project stalled.

More importantly, so did Jonathan.

That small assignment revealed something a résumé and an interview hadn’t.

Leaders don’t succeed because nothing goes wrong. They succeed because they know what to do when it does.

Eventually, the concerns became significant enough that we ended Jonathan’s employment after about six months.

We went looking again.

This time we hired Robert.

Robert had experience in the durable medical equipment industry and came highly recommended by someone we trusted. Once again, on paper, we seemed to have found the right person.

Within weeks, serious ethical concerns involving company property and his conduct surfaced.

There wasn’t much to debate.

We terminated his employment as well.

Two hires.

Two impressive candidates.

Two failures.

At the time, it was frustrating.

Looking back, it was educational.

I had spent much of my career learning how to evaluate competence. Where had someone worked? What had they accomplished? Did they understand the industry? Could they communicate? Could they manage people and solve problems?

Those are important questions.

But I hadn’t given enough weight to another one:

Who is this person when nobody is trying to impress anybody?

That’s much harder to discover in an interview.

People can polish a résumé, rehearse answers, and provide references who can tell you about their accomplishments. None of those things necessarily tell you how someone will respond when something goes wrong, when nobody is watching, or when their own interests conflict with the organization’s.

Competence tells you whether someone can do the job.

Character often determines how they will do it.

After Robert left, we did something different.

Instead of looking outside the organization again, we looked inside.

We promoted Kim Duerst.

Kim already knew a great deal about the business and understood our culture, but she didn’t assume that meant she knew everything she needed to know about the job.

She went to work learning it.

Kim learned every position in the operation. She became familiar enough with the day-to-day work that she could speak with employees at the level of the work they were actually expected to perform.

She was hands-on.

After two failed managers, that was exactly what the position needed.

Kim didn’t lead from a distance. She understood what her employees were doing because she had taken the time to understand their jobs. When there was a problem, she could talk with the people doing the work, understand what was happening, and help find a solution.

She also understood something our previous hires had not demonstrated: leadership wasn’t about what the position could do for her.

It was about serving employees, patients, and the organization.

Under Kim’s leadership, Lane Home Medical Equipment stabilized.

Then it improved.

Eventually, the company became strong enough that we were able to spin it off to another organization where it could continue serving the community.

Looking Back

I wish those experiences had taught me how to hire perfectly.

They didn’t.

I’ve never met anyone who can.

Hiring will always involve judgment, and judgment will always involve risk. But those experiences changed what I looked for.

Experience still mattered. Competence mattered. Intelligence and results mattered.

But character moved much higher on the list.

I’ve also learned not to confuse confidence with character.

Some of the best leaders I’ve known weren’t particularly impressive in their first conversation. They didn’t sell themselves very well.

They simply showed up every day, did what they said they would do, treated people well, accepted responsibility, and solved problems.

Over time, you learned you could trust them.

I’d take that person over the perfect résumé every time.

The older I’ve gotten, the less impressed I’ve become by people who tell me what they’re capable of doing.

I’d rather watch what they consistently do.

Competence may get someone through the door.

Character determines what happens after they walk through it.

He closed the door and asked me a question.

“David, how do we develop these people into who we think we need?”

At the time, it felt like an operational problem.

We had grown quickly and suddenly needed more managers, more directors, and more executives.

We could hire employees.

We could buy computers.

We could lease more office space.

But we couldn’t hire twenty years of leadership experience.

That had to be developed.

And we didn’t have twenty years.

We had months.

Terry and I talked about it for quite a while.

Eventually we came to a fairly simple conclusion.

If we wanted people to think like leaders, we had to start treating them like leaders.

That meant giving them more than instructions.

It meant giving them responsibility.

One of the best examples was Shannon Conley.

Shannon had joined our claims department and quickly distinguished herself.

She was intelligent.

Organized.

Curious.

She asked good questions and wanted to understand why we did things the way we did.

There was only one problem.

Shannon didn’t yet see in herself what some of us were beginning to see in her.

She lacked confidence.

In fact, she probably underestimated her ability far more than any of us did.

So we gave her responsibility.

She handled it well.

We gave her more.

She handled that well too.

One assignment led to another.

One successful project led to a larger one.

Over time, something changed.

Her confidence began catching up with her ability.

That experience taught me something I didn’t fully appreciate at the time.

Trust is a currency.

Leaders spend it every time they give someone an opportunity before the outcome is guaranteed.

There is always risk involved.

Maybe the person isn’t ready.

Maybe they struggle.

Maybe they make a mistake.

But if we wait until people have already proven they can do the next job before giving them the opportunity, we may wait forever.

Somebody has to go first.

Somebody has to say,

“I think you can do this.”

Then give them the chance to prove it.

Years later, Shannon was carrying much greater responsibility and reporting to me.

Eventually she came to me and said she wanted to report directly to Terry.

At first glance, that might sound like an organizational-chart discussion.

It wasn’t.

It was another moment of trust.

Reporting directly to the CEO represented something important to Shannon.

She was beginning to believe she belonged at the executive table.

And quite frankly, I agreed.

So we made the change.

I could have viewed it differently.

I could have wondered why she didn’t want to continue reporting to me.

I could have protected my territory.

But that would have missed the point.

My job wasn’t to keep Shannon dependent on me.

My job was to help her grow until she didn’t need me anymore.

Moving under Terry wasn’t a rejection of my leadership.

It was evidence that the process was working.

Looking back, I think leaders sometimes misunderstand what trust really means.

Trust isn’t simply believing someone is honest.

It isn’t only believing someone will show up or do what they promised.

Leadership trust goes a step further.

It means being willing to place something meaningful in someone else’s hands.

A decision.

A project.

A department.

A relationship.

A piece of the organization.

And then resisting the temptation to take it back the moment they struggle.

That doesn’t mean abandoning people.

Quite the opposite.

You give them meaningful work.

You let them make decisions.

You allow them to struggle.

You coach them when they stumble.

You celebrate them when they succeed.

And eventually, if you’ve done your job well, you step aside.

Looking Back

For much of my career, I thought one of a leader’s primary responsibilities was making good decisions.

I still believe that.

But I’ve come to believe there is another responsibility that may be even more important.

Developing people who can make good decisions without you.

That requires trust.

And trust always carries some risk.

There were people we trusted who disappointed us.

There were hiring decisions that didn’t work.

There were mistakes along the way.

But I would rather occasionally trust the wrong person than build an organization where nobody is ever given the opportunity to grow.

The return on trust isn’t always immediate.

Sometimes it takes years.

But when you watch someone who once doubted themselves become a confident leader, you realize the investment was worth it.

Shannon eventually became a member of our Executive Management Team.

Others we developed went on to lead departments, organizations, and healthcare initiatives far beyond anything we could have imagined when they first came through our doors.

Today, I don’t measure those relationships by how long people worked for me.

I measure them by what they became.

That may be the greatest return trust can ever produce.

A good leader earns trust.

A better leader gives it away.

The career.

The accomplishments.

The leadership positions.

The financial success.

What they rarely see is the foundation that made those things possible.

I’ve been fortunate to have many mentors throughout my life, but the two people who shaped me the most never worked in healthcare, never sat on a corporate board, and never held executive titles.

They were my parents.

My father was a minister of music.

He has played the piano almost every day since he was six years old.

Not because anyone required it.

Because excellence required it.

Some days he practiced for ten minutes.

Other days it was two hours or more.

Year after year.

Decade after decade.

As a child, I didn’t think much about it.

As an adult, I realized I wasn’t just watching someone play the piano.

I was watching discipline.

I was watching commitment.

I was watching someone honor the gifts God had given him by developing them faithfully.

My mother taught me something completely different.

She grew up in a family that didn’t have much money.

Yet somehow, I never felt poor.

She had an incredible ability to stretch every dollar.

She bought clothes so well that kids from wealthier families sometimes wanted to borrow mine.

Looking back, I don’t remember feeling deprived.

I remember feeling cared for.

She taught me that stewardship isn’t about how much you have.

It’s about how faithfully you manage what you’ve been given.

Neither of my parents ever sat me down and gave long lectures about character.

They lived it.

Day after day.

Year after year.

Children notice more than we realize.

Not always in the moment.

But eventually.

I carried my father’s discipline into my work.

I carried my mother’s stewardship into every financial decision I made.

Neither lesson came from a textbook.

Both came from watching ordinary people live extraordinary consistency.

As I’ve gotten older, I’ve become convinced that the greatest influence parents have isn’t found in the advice they give.

It’s found in the life they live.

Children may forget many of our words.

They rarely forget our example.

Looking Back

The older I get, the more grateful I become for foundations that seemed ordinary at the time.

My parents probably never imagined that habits developed in our home would one day influence boardroom decisions, business negotiations, or leadership conversations.

Neither did I.

But that’s the nature of foundations.

Most people never see them.

They only see what was built on top of them.

If I’ve accomplished anything worthwhile in my life, much of the credit belongs to two faithful people who quietly built a foundation long before anyone knew my name.

Their greatest legacy wasn’t what they achieved.

It was what they made possible in the lives of others.

I was working for Tom Griggs, a CPA who had invested a tremendous amount of time teaching me the profession. I had earned my CPA license, gained valuable experience, and worked alongside people I genuinely respected.

But I had become convinced that if I wanted to become a business executive someday, I needed to leave public accounting.

There was just one problem.

I didn’t have another job.

Darlene and I had a mortgage.

We had two young children.

Walking away from a secure career without another opportunity waiting wasn’t something most people would recommend.

In fact, one of my grandfathers thought I had lost my mind.

He couldn’t understand why someone would voluntarily leave a good job without knowing what came next.

To be honest, I understood his concern.

From the outside, it probably looked irresponsible.

But from the inside, it felt different.

I had spent months thinking about the decision.

Praying about it.

Talking with Darlene.

Trying to separate fear from wisdom.

I wasn’t looking for certainty.

I was looking for peace.

People sometimes assume that faith means believing everything will work out exactly the way you hope.

That has never been my understanding.

For me, faith has always been paired with responsibility.

The book of James says, “Faith without works is dead.”

I’ve always believed those two belong together.

Do the work.

Prepare as well as you can.

Think carefully.

Seek wise counsel.

Pray honestly.

Then, when you’ve done everything you know to do, trust God with what you cannot control.

That’s what Darlene and I did.

I gave myself two months to find another job.

I didn’t know where it would come from.

I just knew I couldn’t stay where I was.

About a month later, I was hired by SelectCare.

Looking back, people sometimes ask if I was scared.

Of course I was.

Faith doesn’t remove uncertainty.

It simply gives uncertainty a different perspective.

I knew I might have to return to public accounting if things didn’t work out.

That wasn’t failure.

It was simply one possible outcome.

What mattered most was knowing I had made the decision honestly, prayerfully, and with the support of the people who knew me best.

Looking back now, I don’t remember that season as a gamble.

I remember it as an act of obedience.

Looking Back

As I’ve grown older, I’ve become less interested in predicting outcomes and more interested in making faithful decisions.

The outcome has never been completely mine to control anyway.

My responsibility is to prepare well.

To work hard.

To be honest.

To seek wisdom.

Then to trust God with the rest.

That doesn’t guarantee success.

It never has.

But it does provide something I’ve found even more valuable.

Peace.

And sometimes, peace is the clearest confirmation that you’re already walking in the right direction.

It didn’t matter if I was six years old or sixteen years old.

Just before he hung up, he’d say,

“David, be a leader, not a follower. People are looking for leaders.”

Then he’d tell me goodbye.

That conversation repeated itself for nearly ten years.

As a child, I didn’t fully understand what he meant.

When you’re young, leadership sounds like becoming the captain of the team, the president of the class, or the person standing in front of everyone else.

My grandfather meant something entirely different.

He wasn’t telling me to seek a position.

He was teaching me to accept responsibility.

Over the years, those simple words quietly became part of who I was.

I never felt the need to be the loudest person in the room.

In fact, if you’ve known me very long, you know that’s not my personality at all.

I’m much more comfortable listening than talking.

More comfortable asking questions than giving speeches.

More comfortable working behind the scenes than standing at the podium.

Yet I always expected that, when a situation required someone to step forward, I should be willing to do it.

Not because I wanted recognition.

Because someone had to.

Years later, our organization found itself without a CEO.

For months, we operated in uncertainty while the board searched for the right leader.

Nobody officially asked me to run the organization.

Nobody handed me a new title.

But decisions still had to be made.

Problems still had to be solved.

Physicians still expected answers.

Employees still needed direction.

So I stepped into the gap.

I never considered myself the CEO.

I simply tried to provide the leadership the organization needed until someone else could.

Looking back, I don’t think I was doing anything extraordinary.

I was simply living out words that had been spoken over me since childhood.

“People are looking for leaders.”

I’ve come to believe that leadership has very little to do with titles.

Titles describe authority.

Leadership accepts responsibility.

Some of the finest leaders I’ve ever known never held the highest position in the organization.

They were the people others naturally looked toward when things became uncertain.

They brought calm instead of panic.

Clarity instead of confusion.

Solutions instead of blame.

That’s leadership.

I’ve also learned that leadership carries a quiet cost.

There are days when you make decisions that not everyone understands.

Days when responsibility feels heavy.

Days when you wish someone else would step forward.

Those are usually the moments when leadership matters most.

My grandfather probably never imagined the boardrooms, negotiations, physician meetings, or difficult decisions that would become part of my career.

I doubt he was thinking about healthcare at all.

He was simply teaching his grandson the kind of man he hoped I would become.

His words stayed with me.

They still do.

Looking Back

As I’ve gotten older, I’ve realized that followers wait for permission.

Leaders look for ways to help.

Followers ask,

“Whose job is this?”

Leaders ask,

“What needs to be done?”

Leadership isn’t about having all the answers.

It’s about being willing to carry responsibility when others hesitate.

My grandfather gave me many gifts.

None was more valuable than one sentence repeated hundreds of times.

“Be a leader, not a follower. People are looking for leaders.”

I don’t know if I’ve always lived up to those words.

But I’ve never forgotten them.

During a meeting with our executive team, our CEO, Terry Coplin, looked around the room and said, “David, I think you’re the backbone of this organization.”

I was honored.

At the time, I assumed he was talking about the work I was doing as CFO.

Looking back, I don’t think he was.

I think he was seeing the result of decisions that had been shaping me for more than twenty years.

Long before I negotiated hospital contracts, presented to boards of directors, or led finance teams, I had already decided there were certain things in my life that weren’t negotiable.

When I was sixteen, I worked in the catalog department at JCPenney. My manager wanted me to work Sundays.

I told him I couldn’t.

Sunday was the day my family worshiped together, and I wasn’t willing to give that up.

He wasn’t thrilled with my answer.

But after watching how hard I worked the rest of the week, he finally said, “Let’s give it a try.”

A few years later, I worked in the pharmacy department at Kaiser.

The same conversation happened.

Again, my employer made an exception.

Then I joined Tom Griggs’ CPA firm.

If you’ve ever worked in public accounting during tax season, you know what that means. Long days. Late nights. Seven-day weeks.

Tom worked almost every Sunday.

I told him I wouldn’t.

Not because I wasn’t willing to work.

I was.

I’d gladly put in long hours Monday through Saturday.

But I had already decided there was one commitment I wasn’t willing to compromise.

Tom accepted it.

Looking back, none of those conversations seemed particularly significant.

They certainly didn’t feel like leadership moments.

I wasn’t supervising anyone.

I wasn’t making important business decisions.

I wasn’t trying to make a statement.

I was simply trying to be consistent with what I believed.

Years later, I realized something.

Character is rarely built in life’s biggest moments.

It’s built in the small decisions that nobody remembers.

The world notices the executive who remains calm during a crisis.

It doesn’t notice the teenager who quietly chooses convictions over convenience.

The world notices the leader who earns trust in the boardroom.

It rarely sees the years spent making ordinary decisions that slowly formed that trustworthiness.

When Terry called me the backbone of the organization, he wasn’t complimenting something I had developed overnight.

He was seeing the accumulated weight of thousands of small choices.

Every time I chose consistency over convenience...

Every time I kept a commitment when no one would have blamed me for breaking it...

Every time I decided that my values would shape my schedule instead of the other way around...

Another layer was added to that backbone.

Leadership isn’t built the day someone gives you a title.

It’s built long before anyone notices.

Looking Back

When people ask how leaders earn trust, they usually expect a story about a difficult negotiation, a successful project, or a crisis well handled.

Those moments matter.

But they aren’t where trust begins.

Trust begins when your private decisions consistently match your public values.

The truth is, most of us are building a reputation long before anyone is paying attention.

Looking back, I don’t think Terry was complimenting my leadership.

He was recognizing a lifetime of quiet decisions that had already shaped it.

Backbones aren’t built in boardrooms.

They’re built one decision at a time.

“Tom,” he said, “I bought a brand-new pickup.”

Then he smiled even wider.

“And the best part is...it’s a write-off.”

Tom smiled.

“You still bought a $65,000 truck.”

The tax deduction was real, but it wasn’t free. Spending $65,000 to save a fraction of that in taxes isn’t making money—it’s still spending $65,000.

The owner had become so focused on the tax savings that he lost sight of the much bigger financial decision.

That lesson stayed with me long after I left public accounting.

Years later, I managed a remarkable employee named Coleen. She was everything you hope to find in an accounting manager. Her work papers balanced to the penny—actually, better than that. She wanted everything exactly right. She took ownership of her work, stayed until the job was finished, and made my life as a CFO immeasurably easier.

There was only one problem.

She couldn’t get to work on time.

Our office hours were eight to five. When she started, she asked if she could work nine to six. That seemed perfectly reasonable.

The trouble was, she often couldn’t make it by nine either.

Some mornings she arrived at ten o’clock.

Occasionally even later.

But she would stay until seven-thirty or eight at night if that was what it took to finish the work.

We talked about it.

More than once.

She never argued. She never made excuses. In fact, she’d tell me, “If you need to penalize me, I understand.”

The more I thought about it, the more I realized I was fighting the wrong battle.

What mattered most?

That one of the finest accounting managers I’d ever worked with walked through the door at exactly nine o’clock?

Or that she produced exceptional work, cared deeply about the organization, and never left until the job was done?

Eventually I told her, “I’d like you here by ten whenever possible. If you’re going to be later than that, just stop by my office and let me know.”

Then I stopped fighting it.

Not because punctuality isn’t important.

It is.

But leadership requires more than enforcing rules.

It requires judgment.

Years later, I found myself sitting in a board meeting that had gone on for nearly thirty minutes over a requested payment increase for a physician group.

Finally, I interrupted.

I explained that the increase represented roughly five one-hundredths of one percent of what we were already paying the group each year.

The room went quiet.

The increase was approved, and we moved on.

As I walked out of that meeting, I couldn’t help thinking that we had probably spent more money in executive and board time discussing the issue than the decision itself was worth.

Three different moments.

Three different decades.

Three different careers.

One lesson.

The biggest problem isn’t always the biggest priority.

Leadership isn’t just about solving problems.

It’s about deciding which problems deserve your attention, your time, and your influence.

Every time we insist on winning a small battle, we spend a little leadership capital.

I’d rather spend mine protecting the mission, developing great people, and solving the problems that truly matter.

I’ve found that organizations rarely fail because they ignored one small issue.

They struggle because too many small issues distract them from the important ones.

Every problem deserves a solution.

Not every problem deserves the same urgency.

Not because they changed the outcome.

Because they changed me.

One of those meetings began with a letter from the IRS.

Our organization had been selected for an audit.

I wasn’t particularly concerned. We had good people, a capable CPA, and I genuinely believed we had done everything correctly. In fact, I walked into the meeting expecting the audit to confirm exactly that.

The questions began.

We answered them.

Everything was going about as I expected.

Then I made a mistake.

It wasn’t an accounting mistake.

It wasn’t a financial mistake.

It was a leadership mistake.

Because I was so confident that we had done things correctly, I began talking about how well our organization was doing. I talked about our physicians. I talked about our success. Looking back, I thought I was demonstrating confidence.

What I was really doing was trying to prove something that didn’t need proving.

The audit itself turned out fine.

But that’s not what I remember.

More than twenty years later, I don’t remember most of the tax questions that were asked. I remember walking out of that meeting wishing I had spent less time trying to impress the people across the table and more time simply answering their questions.

For a long time, I believed I had made that mistake because I was overconfident.

I’ve changed my mind.

Looking back now, I don’t think I was overconfident at all.

I think I lacked confidence.

Somewhere inside me was the need to convince the people across the table that I belonged there. I wanted them to know we had built something successful. I wanted them to see that I knew what I was doing.

Years later, I realized something that thirty-five-year-old David couldn’t see.

Performance and confidence are not the same thing.

Performance tries to prove itself.

Confidence doesn’t have to.

That realization changed the way I approached every important meeting after that.

As my career progressed, I had the privilege of watching leaders I deeply respected, especially Terry Coplin and Gregg Melton.

Neither of them walked into a room trying to establish credibility.

They didn’t dominate conversations.

They didn’t rush to answer every question.

They listened.

They asked thoughtful questions.

They were comfortable with silence.

Most importantly, they never seemed to feel the need to prove they belonged in the room.

At the time, I admired that quality.

Today, I understand it.

Real confidence isn’t loud.

Real confidence is comfortable learning.

Somewhere along the way, I learned that my worth wasn’t tied to proving how much I knew.

That may sound like a small distinction, but it changed the way I led.

I became slower to speak.

Quicker to listen.

More willing to say, “I don’t know.”

More willing to ask for another opinion.

Ironically, those changes didn’t make me look weaker.

They made me a better leader.

I still catch myself from time to time.

Before an important meeting, I can feel that old temptation creeping back in—the desire to say just a little more, to demonstrate that I’ve done my homework, to make sure everyone knows I belong.

When that happens, I remind myself of the lesson that IRS audit taught me years ago.

I don’t have to prove myself.

I simply have to contribute.

Looking back, I don’t regret believing we had done things correctly.

I regret believing that being right gave me permission to be impressive.

The day I stopped trying to prove myself was the day I became a better leader.

Looking Back

One of the unexpected gifts of getting older is perspective.

When you’re thirty-five, every important meeting feels like a test.

Every difficult conversation feels like a chance to prove yourself.

Every room feels like it contains people whose opinion will somehow determine your future.

Age doesn’t eliminate those feelings.

But experience teaches you a better question.

Instead of asking, “How do I prove I belong here?”

I now ask,

“How can I leave this conversation better informed than when I walked in?”

That single shift has probably improved more meetings than any presentation skill or financial expertise I ever developed.

I’ve shared this lesson with younger executives over the years, and I usually tell them the same thing.

Don’t confuse talking with leading.

Don’t confuse certainty with wisdom.

And don’t confuse performance with confidence.

The people I’ve respected most throughout my career weren’t the ones with the quickest answers.

They were the ones who made everyone else in the room think more clearly.

That’s the kind of leader I still hope to become.

After retiring, I realized something unexpected.

The lessons that stayed with me weren’t found in spreadsheets. They came from mentors who invested in me, mistakes that humbled me, boardrooms that tested my judgment, conversations that changed my perspective, and the quiet moments when I had to decide what kind of person I wanted to become.

That’s why I created this publication.

It is home to two ongoing series.

The Oregon Health Plan

This series tells the story of an extraordinary chapter in my professional life. It follows the growth of an organization that helped reshape healthcare for thousands of Oregonians and the leadership, financial, and governance decisions that came with it.

These articles are the foundation of a book I’m writing, but they also stand on their own as the story of people trying to build something that mattered.

Lessons Earned

This is a different kind of writing.

Every week, I reflect on one lesson that took me years—sometimes decades—to fully understand.

Some lessons came from success.

Many came from failure.

Others came from watching remarkable people lead with humility, courage, and integrity.

The topics are intentionally broad because life is broad.

Meetings.

Reputation.

Marriage.

Faith.

Risk.

Money.

Friendship.

Boards.

Confidence.

Time.

Grandchildren.

Health.

Leadership.

None of these essays are meant to be the final word on any subject. They’re simply observations from sixty years of living, working, raising a family, building organizations, and trying to become a little wiser than I was yesterday.

If one of these reflections helps you avoid a mistake, make a better decision, or see something from a different perspective, then it has done its job.

What You’ll Find Here

You won’t find outrage.

You won’t find clickbait.

You won’t find easy answers to complicated problems.

What you will find are stories, thoughtful observations, and practical lessons drawn from a lifetime in business, leadership, faith, family, and finance.

My hope is that this becomes more than a newsletter.

I hope it becomes a library—a collection of ideas that people can return to whenever they’re facing an important decision or simply looking for a different perspective.

Whether you’re here because of healthcare, leadership, investing, business, or simple curiosity, I’m grateful you’ve stopped by.

Welcome.

Let’s learn together.

— David Cole

Capitation payments. Physician pools. Hospital pools. Reserves. Provider contracts. Acquisitions. Growth. Financial performance.

Those things mattered.

But looking back now, more than a decade after retiring, I don’t think any of them explain why the organization succeeded.

Not really.

For years, one physician who served both as a provider and Board member would talk about the organization’s secret sauce.

For a long time I assumed he meant contracts. Or reimbursement structures. Or some operational process that made us different from the other plans competing for the same members.

He didn’t.

He meant relationships.

Not contracts. Relationships.

Not reimbursement formulas. Trust.

Trust built over decades of working together, solving problems together, and keeping commitments to one another and to the community we served.

What troubled him after the acquisition wasn’t that the new organization had bad intentions. Quite the opposite. The new leadership valued scale, systems, financial discipline, and standardization. All of those things matter.

But he worried they didn’t fully appreciate how much of the organization’s success rested on relationships that had taken decades to build.

What I remember most about that conversation wasn’t anger.

It was disappointment.

He wasn’t mourning the loss of a contract.

He was mourning something much harder to replace.

Local trust. Local credibility. The human connections that never appear on a balance sheet.

That’s what we built. Over twenty years. One relationship at a time.

Physicians willing to put the community ahead of themselves. Board members willing to make difficult decisions. Leaders willing to think beyond the next quarter. People who kept their word when it would have been easier not to.

The Oregon Health Plan story was never really about healthcare.

Healthcare simply happened to be the setting.

The story was about what can happen when people trust one another, align their incentives, share a common purpose, and commit themselves to building something larger than themselves.

We certainly didn’t get everything right.

No organization ever does.

But for twenty years we built something that improved lives, strengthened a medical community, and served hundreds of thousands of Oregon families.

In the end, that’s enough for me.

Thank you for reading.

Thank you for following along.

This series began as an attempt to explain how one organization grew and why it mattered.

Somewhere along the way, I realized I was writing about something much larger than healthcare.

I’m going to spend some time turning these stories into a book.

I hope you’ll join me when it’s ready.

In 2015 I was CFO of a small regional Medicaid health plan in Lane County, Oregon.

Centene Corporation was one of the largest Medicaid managed care companies in the country.

When they called, I knew exactly what it meant.

What followed wasn’t luck. It was eighteen years of financial discipline that made us impossible to ignore when the moment finally arrived.

I spent eighteen years as CFO of a regional Medicaid health plan in Oregon.

In all that time, no moment stopped me cold like the call from Russell Latham, Chief Examiner for the Oregon Insurance Division.

His message was simple. Raise twelve to fifteen million dollars in ninety days — or we shut your insurance license down.

What happened next taught me something I’ve never forgotten about pressure, positioning, and what financial discipline actually buys you when it matters most.

Watch the clip below.

Not the physicians who contracted with us. Not the hospitals we negotiated with. Not the state agencies we reported to.

The Board.

In a physician-led organization, the Board is easy to take for granted. The doctors are visible. The executives are visible. The Board operates mostly behind closed doors, and their contributions rarely make it into the narrative that gets told afterward.

That needs to be corrected.

Over the years, the Board demonstrated three qualities that I believe were central to everything LIPA and eventually Trillium became. They structured incentives with discipline. They were willing to use their standing within the medical community when the organization needed them to. And they were never too proud to bring in outside voices when the situation called for it.

I want to talk about all three. But I want to start with a story.

It was the early 2000s. We had just absorbed the Providence membership, bringing our total to roughly thirty thousand members. The integration was still fragile. The Providence book of business was not yet profitable, and making it work depended on something that is always harder than it sounds — getting an entire community of specialists to accept adjustments to their reimbursement structures so that the pools funding primary care physicians could function the way they were designed to.

Most specialties had already come to the table. They hadn’t loved it. But they understood the logic and they made the compromises.

The oncologists were a different conversation.

Their position was straightforward, at least from their perspective. They were being asked to accept adjustments on certain procedures, adjustments that would flow into pools that allowed primary care physicians to earn additional income. They didn’t see why that was their problem.

I brought a Board member into that meeting with me. He was an orthopedic surgeon, one of the most respected physicians in Lane County, and a man who would eventually become our Board President. His group had already made the same adjustments we were asking the oncologists to make. He knew exactly what was being asked, because he had already said yes to it himself.

He let the oncologists make their case.

Then he made his.

He didn’t negotiate. He didn’t horse-trade. He pointed out, directly and without much patience for the complaint, that specialists across the community — including his own group — had already made similar sacrifices to make this plan work. He pointed out that specialists as a class were already earning substantially more than the primary care physicians who were the backbone of the entire model. And he told them plainly that asking specialists to make a modest adjustment so that primary care physicians could be fairly compensated was not an injustice. It was the least they could do.

Dr. Friefeld — the physician who had been leading the oncologists’ objections — had nothing left to say.

The meeting ended. The oncologists came to the table.

Later, back in my office, the Board member settled into a chair and laughed.

“Did you see Dr. Friefeld’s face when I called them out?” he said. “He couldn’t even talk.”

I had seen it. The moment the argument was stripped down to its core — you are already the highest paid people in this system, and you’re complaining that primary care physicians might earn a little more — there was nothing left to hide behind. The technical objection evaporated. What remained was a physician who knew he was on the wrong side of a fair argument and had just been told so by someone he couldn’t dismiss.

No CFO could have walked into that room and done what he did. I could have presented the numbers. I could have made the financial case. But the argument that actually landed wasn’t financial. It was moral. And it landed because it came from a physician who had skin in the game, who had made the same sacrifice he was asking them to make, and who had the standing within the medical community to say what needed to be said.

That is what a great Board member looks like.

And that is what I want to spend this epilogue talking about.

The Outside Voice

Not every contribution to the Board came from within the medical community.

At different points over the years, the Board recognized something that physician-led organizations don’t always recognize — that a room full of talented doctors, however accomplished, has blind spots. And that bringing in perspectives from outside healthcare wasn’t a weakness. It was good governance.

The most consequential outside voice arrived around 2010.

Scott Currie came from the CFO world. Long career, sharp instincts, the kind of financial discipline that you either have or you don’t. At the time he joined our Board he was working as a consultant, though he would eventually be recruited to a publicly traded company where he prospered considerably. He was exactly the kind of person the Board needed in that room — someone who could look at a healthcare organization and see it the way a sophisticated businessperson sees it, not just the way a physician sees it.

He didn’t take long to form a view.

What he saw was an organization that had been built carefully over many years, that was performing well, and that had at its center a leadership tandem — Terry and I — that was driving a significant portion of that success. He also saw something the Board may not have fully appreciated from the inside. That the compensation structure, while generous, didn’t adequately reflect what that tandem was worth to the organization’s future. And more importantly, it didn’t create a strong enough reason for us to stay through whatever came next.

He made his case to the Board directly.

He told them they had something rare. Two executives who managed the organization the way you’d want it managed — with discipline, with integrity, with a long view. He argued that protecting that needed to go beyond salary and annual bonus. It required ownership. Real skin in the game. Shares that would vest over time and give Terry and I a compelling reason to see the organization’s story through to its conclusion.

The Board listened. And then they acted.

We had both been accumulating shares for some time, purchasing them gradually as the opportunity arose. But what the Board did in 2010 was different in kind, not just degree. They granted us a considerable equity position that would vest over time — structured specifically to keep us invested in the organization’s long-term success rather than just its annual performance.

When the sale to Centene closed in 2015, our shares vested automatically. Every share. The maximum amount possible.

I have thought about that outcome many times since.

The Board didn’t have to do what they did in 2010. Terry and I were already committed to the organization. We weren’t going anywhere. But they acted anyway, because someone in that room had the experience and the standing to make the case that commitment deserved to be rewarded with ownership — and because the Board had the wisdom to listen.

I have never forgotten that. And I have never stopped being grateful for it.

Scott Currie who made that argument went on to great success of his own, which surprised no one who had spent any time with him. He had the same qualities I always tried to bring to my own work — financial rigor, personal integrity, and the ability to see a situation clearly without letting politics or proximity cloud the view.

I still hold him in the highest regard.

What I Carry With Me

I want to say one more thing before I close this epilogue.

These were physicians at the top of their fields. Surgeons, specialists, community leaders. People who had spent decades earning the kind of standing that can make a room feel smaller the moment they walk in.

With rare exception, I never once felt talked down to.

When we walked into Board meetings they treated me as an equal. Not as staff. Not as a necessary function. As someone whose judgment they respected and whose presence at the table they valued. That carried into other settings too — community events, chance encounters, moments that had nothing to do with business. They spoke well of me when it would have been easy not to bother. They made me feel that what I contributed mattered, not just to the organization, but to them personally.

I have thought about why that stayed with me for so long.

I think it’s because it’s rarer than it should be. Talented people don’t always treat others that way. Accomplished people don’t always make room for the people around them. These physicians did. Consistently. Over twenty years.

They all treated me like I want to treat people.

That is the highest thing I know how to say about someone. And it is the truest thing I can say about the Board that made this organization possible.

(Next: Epilogue 22 — There are a few more things I still need to say.)

When LIPA signed on to manage the health of Lane County’s Medicaid population under a fixed capitation budget, the organization didn’t just take on new paperwork. It took on a fundamentally different identity — one that required reserves, reinsurance, actuarial discipline, and governance infrastructure that hadn’t existed before.

David walks through what that transition actually looked like from the inside: where the uncertainty lived, how IBNR reserves became a daily operational reality, why reinsurance was more art than science, and how the gap between accountability and authority shaped every decision.

With 462,000 OHP members potentially facing new eligibility requirements starting in 2027, and Oregon at risk of losing billions in federal Medicaid funding, the structural tensions LIPA navigated in the 1990s are playing out again — at a much larger scale.

KEY TOPICS COVERED

• What full financial risk actually means for a physician-led organization

• IBNR — Incurred But Not Reported — and why it’s the liability that keeps health plan CFOs humble

• Reinsurance as a tool for managing catastrophic exposure in a fixed-funding environment

• How governance had to become structural, not ceremonial, once real money was at stake

• The gap between accountability and authority — and why that gap never fully closes

• What today’s OHP funding crisis has in common with what LIPA faced thirty years ago

REFERENCED ARTICLE

LIPA Series: “When Responsibility Became Operational”

Read on Substack: david140.substack.com

ABOUT THIS SERIES

Fiscal Pulse Media is a weekly livestream and Substack series hosted by David Cole, retired CFO of LIPA — the physician-led Medicaid health plan that became Trillium Community Health Plan and was acquired by Centene in 2015. The LIPA Series chronicles eighteen years of Oregon Health Plan history from the inside.

These were Lane County physicians who had invested their own money, served on committees, sat through board meetings, and debated decisions that most health plan executives never let doctors near. Trillium wasn’t just a business relationship. It was something they had built together.

When the acquisition closed, an earn-out was structured into the deal — five percent of the purchase price, paid over three years based on continued performance. On paper, it was designed to keep everyone invested in the organization’s success.

What it actually became was a scoreboard.

Each year functioned as its own measurement period. If the agreed-upon targets were achieved, one-third of the earn-out would be paid. If the targets were missed, the payment would be reduced.

At the time, the arrangement made sense to everyone involved.

The acquiring company gained confidence that key relationships and performance would remain intact after the transaction. The physician owners gained an opportunity to participate in the organization’s continued success.

In many ways, I believe both sides genuinely liked the structure.

For the physicians of Lane County, Trillium had become much more than an investment. The company had become a source of pride. It represented something local. Something they had built together. Financially, it had become one of the best investments many of them had ever made. But beyond the financial return, there was a sense of ownership and connection that is difficult to quantify.

The earn-out was intended to preserve some of that connection.

For the first two years, the arrangement appeared to be working.

The performance targets were achieved. The earn-out payments were made.

From the outside, the acquisition looked successful. Membership remained strong. Operations continued. Providers were still seeing patients. The organization remained profitable. Most observers would have concluded that the transition was unfolding largely as expected.

Then came the third year.

The organization was still operating successfully. There was no crisis. There was no dramatic collapse. But several important trends were beginning to move in the wrong direction.

Across the country, healthcare organizations were facing growing cost pressures. Pharmacy expenses were rising rapidly. New specialty medications were entering the market. Behavioral health expenditures continued increasing. Members were utilizing more healthcare services than many organizations had historically projected.

At the same time, maintaining provider relationships was becoming more difficult. Contract negotiations with hospitals, physician groups, and behavioral health providers were becoming increasingly challenging. The relationships that had once helped resolve issues quickly and collaboratively were no longer carrying the same influence they once had.

Around this same period, a new competitor was becoming increasingly active in the market. Whether that alone explains the contracting challenges is impossible to know — but it certainly didn’t make negotiations easier.

What I do know is that the physician community’s relationship with the organization was changing.

The earn-out may have preserved a financial connection, but it did not preserve the same level of engagement. Many of the physicians who had once viewed Trillium as their company gradually shifted their attention elsewhere. The sense of shared ownership that had existed for years began to fade.

That is not a criticism. It is simply the reality of what often happens after an acquisition. People move on. Leadership changes. Priorities change. Organizations evolve.

But when I think back to the physician who called me and described the organization’s “secret sauce,” this is exactly what he was talking about. The contracts still existed. The systems still existed. The reporting structures still existed. But the relationships that had helped make everything work were becoming less central to the organization’s success.

By the third year, the earn-out targets were only partially achieved. The former owners still received a payment, but it was substantially smaller than originally anticipated.

I was not particularly surprised.

By that point, I could already see several trends moving in the wrong direction. Medical expenses were rising faster than funding. Pharmacy costs were increasing throughout the industry. Provider contracting was becoming more difficult. The relationships that had once helped solve problems quickly were no longer as strong as they had been.

For a short time after retirement, I occasionally wondered whether I had left too soon.

Perhaps I should have stayed.

Perhaps the CEO and I should have stayed.

He retired roughly a year after I did, and there were moments when I wondered whether the two of us could have helped navigate some of the challenges that were beginning to emerge.

Those thoughts crossed my mind from time to time.

But only briefly.

The truth is that I was enjoying retirement. After twenty years of helping build the organization, I was ready for a different season of life. I had opened Veneta CrossFit. I was spending more time with family. I was enjoying the freedom that comes when the phone finally stops ringing with operational problems that require immediate attention.

Looking back now, I do not regret my decision.

What the earn-out actually measured wasn’t financial performance.

It measured whether the organization that existed on the day of the acquisition and the organization that would exist three years later were still the same place.

For two years, they were close enough.

By the third year, they weren’t.

No acquisition document captures that. No due diligence process predicts it. It happens gradually — through shifting relationships, changed incentives, new leadership that doesn’t carry the old context. And by the time the scoreboard reflects it, the game has already moved on.

That’s the part of the deal that nobody puts in the press release.

(Next: Epilogue 21 Looking back a decade later — what twenty years inside the boardroom taught me about healthcare, leadership, incentives, and the things that never appear on a balance sheet.)

Health plans are exiting. The state is scrambling. And the headlines are treating this like a new problem.

It isn’t.

Thirty years ago, Oregon made a structural decision to transfer financial risk away from the state and onto local health plans. The mechanism was capitation — a fixed monthly payment per member, paid whether that member used $0 in care or $100,000.

The plan absorbed the loss. Every time.

I spent 18 years as the CFO of LIPA, a physician-led Medicaid health plan right here in Lane County. I lived inside that risk model. I built the spreadsheets. I watched what happened when the assumptions held — and what happened when they didn’t.

In Episode 3, I explain exactly how full financial risk works, why it was survivable in the early years, and how the structural conditions that made it survivable quietly eroded over time.

The $11 billion shortfall didn’t come out of nowhere.

The architecture was always this fragile. We just didn’t see it until the exits started.

🎙️ Listen above or find the podcast wherever you stream. 📖 The companion article — Full Financial Risk: The Quiet Shift — is in the archive. 🔔 New episodes every Tuesday at 8:30am PT. Subscribe so you don’t miss one.

At the time, I was enjoying retirement far more than I had expected.

After years spent managing healthcare operations, budgets, provider negotiations, board meetings, and the countless issues that accompany a growing health plan, I was finally settling into a very different routine. I had opened Veneta CrossFit and was enjoying the challenge of building something completely unrelated to managed healthcare.

In fact, when the call came, I was sitting in Las Vegas enjoying a week of sunshine, relaxation, and admittedly spending some time at the gambling tables.

Healthcare finance was the last thing on my mind.

Apparently, it was very much on theirs.

The acquisition had closed successfully. New leadership structures were in place. The organization was now operating within a much larger corporate environment. I assumed my role in the story had largely ended.

Instead, leadership was beginning to ask questions about the organization’s financial performance and wanted additional perspective from someone who had spent many years helping build the business.

From the outside, the organization still appeared relatively stable.

Membership remained strong. Operations continued. Providers were still seeing patients. Most employees were still showing up every day doing their jobs.

There was no crisis.

The organization was still profitable.

In fact, based on the information available at the time, it appeared likely the organization would still perform well enough to meet the financial targets associated with the earn-out structure established during the acquisition.

The concern was not survival.

The concern was that profitability was not developing the way many expected.

The financial cushion that leadership had anticipated following the acquisition appeared to be narrowing much faster than projected.

Naturally, they wanted to understand why.

Looking back, I think the acquiring organization genuinely believed they could improve performance fairly quickly.

They possessed greater scale, larger resources, more sophisticated systems, and experience operating across multiple healthcare markets. There was understandable confidence that many of the practices and strategies that had worked successfully elsewhere could be applied here as well.

To be fair, those assumptions were not unreasonable.

The organization they had acquired had a long history of growth, strong provider relationships, and solid financial performance.

Combining those strengths with the resources of a larger national organization seemed like a formula for even greater success.

What they would eventually discover, however, was that not every strength of a regional health plan appears neatly on a balance sheet.

Part of the confusion centered around a financial concept that most people outside healthcare organizations rarely think about:

IBNR.

“IBNR” stands for “Incurred But Not Reported” claims reserves.

In simple terms, healthcare organizations must estimate how much money they will eventually owe for medical services that have already occurred but have not yet fully arrived through the claims system.

Those estimates matter enormously because even relatively small differences in reserve assumptions can significantly affect reported profitability.

During my years with the organization, our approach to IBNR had often been more locally calibrated and somewhat more flexible than what larger national organizations typically preferred.

Part of that reflected experience.

Because we operated a smaller regional plan, we knew our provider environment extremely well. We understood local utilization patterns. We understood claims submission timing. We understood which providers historically submitted claims quickly and which tended to submit later.

Over time, we had developed confidence in how aggressively we could manage reserve levels while still remaining financially responsible.

That kind of granular local knowledge takes years to build. It is not something that transfers in an acquisition document or appears in a due diligence report. It lives in the experience of people who sat through the same budget cycles, negotiated with the same providers, and watched the same utilization patterns play out year after year. When those people leave, that knowledge leaves with them.

Importantly, those methodologies were reviewed and supported by outside actuaries who evaluated and approved the reserve assumptions.

Large national healthcare organizations often approach reserves differently.

Once the acquisition occurred, the organization became part of a much larger enterprise-wide financial structure with standardized methodologies applied across multiple health plans and markets.

From their perspective, consistency and conservatism were essential.

Underestimating claims exposure across a national system can create enormous financial risk. More conservative reserve assumptions may reduce reported earnings in the short term, but they also reduce the likelihood of unpleasant surprises later.

As I reviewed the financial information during that temporary return, it became clear that part of the perceived deterioration in profitability reflected those more conservative reserve assumptions.

But that was only part of the story.

Utilization was also increasing.

Members were using more healthcare services. Medical costs were rising. The economics underneath the business were beginning to shift in ways that could not be explained solely by accounting methodology.

The operational pressures documented in earlier weeks had not disappeared. They were simply quieter now — absorbed into a larger system that had not yet fully felt their weight.

After reviewing the information, my conclusion was somewhat different from what some may have expected.

Certainly, utilization trends deserved attention.

The organization was facing real increases in medical expense.

But I also believed a meaningful portion of the financial concern reflected reserve philosophy rather than underlying operational performance.

Based on my familiarity with the provider community, claims submission patterns, and our historical reserve experience, I suggested leadership consider whether the reserve levels had become more conservative than necessary for the local market.

In simple terms, I believed they might be holding more money in reserve than was actually required.

Whether that recommendation was ultimately adopted, I honestly do not know. But in some ways it no longer mattered. The more important question was not whether the reserves were calibrated correctly. It was whether the financial trajectory the acquiring organization had envisioned was still achievable — and that question was becoming harder to answer with confidence.

What leadership was struggling to determine was whether these financial pressures represented temporary integration challenges that would eventually stabilize or whether they reflected more fundamental changes occurring within the business itself.

At the time, I do not believe anyone fully knew the answer.

That is the difference between a problem and a trend. A problem has a fix. A trend has a direction.

What was becoming increasingly clear was that the financial trajectory many had envisioned immediately following the acquisition was not unfolding exactly as planned.

And over the next several years, one unexpected measurement would quietly reveal just how much that trajectory had changed.

(Next: how the earn-out structure gradually became an unexpected measure of how the organization’s financial performance evolved after the acquisition.)

In Episode 2, we go deeper on the question nobody is asking loudly enough: How did we get here?

The answer starts in 1977 — when Oregon made a bet that turned out to be one of its best healthcare policy decisions. But the organizations handed that responsibility weren’t nearly as ready as the contracts implied.

I was one of them.

This episode covers what it actually looked like inside a regional health plan in its early years — the skeleton crew, the reinsurance strategy, the financial risks we were carrying before we fully understood them, and the moment LIPA went from coordinating care to being fully responsible for it.

If you want to understand why regional nonprofits are failing right now, you need to understand what it took to survive then.

The history is the explanation.

He had visibility into both worlds:
the physician community externally,
and the discussions occurring internally within the larger corporate structure.

I could immediately hear the discouragement in his voice.

For years, he had often described the organization’s “secret sauce” as the relationship between the health plan and the physicians throughout the community.

Not simply contracts or reimbursement rates.

Relationships.

Trust built gradually over many years.
Responsiveness during difficult situations.
Familiarity between providers and leadership.
A sense that physicians were working with people who understood the realities of the local healthcare system because they had grown up inside it together.

From his perspective, that “secret sauce” was beginning to disappear.

As both a physician and a board member, he could see the gap widening between how local providers experienced the organization and how the larger corporation viewed the business.

The new organization valued many things appropriately:
scale,
systems,
reporting structures,
financial controls,
and standardization across multiple markets.

But from his perspective, they did not fully appreciate how much of the organization’s historical success had depended upon the strength of its physician relationships and local credibility.

What struck me most during that conversation was not anger.

It was disappointment.

He understood acquisitions naturally bring change.
He understood large organizations require consistency and centralized oversight.
But he also believed something important was being lost during the transition that could not easily be recreated later through process improvements or organizational charts.

That conversation stayed with me because it reinforced something I had already begun sensing from retirement.

From the outside, the organization still appeared stable.

Membership remained large.
The company name still existed.
Most employees continued showing up every day doing their jobs.
And many people looking from a distance would not have recognized how much was changing internally.

But beneath the surface, multiple forms of pressure were building at the same time.

Claims processing problems were frustrating providers.
Decision-making authority had become more centralized.
Longstanding relationships were beginning to weaken.
And utilization was continuing to rise underneath the financial picture.

Individually, each issue might have been manageable.

Together, they began changing the character of the organization itself.

One of the first places this became noticeable was within the provider community.

Healthcare organizations depend heavily on contracts, but contracts alone rarely sustain long-term trust during difficult periods.

Providers want predictability.
They want responsiveness.
And most importantly, they want confidence that when problems arise, someone inside the organization both understands the issue and has the authority to help resolve it.

For many years, much of that trust had been built informally through familiarity and direct access.

Physicians often knew exactly who to call.
Provider offices understood how problems would be escalated.
And over time, confidence developed that issues would eventually get solved, even when the process became difficult.

As organizational complexity increased after the acquisition, that confidence became harder to maintain.

Problems that once might have been resolved through direct communication increasingly moved through larger administrative systems.
Responses sometimes became slower.
Escalation pathways became less clear.
And providers began spending more time navigating process rather than focusing on patient care.

None of this necessarily reflected bad intentions.

In large organizations, standardization is often viewed as discipline and efficiency.

But local healthcare markets often function through relationships as much as systems.

History matters.
Reputation matters.
Trust matters.

And once providers begin losing confidence in responsiveness, frustration spreads quickly.

At the same time, employees inside the organization were also experiencing increasing pressure.

Many had already worked through years of rapid growth and organizational change.
Now they were adapting to new reporting structures, new systems, and new expectations while also managing growing frustration from providers externally.

Healthcare organizations can become emotionally exhausting during periods like this.

Employees often absorb pressure from every direction simultaneously:
from leadership,
from providers,
from regulators,
and from members.

Unlike financial reports, employee fatigue is not always immediately measurable.

People simply begin carrying stress differently.

Communication becomes shorter.
Collaboration becomes harder.
Turnover slowly increases.
Institutional knowledge quietly walks out the door.

One lesson I learned over many years in healthcare is that organizations rarely weaken because of one catastrophic event.

More often, strain accumulates gradually through dozens of smaller unresolved pressures that compound over time.

Relationships weaken.
Trust erodes.
Decision-making slows.
Financial flexibility narrows.

And eventually, leadership finds itself spending more time reacting to problems than preventing them.

At that stage, restoring stability becomes much more difficult.

Looking back now, I do not believe most people fully understood how many simultaneous transitions were occurring beneath the surface during those early post-acquisition years.

The organization still looked successful externally.

But internally, many of the stabilizing forces that had quietly supported it for years were becoming far less durable.

And once enough of those invisible supports begin weakening simultaneously, the effects eventually become impossible to hide.

(Next: returning briefly after retirement to help leadership understand why the financial performance underneath the organization was beginning to change.)

In 1977, a group of Lane County physicians made a quiet decision that most people in the community never noticed. That decision created an organization that would eventually control hundreds of millions of dollars in Medicaid funding — and set the stage for everything that followed over the next four decades.

This is Episode 2 of the LIPA series — the story of how Lane County’s Medicaid system was built, who built it, and why it matters that a local physician-led organization was at the center of it long before anyone was paying attention.

I was the CFO of that organization for 18 years. This is the story I watched from the inside.

In this episode:

• Who founded LIPA and why

• The physician autonomy argument that shaped its original structure

• Why local control mattered — and what it cost to maintain it

• How this one decision created the foundation for everything Trillium and Centene inherited

Episode Number: 1

Season: 1

Tags/Keywords: Medicaid, Oregon Health Plan, Lane County, Healthcare Finance, Health Plan, CFO, Trillium, LIPA