November 21, 2025 • 43 mins
Rural health care has been facing significant headwinds, and that was before the passage of the One Big Beautiful Bill Act (OBBBA), which has introduced additional uncertainty. Donn Herring, Partner, Spencer Fane LLP, speaks with Lori Wightman, CEO, Bothwell Regional Health Center, and Jon Doolittle, President, Missouri Hospital Association, about the unique challenges facing rural health facilities and how government policy has a disproportionate impact on them, focusing on the journey of Wightman’s rural Missouri hospital. Wightman shares some innovative things her hospital is doing to address these challenges while remaining independent, and Doolittle shares how the OBBBA’s Rural Health Transformation Fund is being implemented.
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Episode Transcript
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SPEAKER_00 (00:04):
This episode of AHLA Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmerican Health Law.org.
SPEAKER_03 (00:17):
Hello everyone.
My name is Don Herring.
I'm a partner in the St.
Louis office of the law firm ofSpencer Fain.
I've been practicing law for 35plus years and spent most of my
time in healthcare space thelast 15 years, spending a big
portion of my time working withrural hospitals.
(00:38):
And today we're going to have asession of the Speaking of
Health Law podcast.
We're going to focus on ruralhealthcare and rural hospitals.
And there are a couple of folkswho are really going to lead
this discussion.
I want to take a minute tointroduce each of them so you'll
know who they are and know theirbackground and in that have a
sense of the place from whichthey're speaking as far as their
(00:59):
experience.
First off, our first guest isLori Whiteman.
Lori is the CEO of BothwellRegional Health Center in
Sedalia, Missouri.
And Lurie's background is Loriis the daughter of a father who
was a hospital administrator andthe mother who was a nurse.
And because of that background,she decided she wanted to pursue
(01:21):
both careers.
And she has spent her whole lifein the Midwest living in North
Dakota, Minnesota, Oklahoma, andnow Missouri.
Just a little background onBothwell.
Bothwell is a rural hospital.
It has, in addition to thehospital, 21 clinics and over a
thousand employees and generatesin the neighborhood of$175
(01:43):
million in net revenue per year.
In addition to being a hospitaladministrator, Lori is also a
nurse and has had a nursinglicense for over 45 years, in
addition to 25 years of hospitaladministration experience.
And above, and above all ofthose things, and I've known
Lori for a fairly long period oftime now, I can tell you with
(02:06):
great certainty that Lori is, ifnothing, passionate about rural
communities and how ruralhealthcare serves those
communities.
And so she is in a great placeto be able to share her thoughts
about what currently is takingplace with rural health care.
Our second guest is JohnDoolittle.
John is currently the CEO of theMissouri Hospital Association.
(02:28):
But before that, John wasliterally a small town boy who
left his small town to see theworld and then came back to be
the CEO of his local boyhoodhospital.
John was raised in Albany,Missouri.
And following graduation fromAlbany High School, left Albany
to pursue an undergraduatedegree in government from
(02:50):
Harvard University.
And at least according to onebio I read, John might have may
have been the first person fromAlbany to actually attend
Harvard.
But we will let that stand.
I can't prove it, but that couldbe the case.
Following graduation fromHarvard, John returned to
Missouri and after a period oftime working for the Federal
(03:10):
Reserve in Kansas City, took aposition with Cerner, which is
now part of Oracle.
Eventually he left that positionto become the CEO of his
hospital in Albany, Missouri,where he led that hospital with
an affiliation with a largerfacility in St.
Joseph, Missouri, and in doingso secured a stable future for
(03:33):
his hospital.
In 2021, John became the CEO ofthe Missouri Hospital
Association.
And in that role, he and hisstaff serve the 136
Missouri-based hospitals and thecitizens of Missouri that they
serve.
And so, with that as background,I want to just do a quick kind
(03:54):
of where are we going momentwithin the podcast.
So here, I think we all knowthat healthcare has been a
significant focus of politicaland societal action over the
last several years and really iskind of a top-of-the-news item.
That's especially true since thebeginning of this year, with the
(04:15):
passage of the One Big BeautifulBill Act and the various changes
it's going to cause to Medicaidand ACA coverage.
And with all of those thingshappening, indicators are that
some of the organizations mostheavily affected by those
changes are going to be ruralhealthcare providers and rural
(04:35):
hospitals in particular.
And it isn't as if the OBBBA wasthe beginning point of these
issues.
According to nationalstatistics, over 190 hospitals
have either rural hospitals haveeither closed or ceased
providing inpatient servicessince 2005.
(04:57):
And as of the beginning of thisyear, over 700 rural hospitals
were at risk of closure due tofinancial conditions.
And this is before any changesthat are being uh caused by the
passage of OBBBA.
And so as we sit here today,rural hospitals and rural health
care are facing significantheadwinds.
(05:19):
And really, our purpose of theconversation today is to let
Lori and John discuss thoseissues a little bit and talk
about the path they see forward.
I think the three of us, and Iknow we're not alone, believe
rural health care is vital tothe survival of rural
communities.
And so we are all committed todoing everything we can to make
sure these hospitals survive.
(05:41):
But I think we need to unpackthose issues and hear from the
people in the trenches as towhat's going on so we can help
better understand the issues andwhat that path forward looks
like.
So we're going to do this in aquestion-answer format.
Um, and just to start out, firstquestion, and I'll open it up to
both John and Lori.
(06:01):
For a variety of reasons,healthcare has been a prominent
political and economic issue inthe United States for the last
five years and quite frankly,for years before that.
From your experience, who arethe major stakeholders that are
driving this discussion?
What are their interests?
What are they trying toaccomplish?
(06:22):
And how do hospitals, as kind ofone of the marquee healthcare
providers out there, how do theyfeature in those discussions?
SPEAKER_02 (06:31):
Yeah.
Since most of this conversationshould really feature Lori and
what's going on at Bothwell,I'll take a crack at this one,
Don.
Thanks, John.
Healthcare is uh, I think, moreof a tier one political issue in
this country right now than ithas been in the you know 30 or
so years that I've been agrown-up.
(06:52):
And uh that started a littlebit, I think, with the COVID
pandemic.
I think obviously health andhealthcare came to top of mind
for everybody.
There was a massive societalresponse.
Um, and it really started askingsome interesting questions about
who's an essential worker?
What are the things thatabsolutely have to happen?
(07:13):
What are our obligations andrights uh to each other and all
the rest?
And it really started a framinguh from the perspective of
someone who was a hospitalpresident in a small town when
in in 2020 and 2021.
Um it prompted uh thinking aboutwhy we do what we do from a
(07:34):
healthcare system perspective ina way that I most people had
never done.
And so I think what's followedfrom that has been a lot of
conversation uh about okay, whatdoes it mean access to
healthcare, um, affordability,availability, uh kind of who's
(07:55):
entitled to what, and and howhow do we help each other, how
do we infringe upon each otherwith the decisions that get made
from a healthcare standpoint?
When you talk aboutstakeholders, um, healthcare is
kind of an interesting thingbecause the purchasers of care
aren't always the people whoreceive care, right?
When we think of purchasers ofcare, we might think of the
(08:16):
person who's providing theinsurance.
That could be for people who areon Medicare, Medicaid, a few
other programs.
Those are governmental entities.
Um, largely the privateinsurance in this country comes
through employers.
Um, with that system in placeseveral years ago, we were a
country that had 300 millionpeople and 40 million of them
were uninsured.
(08:37):
And so we went through a processthrough what is now often
referred to as Obamacare, right?
The Affordable Care Act, offiguring out how are we going to
provide access to those 40million people who are
uninsured.
And it was a mix mostly ofeither government programs or
government subsidies.
And as we're recording thistoday, Don, it's early November
(08:57):
and the government has closeddown in part because we're
having conversations aboutwhether or not subsidies should
be available to people who don'tqualify at that sort of safety
net Medicaid level, aren'teligible for Medicare, aren't
covered by employer-sponsoredinsurance, and how much do we as
a society want to intervene inhow affordable health insurance
(09:21):
and how adequate healthinsurance coverage is for those
people.
So that's at the macro level.
People are concerned aboutaffordability.
If you're a purchaser, you'reabsolutely concerned about
affordability and you'reconcerned about quality.
If you're on the provider side,obviously I'll let Lori speak
for herself, but I spent alittle time there and I
represent all the hospitals inMissouri.
(09:42):
You want to be able to take careof people.
These are mission-drivenorganizations that exist to take
care of people.
That means being there when theyneed you with the expertise and
technology to do the job.
We have extraordinary capabilityin this country and we have
extraordinary access, much morethan a lot of countries that
sort of ration or meterhealthcare.
(10:04):
Here, you can get it.
The weights are shorter, thetechnology is available, and
then there are economicrealities around that.
And that that's the mix that weoperate in today is how are we,
as healthcare providers,hospitals and health systems
among them, going to providewhat this country wants and
needs in a way that'ssustainable?
And for us, that often turns tocan we get paid for our work?
(10:28):
Because our work is expensive toproduce, unfortunately.
SPEAKER_03 (10:32):
So, John, listening to your answer, it sounds like
from your perspective, thepandemic, in a way, was almost a
filter that caused people toreally think more critically
about why healthcare isimportant and the value of
having access to it.
And it kind of caused aconsideration of issues that
(10:55):
maybe always lived in thebackground, but people just
didn't think about.
And so this kind of put it inthe front, and now people
started to think about it.
Is that accurate in how you sawthe kind of the sudden or the
renewed focus on healthcare ofthe last five years?
SPEAKER_02 (11:12):
I think it was one of the causal factors, yes.
And I think healthcare providersearly in that time were viewed
as heroic and selfless.
Um, public opinion, it's easy tomeasure.
It really turned againstexperts, against institutions,
in some cases against thegovernment, and against
healthcare providers.
(11:32):
And for those of us who were inthere in the middle of the
pandemic response, it's a verydifficult thing to hear now, a
little bit of revisionisthistory around people thinking
that we were doing things topeople for money.
I was there, man.
Um, we weren't doing things formoney.
We were part of a massiveresponse trying to keep people
safe and save lives.
(11:53):
But from a political standpoint,um, a lot of viewpoints around
COVID response and theinstitutions who were part of it
is a huge causal factor today.
And I think it paves the way forsome of the governmental sort of
policy decisions that we'vetaken around how broadly do we
want to provide coverage, uh,who deserves it, how much should
(12:14):
they pay, and whether or notpeople are seeking to benefit um
in uh inappropriate ways fromthe money that does that flows
through what is a very largepart of the U.S.
economy.
I mean, you gotta say it.
It's five trillion dollars is alot of money.
The U.S.
health economy is the size ofGermany's GDP.
Um, so it's reasonable forpeople to ask those questions
(12:37):
and have their uh perspectivesrepresented from a provider
perspective.
We really try to navigate inthat that in ways that we can
afford to keep providing some ofthe best healthcare services in
the world.
Thanks.
SPEAKER_03 (12:52):
Okay.
Um, Lori, you've lived your lifeas a or your career anyway, in
rural healthcare.
Um, and so you've been deep intothis area for really your entire
career.
For the purposes ofunderstanding, because certainly
most of the population now livesin urban and suburban areas and
(13:13):
experience health care comingfrom that environment.
If we suddenly shift gears andtake all those people and put
them into a rural environment,how would does rural health care
differ from what they might befamiliar with in a suburban or
urban setting?
SPEAKER_01 (13:30):
Well, in many ways, I would say we are uniquely the
same.
Um, we face similar challenges,rural and urban and suburban.
Um, but in a community hospital,we have very personal reasons of
why our care needs to be thesafest, the best, the
friendliest, because we aretaking care of our family
(13:51):
members, our um the teachers ofour children, our co-workers.
Um, it's very personal here.
And for example, a third of theleaders that work here at the
hospital were born here.
I tell them they need to come upwith a secret knock and
handshake.
I mean, it's very personal.
And the connection to worthwhilework and making a difference
(14:16):
happens every day.
Um, and that's why I lovehealthcare and in particular
community hospitals.
Um, I always tell people if Ididn't love it so, I'd be curled
up in the fetal position in thein the corner.
Um the so the challenges are thesame for rural and urban, yet
(14:38):
our ability as a rural hospitalto excel is handicapped by our
size and our location, whetherthat's economies of scale, um,
having robust data capabilities,uh, strategic partnerships with
payers, um, the ability to keepup with our aging
infrastructure.
(14:58):
I'm I'm sitting in a 96-year-oldbuilding, um, and all of the
technological advances, um, thesize of our talent pool and the
ability to recruit to rural uhareas is it handicaps us as a
rural hospital.
Um, and as a rural independenthospital, we are literally at
(15:21):
the bottom of the healthcarefood chain.
Um, there are people in thehealthcare industry that are
making money.
It is not the rural independenthospital.
SPEAKER_03 (15:32):
Now, in in your situation, um, you mentioned
some of the obstacles that youface as far as because of a
remote location, because ofaccess to talent pool, um,
issues along those particularlines.
Um obviously, one of the thingsthat impacts you in a way that
(15:55):
is different from a larger uhurban or suburban hospital has
to be payer mix.
And part of the reason these newchanges that are taking place to
Medicaid and potentially to theACA coverage have a maybe a
disproportionate impact on arural hospital versus a suburban
or urban hospital.
(16:15):
Can you walk through that issuea little bit to help people
understand how that differenceexists and what that really
means in the context of ahospital like Bothwell?
SPEAKER_01 (16:26):
Payer mix you brought up is very different in
rural settings as compared toespecially suburban.
Um and payer mix has to do whatpercentage of your the people
you care for are commercialinsurance or governmental
payers.
And for Bothwell, um, we'rewe're like our rural
(16:47):
counterparts in that 78% of thepatients we care for are paid,
the source of payment is agovernmental, either Medicare or
Medicaid or a small percentageTRICARE, the military.
Um so 78% are not paying at alevel that covers our costs.
(17:10):
So, because governmental payersdon't pay their fair share when
it comes to covering the cost ofproviding care.
Well, you don't make that up involume by 78% not covering the
cost of providing care.
Um, so there's, you know, um, sowe've tried to patch onto that
(17:31):
system of getting an extra boostbecause we have so many of our
patients are being covered byMedicare or Medicaid or our
self-pay.
Um and it it gets chipped awayall the time.
Um, and especially you talkedabout the One Big Beautiful
(17:52):
Bill.
Uh I was recently um uhinterviewed for a different
podcast of how are we going toprepare for the changes that are
coming based on the One BigBeautiful Bill?
I wish we had the luxury ofbeing able to prepare because
we're still trying to deal withdigging out of a major COVID
(18:13):
hole, um, always having umadditional challenges for
reimbursement, uh, MedicareAdvantage plans taking forever
to actually pay us when theyhave a at least have approved,
authorized uh uh the care that'sfor a patient.
So we're we're blocking andtackling with existing
(18:36):
challenges and really notknowing how we are going to um
handle what's out in uh in thefuture.
SPEAKER_03 (18:46):
So uh as I said at the beginning, the one big
beautiful bill act is just onemore brick in a otherwise very
difficult wall to overcome, um,which has been there for a
while.
Now, John mentioned that thatone of the things that that you
have been doing at Bothwell isis continually working in trying
(19:07):
to innovate how care is providedand those types of
relationships, obviously with agoal of enhancing Bothwell's
ability to be financiallystable.
Can you talk about some of theinnovations that you've been
putting into place or thingsyou've done or things that are
kind of on the drawing board tothe extent you're able to share
that information?
SPEAKER_01 (19:28):
Yeah, well, I'll first start with workforce
because we've had some grow yourown program in place for like
long before I got here.
Uh, we've been involved withmedical explorers through the
Boy Scouts for at least 15, 18years.
And in fact, one, and that'sthat's a program through the Boy
(19:48):
Scouts that um, which is now theScouts, I guess, um, that any
high schooler that's interestedthinks they're interested in
healthcare, has an opportunityto shadow, to get some hands-on
experience.
And we even have uh uh uh ENTphysician coming back home in
two years, and he started out asa medical explorer.
(20:12):
So that, I mean, that's uh youhave to have a lot of patience,
but it it's um we've had manycome back that started out as
medical explorers are now nursesor lab techs or um physicians.
Um we've turned up the volume onthat thought in terms of getting
high schoolers um interested inhealthcare careers by being the
(20:35):
healthcare host of thehealthcare strand for the uh
CAPS program that is being doneby our local school district.
And don't ask me what CAPS standfor because I can't remember
right now, but um this is umjuniors and seniors in high
school that have applied to bepart of and they are on site
(21:01):
three, it's um it's a regular umclass they take for the entire
year, and they are here everyday of the week, um, either in
the morning and then a differentsegment is here in the
afternoon.
We have a total of 35 um CAPstudents that are here.
And we're in our second year.
(21:22):
Um that is very immersive.
Uh, the first semester, they aredoing a lot of shadowing, trying
to hone down what of what arethe areas of interest, and then
the second half of the semesteris um the second half of the
year is actually doing projectsum within um in the hospital,
(21:43):
within specific departments orin the clinic.
Um I think it, you know, we'vewe're now have have a total of
70 high schoolers that havecrawled all over our hospital
and clinic, have discoveredpositions they never knew even
existed.
We had um one girl that was veryinterested in um uh being a
(22:05):
nurse, but then she got exposedto social work and decided that
is really what you know wouldget her up in the morning.
So I think uh those kind ofprograms you have to, you know,
it's a long tale or a long uhentry uh uh to that, but I think
uh we're trying to um build thehealthcare workforce of the
(22:28):
future.
You have a greater likelihood ofsomeone uh that wants to stay um
in their hometown uh where alltheir family is to grow your
own.
Uh we grow our own also throughum, we have the first rural
family medicine residencyprogram.
Um we just graduated our ourfirst two um residents this last
(22:53):
summer.
Uh so we have two in everyclass.
It's a three-year program, it'sa fully accredited um GMAC uh
residency program because peoplethat and the first um the last
two years of that three years isspent full time in Sedalia.
Um, so you have a greaterlikelihood that um medical
(23:15):
students or physicians that havespent three years in Sedalia
have a greater likelihood ofwanting to stay or even stay in
a rural area uh when they'redone with their residency
program.
SPEAKER_03 (23:29):
So it sounds so it sounds like you've made some
really big strides in addressingone of the issues that John
referenced earlier, which isworkforce because you the
inability to access qualitycandidates for jobs makes
keeping those jobs filleddifficult.
In a sense, you're doing thebest you can to grow them at
home so that when that timecomes, they're they're already
(23:52):
there and they already know yourorganization.
Um, which again, certainlycoming out of the pandemic, one
of the things that was mostfrequently referenced as a cost
driver was the continual needfor agency nursing and other
outside services to come in tokeep the hospital functioning.
This program over time wouldminimize or eliminate that need
(24:17):
for a hospital like Bothwell.
Is that a fair statement?
SPEAKER_01 (24:20):
Yeah, yes.
And we are fortunate that wehave um a community college in
our town as well.
And we partner very well withthem around nursing, uh, x-ray
lab.
Uh, we developed a nurseresidency program um to um
support nurses as they're umgoing to school and then as they
(24:44):
are a new graduate to help themease into going from student to
being um a nurse.
So it's it's all in um we knowthere's a nursing shortage, it's
only gonna get worse.
Um, and we're trying to keep thepeople that are interested or
(25:04):
get them interested inhealthcare and keep them in
rural communities.
Um I so that's growing your own.
I would also say I identified,you know, we're at the bottom of
the healthcare food chainbecause of size.
Um, and so we are, I'm veryexcited that there are 20 of us
(25:26):
independent hospitals inMissouri that have recently
launched um an independenthospital network.
We haven't even gotten anofficial name yet, um, but we
are um wanting to gain scale,uh, create a clinically
integrated network that puts usat the ability to um have a
(25:49):
robust data warehouse so that wecan also get really good at
improving the health of thepatients we serve and keep them
out of expensive places like ouremergency room or the hospital,
and do that together.
Um in a we're really trying tocreate what uh large health
(26:10):
systems have while remainingindependent.
So I'm I'm very excited aboutthat, and that will help us move
up that healthcare food chain,develop stronger and better
relationships with payers.
Uh, the other thing we do ispilot everything.
Um uh trying out things.
(26:30):
We are one of six pilots in ourstate with our Medicaid program
to pilot being able to provideto Medicaid recipients in our um
county things that are not youtypically covered by Medicaid.
So housing modifications,nutrition counseling, different
(26:50):
home-delivered meals,transportation.
Um, and uh we are in the secondyear of this, and we're showing
that we are able to, once youare able to um uh solve what is
getting in the way of peoplebeing able to focus on health,
like they don't have any heat intheir home, or they um they have
(27:14):
uh no way to access food, um,then they can start talking then
you can get their attention onbeing able to lower their A1C or
address their hypertension.
And we've been successful in umshowing that we can move the
needle on um improving uhpeople's health.
(27:36):
And in a population that'stypically really hard to
influence behavior.
I mean, we talk about we'regoing towards um population
health and getting paid indifferent ways.
Well, it's really about we'removing from getting paid for
doing to getting paid for theability to influence behavior.
(27:58):
Well, that's really hard to do,and especially in a population
that is more concerned about umsocial determinants of health,
um, the things that get in theway of you know, focusing on
health.
SPEAKER_03 (28:16):
So now, John Laurie has given us a laundry list of
things that are taking place atBothwell and the things they're
doing to innovate how care isprovided.
You have a position from whichyou can see what's going on
across the state.
Uh how are things going at theother rural hospitals?
Are you seeing similar types ofinitiatives taking place?
(28:39):
What does that look like fromyour perspective?
SPEAKER_02 (28:43):
Yeah, no, thanks, Don.
I a couple of things, right?
I it's always and or but, right?
So, number one, uh Lori and andBothwell um are at the forefront
of a lot of really interestingdevelopments.
There, there's no question aboutthat.
But she said a couple thingsthat brought to mind for me some
things that I I want thelisteners of this podcast to
understand.
(29:03):
Um my experience with uhhospitals in general, and
perhaps rural hospitals inparticular and rural people, is
that um they're trying to solvea lot of their own problems,
right?
So when we talk about grow yourown strategies, when you talk
about connecting the community,when you talk about going
(29:25):
upstream into these causalfactors and all the rest,
there's not a lot of blameflying around.
And and there's anaccountability that comes with
hospitals and health systems.
Um it sometimes when all elsegoes wrong in society, people
end up in the emergencydepartment.
Uh, when there's a majordisaster, the healthcare
infrastructure is a huge part ofthe response.
(29:45):
And and and the point I want tomake here um strong rural
matters to rural people.
Strong rural matters to thiscountry.
Um, sparsely populated areasthat produce incredible amounts
of food.
Um, that contribute to nationalsecurity, that house a lot of uh
very critical infrastructure forthe country, they're important
(30:07):
to people no matter where theylive.
And the construct that's mostimportant here is um nobody
wants to be anybody's charitycase.
And so, to answer your question,as I look at rural hospitals
around the state, otherhospitals also, but you ask a
question about rural, they'retrying to figure out how to
solve a lot of really difficultchallenges, and they're sharing
(30:30):
ideas and they're comingtogether in different ways.
They're collegial, they'rehelpful, as you would imagine.
Sometimes, sometimes stereotypesare true.
Rural people are hardworking,industrious, and innovative.
And so there are a lot of folkswho are doing the sorts of
things that Lori mentioned here,and they're doing it for the
betterment of the state, thecountry, in addition to
themselves.
SPEAKER_03 (30:50):
You know, that actually, John, makes a great
segue because I think one of thetopics, at least for those of us
that are in the healthcareindustry, that's really been
kind of top of mind for the lastseveral months is part of the
OBBBA, which is these ruralhealth transformation program
funds, which is some additionalmoney that's being put into the
(31:12):
system by the federal governmentin order to enhance innovation
in rural health care in order tomaybe help overcome some of
these things.
And certainly when you readthrough what the federal
government is looking for, thisidea of collaboration and
working together and kind ofovercoming some of the obstacles
(31:33):
created by isolation is kind offorefront in this.
From what you've seen, you know,where where is this process?
I mean, what is what has thestate of Missouri done?
Is it, you know, is it in line?
Obviously, this podcast isn'tMissouri only, but what are you
seeing as far as how the statesare inputting into this process,
what they're setting up asprogramming?
(31:54):
Where do you anticipate thatgoing over the next several
months as this program kind ofhits the ground?
So thoughts on that?
SPEAKER_02 (32:03):
Yeah, no, let me share.
Um Rural Health TransformationProgram was uh an idea that was
born as part of the discussionswith with OBBA.
Um OB3, we start calling it.
Um HR1, you pick.
Um the estimated impact over 10years of the provisions in that
(32:26):
bill, uh pick pick whoever'sestimate you want, uh, could be
close to a trillion dollars inimpact on funding that flows
through states today uh to takecare of people in those states
through social programs,including Medicaid.
So there's no question that umthe way it's written, um impacts
(32:48):
don't happen for a while.
They happen along a timeline.
Um when it comes to eligibilitychecking and things like that,
that that happens a lot sooner.
When it comes to financingchanges around what provider
taxes, state directed payments,a few other things, those are a
little bit further in thefuture.
But they're on the books, andand we we're forced to deal with
the reality that things are uhexpected to change radically in
(33:14):
the amount of federal supportthat will flow to states so that
states can then administer thatMedicaid program that's uh you
know a joint offering of thefederal and state government.
So that's a really big numberand a really big impact
nationwide, maybe a trilliondollars over 10 years.
The rural health transformationprogram, as part of the
(33:35):
negotiations for that bill, wasit was an idea that was born and
eventually it passed as part ofthe law, and it was funded at$50
billion over five years.
Um$50 billion is not a smallamount of money.
Um it pales in comparison to thesize of the impacts that are
expected from other parts ofOB3.
(33:56):
Um, but it should be availablesooner.
Here's how it was structuredhigh-level.
Um it's gonna be equallydistributed over a five-year
period and distributed throughstates.
So individual providerorganizations, hospital
associations, whoever else, theythey got to give input to this
process, but the 50 states wereable to put in an application.
(34:16):
All the states that put in aqualifying application were
going to get um their 150th peryear.
Um, and and those applicationsnow have gone in.
I don't think we've receivedfinal determination on.
I think we did hear that all 50states applied.
I don't know if that means allthe applications were accepted.
But when you think of half ofthe money, 25 billion or 5
(34:39):
billion a year would be equallyspread across 50 states,
regardless of how large theyare, how rural they are, uh,
anything else.
The other part are part of acompetitive process that does
have weighting of how rural areyou, what is the need, what's
your population, and then whatare your ideas?
And CMS came out with a noticeof funding opportunity on
(35:00):
September 15th and said, hey,here's how we want you to apply.
And these are the, this is howwe're gonna score it, and these
are some ideas of what we wantto do.
Um, I'm not the only person whobelieves that there was a fairly
major difference in verbiagebetween um things that came from
individual members of the Houseand Senate in regard to this
(35:21):
fund that talked a lot aboutstabilization, talked a lot
about rural hospitals, talked alot about preserving um rural
infrastructure.
And then the notice of fundingopportunity came out from CMS
and it had a different focus.
And it's not exclusive.
It's not that it's not forhospitals, um, but it was very
much around transformation,which is a different idea than
(35:44):
stabilization.
I get that to stabilize and thenmake sustainable probably is to
transform.
And I'm and I'm not trying tomake an argument here about
anything uh good or bad relatedto RHTP.
Um, you asked, you know, as wepivot here, what are people
thinking?
The 50 states each took anapproach to how they would want
to use this money to help get toa sustainable rural health
(36:08):
delivery system.
Helping the incumbents uh isgoing to be a part of that
everywhere.
Helping the incumbentstransform, helping grow
workforce, helping upskillpeople, helping get people
practicing at the top of theirlicenses.
There are a lot of use oftelehealth, there are a lot of
very popular concepts that werenoted by CMS.
Um the challenge now will be CMSwill make its scoring
(36:31):
determinations, fundingdeterminations.
We should know about thosedeterminations by the end of
this calendar year.
And then states will start toadminister programs over five
years with the goal of helpingrural citizens receive care.
Rural citizens receive care insuburban and urban areas.
But they but that a lot of thecare they receive, a lot of the
(36:52):
connections they have are local,they are very rural.
Um, and and we in Missouri, likeother states, will work to try
to um use this money very wellto help solidify, I would say
stabilize.
I think it's awfully important,uh, and then also seek to
transform uh the delivery systemfor people who receive care in
(37:17):
rural areas.
I have such incredible respectuh for Lori and a whole lot of
people like her who um are inthat situation where the
accountability that I talkedabout for hospitals and health
systems, when all else fails,you go to the ER.
That's true in urban, suburban,and rural settings.
In rural settings, um, folksoften are um the only game in
(37:42):
town in a different way.
And I don't mean that therearen't other independent clinics
or dentists or pharmacists orwhat I mean is from a hospital
or health system perspective,the buck stops with them.
And I think we need to help themdo that well.
SPEAKER_03 (37:57):
Yeah, and and and and again, I do think what you
pointed out there, John, aboutdiscussion of stabilization, but
then pivoting to transformationas it moved from legislation
into kind of regulatory actionfrom CMS is important because
again, the if the focus of thisis these rural hospitals who
(38:19):
have already been identified asyou know, facing an uphill
battle financially, it'sinherently difficult to try to
be innovative while still tryingto just survive.
And so, I mean, I think the waythis has been rolled out, it
it's like they've they've thrownkind of a life preserver out
there, but now they've made itdifficult to get to the life
(38:41):
preserver in order in order tobe stabilized.
So I think it's I think how thisplays out is gonna be uh I would
use the word interesting, butinteresting doesn't really
convey the importance of itbecause how this rolls out for
some will be the differencebetween survival and closing.
SPEAKER_02 (38:58):
Um as an association, Don, we have to
help this go well.
We want to help this go well.
If um if the program pivots alot to studies and technical
assistance, uh and yet it alsois being given the job by
government officials ofstabilizing rural health, then
(39:20):
we've got a difference betweenperception and reality that
could be very damaging.
We we we have clear directionfrom the Missouri congressional
delegation, put this money towork, use it to help people, um,
and and and use it to help ourproviders in the state.
And that's a part of the workthat we'll be doing along with
the state of Missouri.
Great partnerships with thestate, with the governor, with
(39:41):
folks who are trying to figureout how to use this to
transform, uh, but use itresponsibly and and use it for
real effect.
SPEAKER_03 (39:51):
Well, I would love to keep talking longer because I
mean, quite honestly, theseissues we could spend a day and
probably still not scratch thesurface of all of the things
that are taking place and theheadwinds that that hospitals
are facing, rural hospitals inparticular.
Um, but we do have a short time,and I I want to wrap this up
(40:12):
with one, I guess maybe slightlymore personal question.
Um I guess my question for eachof you is how do you maintain
what I perceive as a verypositive attitude when facing
these great difficulties thatare on the horizon?
And I think to survive requiresit, but I even could say
(40:35):
personally, there are days it isreally hard to feel positive
when you when you see theobstacles that are coming, but I
know that you both do.
How do you do that?
How do how does John Doolittle?
How does Lori Whiteman get up inthe morning, you know, with a
smile on your face, ready to goout there and and try again to
slay the dragon that's kind ofheading toward us, but knowing
(40:57):
the difficulty of the task?
SPEAKER_01 (41:02):
Well, I could say I probably need a a healthier way
to deal with stress than Jin.
But uh, you know, I I'm I I'mfueled by that this is the right
work, and I don't want to letthis community or the thousand
people that work for me down.
SPEAKER_02 (41:25):
She means it, man.
SPEAKER_03 (41:26):
Um people I I I I could that was as sincere as the
day is long.
I think that is 100%.
SPEAKER_02 (41:32):
That's why I tried to go first.
I wanted to give Lori the lastword.
Instead, I'm just gonna amplifyher.
Um, she's cool, but she's notunique.
Um there are people all aroundthis state who understand the
tasks they've been given.
Um, they are they are there's alot of pressure being placed on
the healthcare system.
There is a sense that it has toomuch money, it's not providing
(41:55):
good enough outcomes.
Somebody needs to do thisbetter.
I will tell you that there are alot of people who come into this
space looking to carve off asmall piece of that$5 trillion
and try and make a pretty goodliving.
They're not the ones who arecompeting with us to be open at
3 a.m.
taking care of whatever walks inthe emergency department.
People who see the miracles thatare worked in their
(42:15):
organizations and understandthat they are the last line of
defense and the best line ofdefense in so many areas.
It's easy to be mission-driven.
It's easy to get excited abouttaking care of people who take
care of people.
And that's what I think keeps usgoing.
SPEAKER_03 (42:29):
All right.
Well, again, thank you, John andLori, for your time, for your
willingness to share your ideas.
Again, I hope and I believe thatthis information will be helpful
for others.
Um, and and obviously, I wishyou both the best as you
continue down the path of tryingto find the way to get through
the next few years so that we'reall still moving forward,
(42:52):
serving the community uh in thefuture.
So thanks so much, guys.
I appreciate your time, andwe're gonna sign off.
SPEAKER_00 (43:00):
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(43:22):
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SPEAKER_03 (00:17):
Hello everyone.
My name is Don Herring.
I'm a partner in the St.
Louis office of the law firm ofSpencer Fain.
I've been practicing law for 35plus years and spent most of my
time in healthcare space thelast 15 years, spending a big
portion of my time working withrural hospitals.
(00:38):
And today we're going to have asession of the Speaking of
Health Law podcast.
We're going to focus on ruralhealthcare and rural hospitals.
And there are a couple of folkswho are really going to lead
this discussion.
I want to take a minute tointroduce each of them so you'll
know who they are and know theirbackground and in that have a
sense of the place from whichthey're speaking as far as their
(00:59):
experience.
First off, our first guest isLori Whiteman.
Lori is the CEO of BothwellRegional Health Center in
Sedalia, Missouri.
And Lurie's background is Loriis the daughter of a father who
was a hospital administrator andthe mother who was a nurse.
And because of that background,she decided she wanted to pursue
(01:21):
both careers.
And she has spent her whole lifein the Midwest living in North
Dakota, Minnesota, Oklahoma, andnow Missouri.
Just a little background onBothwell.
Bothwell is a rural hospital.
It has, in addition to thehospital, 21 clinics and over a
thousand employees and generatesin the neighborhood of$175
(01:43):
million in net revenue per year.
In addition to being a hospitaladministrator, Lori is also a
nurse and has had a nursinglicense for over 45 years, in
addition to 25 years of hospitaladministration experience.
And above, and above all ofthose things, and I've known
Lori for a fairly long period oftime now, I can tell you with
(02:06):
great certainty that Lori is, ifnothing, passionate about rural
communities and how ruralhealthcare serves those
communities.
And so she is in a great placeto be able to share her thoughts
about what currently is takingplace with rural health care.
Our second guest is JohnDoolittle.
John is currently the CEO of theMissouri Hospital Association.
(02:28):
But before that, John wasliterally a small town boy who
left his small town to see theworld and then came back to be
the CEO of his local boyhoodhospital.
John was raised in Albany,Missouri.
And following graduation fromAlbany High School, left Albany
to pursue an undergraduatedegree in government from
(02:50):
Harvard University.
And at least according to onebio I read, John might have may
have been the first person fromAlbany to actually attend
Harvard.
But we will let that stand.
I can't prove it, but that couldbe the case.
Following graduation fromHarvard, John returned to
Missouri and after a period oftime working for the Federal
(03:10):
Reserve in Kansas City, took aposition with Cerner, which is
now part of Oracle.
Eventually he left that positionto become the CEO of his
hospital in Albany, Missouri,where he led that hospital with
an affiliation with a largerfacility in St.
Joseph, Missouri, and in doingso secured a stable future for
(03:33):
his hospital.
In 2021, John became the CEO ofthe Missouri Hospital
Association.
And in that role, he and hisstaff serve the 136
Missouri-based hospitals and thecitizens of Missouri that they
serve.
And so, with that as background,I want to just do a quick kind
(03:54):
of where are we going momentwithin the podcast.
So here, I think we all knowthat healthcare has been a
significant focus of politicaland societal action over the
last several years and really iskind of a top-of-the-news item.
That's especially true since thebeginning of this year, with the
(04:15):
passage of the One Big BeautifulBill Act and the various changes
it's going to cause to Medicaidand ACA coverage.
And with all of those thingshappening, indicators are that
some of the organizations mostheavily affected by those
changes are going to be ruralhealthcare providers and rural
(04:35):
hospitals in particular.
And it isn't as if the OBBBA wasthe beginning point of these
issues.
According to nationalstatistics, over 190 hospitals
have either rural hospitals haveeither closed or ceased
providing inpatient servicessince 2005.
(04:57):
And as of the beginning of thisyear, over 700 rural hospitals
were at risk of closure due tofinancial conditions.
And this is before any changesthat are being uh caused by the
passage of OBBBA.
And so as we sit here today,rural hospitals and rural health
care are facing significantheadwinds.
(05:19):
And really, our purpose of theconversation today is to let
Lori and John discuss thoseissues a little bit and talk
about the path they see forward.
I think the three of us, and Iknow we're not alone, believe
rural health care is vital tothe survival of rural
communities.
And so we are all committed todoing everything we can to make
sure these hospitals survive.
(05:41):
But I think we need to unpackthose issues and hear from the
people in the trenches as towhat's going on so we can help
better understand the issues andwhat that path forward looks
like.
So we're going to do this in aquestion-answer format.
Um, and just to start out, firstquestion, and I'll open it up to
both John and Lori.
(06:01):
For a variety of reasons,healthcare has been a prominent
political and economic issue inthe United States for the last
five years and quite frankly,for years before that.
From your experience, who arethe major stakeholders that are
driving this discussion?
What are their interests?
What are they trying toaccomplish?
(06:22):
And how do hospitals, as kind ofone of the marquee healthcare
providers out there, how do theyfeature in those discussions?
SPEAKER_02 (06:31):
Yeah.
Since most of this conversationshould really feature Lori and
what's going on at Bothwell,I'll take a crack at this one,
Don.
Thanks, John.
Healthcare is uh, I think, moreof a tier one political issue in
this country right now than ithas been in the you know 30 or
so years that I've been agrown-up.
(06:52):
And uh that started a littlebit, I think, with the COVID
pandemic.
I think obviously health andhealthcare came to top of mind
for everybody.
There was a massive societalresponse.
Um, and it really started askingsome interesting questions about
who's an essential worker?
What are the things thatabsolutely have to happen?
(07:13):
What are our obligations andrights uh to each other and all
the rest?
And it really started a framinguh from the perspective of
someone who was a hospitalpresident in a small town when
in in 2020 and 2021.
Um it prompted uh thinking aboutwhy we do what we do from a
(07:34):
healthcare system perspective ina way that I most people had
never done.
And so I think what's followedfrom that has been a lot of
conversation uh about okay, whatdoes it mean access to
healthcare, um, affordability,availability, uh kind of who's
(07:55):
entitled to what, and and howhow do we help each other, how
do we infringe upon each otherwith the decisions that get made
from a healthcare standpoint?
When you talk aboutstakeholders, um, healthcare is
kind of an interesting thingbecause the purchasers of care
aren't always the people whoreceive care, right?
When we think of purchasers ofcare, we might think of the
(08:16):
person who's providing theinsurance.
That could be for people who areon Medicare, Medicaid, a few
other programs.
Those are governmental entities.
Um, largely the privateinsurance in this country comes
through employers.
Um, with that system in placeseveral years ago, we were a
country that had 300 millionpeople and 40 million of them
were uninsured.
(08:37):
And so we went through a processthrough what is now often
referred to as Obamacare, right?
The Affordable Care Act, offiguring out how are we going to
provide access to those 40million people who are
uninsured.
And it was a mix mostly ofeither government programs or
government subsidies.
And as we're recording thistoday, Don, it's early November
(08:57):
and the government has closeddown in part because we're
having conversations aboutwhether or not subsidies should
be available to people who don'tqualify at that sort of safety
net Medicaid level, aren'teligible for Medicare, aren't
covered by employer-sponsoredinsurance, and how much do we as
a society want to intervene inhow affordable health insurance
(09:21):
and how adequate healthinsurance coverage is for those
people.
So that's at the macro level.
People are concerned aboutaffordability.
If you're a purchaser, you'reabsolutely concerned about
affordability and you'reconcerned about quality.
If you're on the provider side,obviously I'll let Lori speak
for herself, but I spent alittle time there and I
represent all the hospitals inMissouri.
(09:42):
You want to be able to take careof people.
These are mission-drivenorganizations that exist to take
care of people.
That means being there when theyneed you with the expertise and
technology to do the job.
We have extraordinary capabilityin this country and we have
extraordinary access, much morethan a lot of countries that
sort of ration or meterhealthcare.
(10:04):
Here, you can get it.
The weights are shorter, thetechnology is available, and
then there are economicrealities around that.
And that that's the mix that weoperate in today is how are we,
as healthcare providers,hospitals and health systems
among them, going to providewhat this country wants and
needs in a way that'ssustainable?
And for us, that often turns tocan we get paid for our work?
(10:28):
Because our work is expensive toproduce, unfortunately.
SPEAKER_03 (10:32):
So, John, listening to your answer, it sounds like
from your perspective, thepandemic, in a way, was almost a
filter that caused people toreally think more critically
about why healthcare isimportant and the value of
having access to it.
And it kind of caused aconsideration of issues that
(10:55):
maybe always lived in thebackground, but people just
didn't think about.
And so this kind of put it inthe front, and now people
started to think about it.
Is that accurate in how you sawthe kind of the sudden or the
renewed focus on healthcare ofthe last five years?
SPEAKER_02 (11:12):
I think it was one of the causal factors, yes.
And I think healthcare providersearly in that time were viewed
as heroic and selfless.
Um, public opinion, it's easy tomeasure.
It really turned againstexperts, against institutions,
in some cases against thegovernment, and against
healthcare providers.
(11:32):
And for those of us who were inthere in the middle of the
pandemic response, it's a verydifficult thing to hear now, a
little bit of revisionisthistory around people thinking
that we were doing things topeople for money.
I was there, man.
Um, we weren't doing things formoney.
We were part of a massiveresponse trying to keep people
safe and save lives.
(11:53):
But from a political standpoint,um, a lot of viewpoints around
COVID response and theinstitutions who were part of it
is a huge causal factor today.
And I think it paves the way forsome of the governmental sort of
policy decisions that we'vetaken around how broadly do we
want to provide coverage, uh,who deserves it, how much should
(12:14):
they pay, and whether or notpeople are seeking to benefit um
in uh inappropriate ways fromthe money that does that flows
through what is a very largepart of the U.S.
economy.
I mean, you gotta say it.
It's five trillion dollars is alot of money.
The U.S.
health economy is the size ofGermany's GDP.
Um, so it's reasonable forpeople to ask those questions
(12:37):
and have their uh perspectivesrepresented from a provider
perspective.
We really try to navigate inthat that in ways that we can
afford to keep providing some ofthe best healthcare services in
the world.
Thanks.
SPEAKER_03 (12:52):
Okay.
Um, Lori, you've lived your lifeas a or your career anyway, in
rural healthcare.
Um, and so you've been deep intothis area for really your entire
career.
For the purposes ofunderstanding, because certainly
most of the population now livesin urban and suburban areas and
(13:13):
experience health care comingfrom that environment.
If we suddenly shift gears andtake all those people and put
them into a rural environment,how would does rural health care
differ from what they might befamiliar with in a suburban or
urban setting?
SPEAKER_01 (13:30):
Well, in many ways, I would say we are uniquely the
same.
Um, we face similar challenges,rural and urban and suburban.
Um, but in a community hospital,we have very personal reasons of
why our care needs to be thesafest, the best, the
friendliest, because we aretaking care of our family
(13:51):
members, our um the teachers ofour children, our co-workers.
Um, it's very personal here.
And for example, a third of theleaders that work here at the
hospital were born here.
I tell them they need to come upwith a secret knock and
handshake.
I mean, it's very personal.
And the connection to worthwhilework and making a difference
(14:16):
happens every day.
Um, and that's why I lovehealthcare and in particular
community hospitals.
Um, I always tell people if Ididn't love it so, I'd be curled
up in the fetal position in thein the corner.
Um the so the challenges are thesame for rural and urban, yet
(14:38):
our ability as a rural hospitalto excel is handicapped by our
size and our location, whetherthat's economies of scale, um,
having robust data capabilities,uh, strategic partnerships with
payers, um, the ability to keepup with our aging
infrastructure.
(14:58):
I'm I'm sitting in a 96-year-oldbuilding, um, and all of the
technological advances, um, thesize of our talent pool and the
ability to recruit to rural uhareas is it handicaps us as a
rural hospital.
Um, and as a rural independenthospital, we are literally at
(15:21):
the bottom of the healthcarefood chain.
Um, there are people in thehealthcare industry that are
making money.
It is not the rural independenthospital.
SPEAKER_03 (15:32):
Now, in in your situation, um, you mentioned
some of the obstacles that youface as far as because of a
remote location, because ofaccess to talent pool, um,
issues along those particularlines.
Um obviously, one of the thingsthat impacts you in a way that
(15:55):
is different from a larger uhurban or suburban hospital has
to be payer mix.
And part of the reason these newchanges that are taking place to
Medicaid and potentially to theACA coverage have a maybe a
disproportionate impact on arural hospital versus a suburban
or urban hospital.
(16:15):
Can you walk through that issuea little bit to help people
understand how that differenceexists and what that really
means in the context of ahospital like Bothwell?
SPEAKER_01 (16:26):
Payer mix you brought up is very different in
rural settings as compared toespecially suburban.
Um and payer mix has to do whatpercentage of your the people
you care for are commercialinsurance or governmental
payers.
And for Bothwell, um, we'rewe're like our rural
(16:47):
counterparts in that 78% of thepatients we care for are paid,
the source of payment is agovernmental, either Medicare or
Medicaid or a small percentageTRICARE, the military.
Um so 78% are not paying at alevel that covers our costs.
(17:10):
So, because governmental payersdon't pay their fair share when
it comes to covering the cost ofproviding care.
Well, you don't make that up involume by 78% not covering the
cost of providing care.
Um, so there's, you know, um, sowe've tried to patch onto that
(17:31):
system of getting an extra boostbecause we have so many of our
patients are being covered byMedicare or Medicaid or our
self-pay.
Um and it it gets chipped awayall the time.
Um, and especially you talkedabout the One Big Beautiful
(17:52):
Bill.
Uh I was recently um uhinterviewed for a different
podcast of how are we going toprepare for the changes that are
coming based on the One BigBeautiful Bill?
I wish we had the luxury ofbeing able to prepare because
we're still trying to deal withdigging out of a major COVID
(18:13):
hole, um, always having umadditional challenges for
reimbursement, uh, MedicareAdvantage plans taking forever
to actually pay us when theyhave a at least have approved,
authorized uh uh the care that'sfor a patient.
So we're we're blocking andtackling with existing
(18:36):
challenges and really notknowing how we are going to um
handle what's out in uh in thefuture.
SPEAKER_03 (18:46):
So uh as I said at the beginning, the one big
beautiful bill act is just onemore brick in a otherwise very
difficult wall to overcome, um,which has been there for a
while.
Now, John mentioned that thatone of the things that that you
have been doing at Bothwell isis continually working in trying
(19:07):
to innovate how care is providedand those types of
relationships, obviously with agoal of enhancing Bothwell's
ability to be financiallystable.
Can you talk about some of theinnovations that you've been
putting into place or thingsyou've done or things that are
kind of on the drawing board tothe extent you're able to share
that information?
SPEAKER_01 (19:28):
Yeah, well, I'll first start with workforce
because we've had some grow yourown program in place for like
long before I got here.
Uh, we've been involved withmedical explorers through the
Boy Scouts for at least 15, 18years.
And in fact, one, and that'sthat's a program through the Boy
(19:48):
Scouts that um, which is now theScouts, I guess, um, that any
high schooler that's interestedthinks they're interested in
healthcare, has an opportunityto shadow, to get some hands-on
experience.
And we even have uh uh uh ENTphysician coming back home in
two years, and he started out asa medical explorer.
(20:12):
So that, I mean, that's uh youhave to have a lot of patience,
but it it's um we've had manycome back that started out as
medical explorers are now nursesor lab techs or um physicians.
Um we've turned up the volume onthat thought in terms of getting
high schoolers um interested inhealthcare careers by being the
(20:35):
healthcare host of thehealthcare strand for the uh
CAPS program that is being doneby our local school district.
And don't ask me what CAPS standfor because I can't remember
right now, but um this is umjuniors and seniors in high
school that have applied to bepart of and they are on site
(21:01):
three, it's um it's a regular umclass they take for the entire
year, and they are here everyday of the week, um, either in
the morning and then a differentsegment is here in the
afternoon.
We have a total of 35 um CAPstudents that are here.
And we're in our second year.
(21:22):
Um that is very immersive.
Uh, the first semester, they aredoing a lot of shadowing, trying
to hone down what of what arethe areas of interest, and then
the second half of the semesteris um the second half of the
year is actually doing projectsum within um in the hospital,
(21:43):
within specific departments orin the clinic.
Um I think it, you know, we'vewe're now have have a total of
70 high schoolers that havecrawled all over our hospital
and clinic, have discoveredpositions they never knew even
existed.
We had um one girl that was veryinterested in um uh being a
(22:05):
nurse, but then she got exposedto social work and decided that
is really what you know wouldget her up in the morning.
So I think uh those kind ofprograms you have to, you know,
it's a long tale or a long uhentry uh uh to that, but I think
uh we're trying to um build thehealthcare workforce of the
(22:28):
future.
You have a greater likelihood ofsomeone uh that wants to stay um
in their hometown uh where alltheir family is to grow your
own.
Uh we grow our own also throughum, we have the first rural
family medicine residencyprogram.
Um we just graduated our ourfirst two um residents this last
(22:53):
summer.
Uh so we have two in everyclass.
It's a three-year program, it'sa fully accredited um GMAC uh
residency program because peoplethat and the first um the last
two years of that three years isspent full time in Sedalia.
Um, so you have a greaterlikelihood that um medical
(23:15):
students or physicians that havespent three years in Sedalia
have a greater likelihood ofwanting to stay or even stay in
a rural area uh when they'redone with their residency
program.
SPEAKER_03 (23:29):
So it sounds so it sounds like you've made some
really big strides in addressingone of the issues that John
referenced earlier, which isworkforce because you the
inability to access qualitycandidates for jobs makes
keeping those jobs filleddifficult.
In a sense, you're doing thebest you can to grow them at
home so that when that timecomes, they're they're already
(23:52):
there and they already know yourorganization.
Um, which again, certainlycoming out of the pandemic, one
of the things that was mostfrequently referenced as a cost
driver was the continual needfor agency nursing and other
outside services to come in tokeep the hospital functioning.
This program over time wouldminimize or eliminate that need
(24:17):
for a hospital like Bothwell.
Is that a fair statement?
SPEAKER_01 (24:20):
Yeah, yes.
And we are fortunate that wehave um a community college in
our town as well.
And we partner very well withthem around nursing, uh, x-ray
lab.
Uh, we developed a nurseresidency program um to um
support nurses as they're umgoing to school and then as they
(24:44):
are a new graduate to help themease into going from student to
being um a nurse.
So it's it's all in um we knowthere's a nursing shortage, it's
only gonna get worse.
Um, and we're trying to keep thepeople that are interested or
(25:04):
get them interested inhealthcare and keep them in
rural communities.
Um I so that's growing your own.
I would also say I identified,you know, we're at the bottom of
the healthcare food chainbecause of size.
Um, and so we are, I'm veryexcited that there are 20 of us
(25:26):
independent hospitals inMissouri that have recently
launched um an independenthospital network.
We haven't even gotten anofficial name yet, um, but we
are um wanting to gain scale,uh, create a clinically
integrated network that puts usat the ability to um have a
(25:49):
robust data warehouse so that wecan also get really good at
improving the health of thepatients we serve and keep them
out of expensive places like ouremergency room or the hospital,
and do that together.
Um in a we're really trying tocreate what uh large health
(26:10):
systems have while remainingindependent.
So I'm I'm very excited aboutthat, and that will help us move
up that healthcare food chain,develop stronger and better
relationships with payers.
Uh, the other thing we do ispilot everything.
Um uh trying out things.
(26:30):
We are one of six pilots in ourstate with our Medicaid program
to pilot being able to provideto Medicaid recipients in our um
county things that are not youtypically covered by Medicaid.
So housing modifications,nutrition counseling, different
(26:50):
home-delivered meals,transportation.
Um, and uh we are in the secondyear of this, and we're showing
that we are able to, once youare able to um uh solve what is
getting in the way of peoplebeing able to focus on health,
like they don't have any heat intheir home, or they um they have
(27:14):
uh no way to access food, um,then they can start talking then
you can get their attention onbeing able to lower their A1C or
address their hypertension.
And we've been successful in umshowing that we can move the
needle on um improving uhpeople's health.
(27:36):
And in a population that'stypically really hard to
influence behavior.
I mean, we talk about we'regoing towards um population
health and getting paid indifferent ways.
Well, it's really about we'removing from getting paid for
doing to getting paid for theability to influence behavior.
(27:58):
Well, that's really hard to do,and especially in a population
that is more concerned about umsocial determinants of health,
um, the things that get in theway of you know, focusing on
health.
SPEAKER_03 (28:16):
So now, John Laurie has given us a laundry list of
things that are taking place atBothwell and the things they're
doing to innovate how care isprovided.
You have a position from whichyou can see what's going on
across the state.
Uh how are things going at theother rural hospitals?
Are you seeing similar types ofinitiatives taking place?
(28:39):
What does that look like fromyour perspective?
SPEAKER_02 (28:43):
Yeah, no, thanks, Don.
I a couple of things, right?
I it's always and or but, right?
So, number one, uh Lori and andBothwell um are at the forefront
of a lot of really interestingdevelopments.
There, there's no question aboutthat.
But she said a couple thingsthat brought to mind for me some
things that I I want thelisteners of this podcast to
understand.
(29:03):
Um my experience with uhhospitals in general, and
perhaps rural hospitals inparticular and rural people, is
that um they're trying to solvea lot of their own problems,
right?
So when we talk about grow yourown strategies, when you talk
about connecting the community,when you talk about going
(29:25):
upstream into these causalfactors and all the rest,
there's not a lot of blameflying around.
And and there's anaccountability that comes with
hospitals and health systems.
Um it sometimes when all elsegoes wrong in society, people
end up in the emergencydepartment.
Uh, when there's a majordisaster, the healthcare
infrastructure is a huge part ofthe response.
(29:45):
And and and the point I want tomake here um strong rural
matters to rural people.
Strong rural matters to thiscountry.
Um, sparsely populated areasthat produce incredible amounts
of food.
Um, that contribute to nationalsecurity, that house a lot of uh
very critical infrastructure forthe country, they're important
(30:07):
to people no matter where theylive.
And the construct that's mostimportant here is um nobody
wants to be anybody's charitycase.
And so, to answer your question,as I look at rural hospitals
around the state, otherhospitals also, but you ask a
question about rural, they'retrying to figure out how to
solve a lot of really difficultchallenges, and they're sharing
(30:30):
ideas and they're comingtogether in different ways.
They're collegial, they'rehelpful, as you would imagine.
Sometimes, sometimes stereotypesare true.
Rural people are hardworking,industrious, and innovative.
And so there are a lot of folkswho are doing the sorts of
things that Lori mentioned here,and they're doing it for the
betterment of the state, thecountry, in addition to
themselves.
SPEAKER_03 (30:50):
You know, that actually, John, makes a great
segue because I think one of thetopics, at least for those of us
that are in the healthcareindustry, that's really been
kind of top of mind for the lastseveral months is part of the
OBBBA, which is these ruralhealth transformation program
funds, which is some additionalmoney that's being put into the
(31:12):
system by the federal governmentin order to enhance innovation
in rural health care in order tomaybe help overcome some of
these things.
And certainly when you readthrough what the federal
government is looking for, thisidea of collaboration and
working together and kind ofovercoming some of the obstacles
(31:33):
created by isolation is kind offorefront in this.
From what you've seen, you know,where where is this process?
I mean, what is what has thestate of Missouri done?
Is it, you know, is it in line?
Obviously, this podcast isn'tMissouri only, but what are you
seeing as far as how the statesare inputting into this process,
what they're setting up asprogramming?
(31:54):
Where do you anticipate thatgoing over the next several
months as this program kind ofhits the ground?
So thoughts on that?
SPEAKER_02 (32:03):
Yeah, no, let me share.
Um Rural Health TransformationProgram was uh an idea that was
born as part of the discussionswith with OBBA.
Um OB3, we start calling it.
Um HR1, you pick.
Um the estimated impact over 10years of the provisions in that
(32:26):
bill, uh pick pick whoever'sestimate you want, uh, could be
close to a trillion dollars inimpact on funding that flows
through states today uh to takecare of people in those states
through social programs,including Medicaid.
So there's no question that umthe way it's written, um impacts
(32:48):
don't happen for a while.
They happen along a timeline.
Um when it comes to eligibilitychecking and things like that,
that that happens a lot sooner.
When it comes to financingchanges around what provider
taxes, state directed payments,a few other things, those are a
little bit further in thefuture.
But they're on the books, andand we we're forced to deal with
the reality that things are uhexpected to change radically in
(33:14):
the amount of federal supportthat will flow to states so that
states can then administer thatMedicaid program that's uh you
know a joint offering of thefederal and state government.
So that's a really big numberand a really big impact
nationwide, maybe a trilliondollars over 10 years.
The rural health transformationprogram, as part of the
(33:35):
negotiations for that bill, wasit was an idea that was born and
eventually it passed as part ofthe law, and it was funded at$50
billion over five years.
Um$50 billion is not a smallamount of money.
Um it pales in comparison to thesize of the impacts that are
expected from other parts ofOB3.
(33:56):
Um, but it should be availablesooner.
Here's how it was structuredhigh-level.
Um it's gonna be equallydistributed over a five-year
period and distributed throughstates.
So individual providerorganizations, hospital
associations, whoever else, theythey got to give input to this
process, but the 50 states wereable to put in an application.
(34:16):
All the states that put in aqualifying application were
going to get um their 150th peryear.
Um, and and those applicationsnow have gone in.
I don't think we've receivedfinal determination on.
I think we did hear that all 50states applied.
I don't know if that means allthe applications were accepted.
But when you think of half ofthe money, 25 billion or 5
(34:39):
billion a year would be equallyspread across 50 states,
regardless of how large theyare, how rural they are, uh,
anything else.
The other part are part of acompetitive process that does
have weighting of how rural areyou, what is the need, what's
your population, and then whatare your ideas?
And CMS came out with a noticeof funding opportunity on
(35:00):
September 15th and said, hey,here's how we want you to apply.
And these are the, this is howwe're gonna score it, and these
are some ideas of what we wantto do.
Um, I'm not the only person whobelieves that there was a fairly
major difference in verbiagebetween um things that came from
individual members of the Houseand Senate in regard to this
(35:21):
fund that talked a lot aboutstabilization, talked a lot
about rural hospitals, talked alot about preserving um rural
infrastructure.
And then the notice of fundingopportunity came out from CMS
and it had a different focus.
And it's not exclusive.
It's not that it's not forhospitals, um, but it was very
much around transformation,which is a different idea than
(35:44):
stabilization.
I get that to stabilize and thenmake sustainable probably is to
transform.
And I'm and I'm not trying tomake an argument here about
anything uh good or bad relatedto RHTP.
Um, you asked, you know, as wepivot here, what are people
thinking?
The 50 states each took anapproach to how they would want
to use this money to help get toa sustainable rural health
(36:08):
delivery system.
Helping the incumbents uh isgoing to be a part of that
everywhere.
Helping the incumbentstransform, helping grow
workforce, helping upskillpeople, helping get people
practicing at the top of theirlicenses.
There are a lot of use oftelehealth, there are a lot of
very popular concepts that werenoted by CMS.
Um the challenge now will be CMSwill make its scoring
(36:31):
determinations, fundingdeterminations.
We should know about thosedeterminations by the end of
this calendar year.
And then states will start toadminister programs over five
years with the goal of helpingrural citizens receive care.
Rural citizens receive care insuburban and urban areas.
But they but that a lot of thecare they receive, a lot of the
(36:52):
connections they have are local,they are very rural.
Um, and and we in Missouri, likeother states, will work to try
to um use this money very wellto help solidify, I would say
stabilize.
I think it's awfully important,uh, and then also seek to
transform uh the delivery systemfor people who receive care in
(37:17):
rural areas.
I have such incredible respectuh for Lori and a whole lot of
people like her who um are inthat situation where the
accountability that I talkedabout for hospitals and health
systems, when all else fails,you go to the ER.
That's true in urban, suburban,and rural settings.
In rural settings, um, folksoften are um the only game in
(37:42):
town in a different way.
And I don't mean that therearen't other independent clinics
or dentists or pharmacists orwhat I mean is from a hospital
or health system perspective,the buck stops with them.
And I think we need to help themdo that well.
SPEAKER_03 (37:57):
Yeah, and and and and again, I do think what you
pointed out there, John, aboutdiscussion of stabilization, but
then pivoting to transformationas it moved from legislation
into kind of regulatory actionfrom CMS is important because
again, the if the focus of thisis these rural hospitals who
(38:19):
have already been identified asyou know, facing an uphill
battle financially, it'sinherently difficult to try to
be innovative while still tryingto just survive.
And so, I mean, I think the waythis has been rolled out, it
it's like they've they've thrownkind of a life preserver out
there, but now they've made itdifficult to get to the life
(38:41):
preserver in order in order tobe stabilized.
So I think it's I think how thisplays out is gonna be uh I would
use the word interesting, butinteresting doesn't really
convey the importance of itbecause how this rolls out for
some will be the differencebetween survival and closing.
SPEAKER_02 (38:58):
Um as an association, Don, we have to
help this go well.
We want to help this go well.
If um if the program pivots alot to studies and technical
assistance, uh and yet it alsois being given the job by
government officials ofstabilizing rural health, then
(39:20):
we've got a difference betweenperception and reality that
could be very damaging.
We we we have clear directionfrom the Missouri congressional
delegation, put this money towork, use it to help people, um,
and and and use it to help ourproviders in the state.
And that's a part of the workthat we'll be doing along with
the state of Missouri.
Great partnerships with thestate, with the governor, with
(39:41):
folks who are trying to figureout how to use this to
transform, uh, but use itresponsibly and and use it for
real effect.
SPEAKER_03 (39:51):
Well, I would love to keep talking longer because I
mean, quite honestly, theseissues we could spend a day and
probably still not scratch thesurface of all of the things
that are taking place and theheadwinds that that hospitals
are facing, rural hospitals inparticular.
Um, but we do have a short time,and I I want to wrap this up
(40:12):
with one, I guess maybe slightlymore personal question.
Um I guess my question for eachof you is how do you maintain
what I perceive as a verypositive attitude when facing
these great difficulties thatare on the horizon?
And I think to survive requiresit, but I even could say
(40:35):
personally, there are days it isreally hard to feel positive
when you when you see theobstacles that are coming, but I
know that you both do.
How do you do that?
How do how does John Doolittle?
How does Lori Whiteman get up inthe morning, you know, with a
smile on your face, ready to goout there and and try again to
slay the dragon that's kind ofheading toward us, but knowing
(40:57):
the difficulty of the task?
SPEAKER_01 (41:02):
Well, I could say I probably need a a healthier way
to deal with stress than Jin.
But uh, you know, I I'm I I'mfueled by that this is the right
work, and I don't want to letthis community or the thousand
people that work for me down.
SPEAKER_02 (41:25):
She means it, man.
SPEAKER_03 (41:26):
Um people I I I I could that was as sincere as the
day is long.
I think that is 100%.
SPEAKER_02 (41:32):
That's why I tried to go first.
I wanted to give Lori the lastword.
Instead, I'm just gonna amplifyher.
Um, she's cool, but she's notunique.
Um there are people all aroundthis state who understand the
tasks they've been given.
Um, they are they are there's alot of pressure being placed on
the healthcare system.
There is a sense that it has toomuch money, it's not providing
(41:55):
good enough outcomes.
Somebody needs to do thisbetter.
I will tell you that there are alot of people who come into this
space looking to carve off asmall piece of that$5 trillion
and try and make a pretty goodliving.
They're not the ones who arecompeting with us to be open at
3 a.m.
taking care of whatever walks inthe emergency department.
People who see the miracles thatare worked in their
(42:15):
organizations and understandthat they are the last line of
defense and the best line ofdefense in so many areas.
It's easy to be mission-driven.
It's easy to get excited abouttaking care of people who take
care of people.
And that's what I think keeps usgoing.
SPEAKER_03 (42:29):
All right.
Well, again, thank you, John andLori, for your time, for your
willingness to share your ideas.
Again, I hope and I believe thatthis information will be helpful
for others.
Um, and and obviously, I wishyou both the best as you
continue down the path of tryingto find the way to get through
the next few years so that we'reall still moving forward,
(42:52):
serving the community uh in thefuture.
So thanks so much, guys.
I appreciate your time, andwe're gonna sign off.
SPEAKER_00 (43:00):
Take care all.org and stay updated on breaking
(43:22):
healthcare industry news fromthe major media outlets with
AHLA's Health Law Daily Podcast,exclusively for AHLA
comprehensive members.
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
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