In this episode, host Stacey Richter revisits a conversation with Nikki King, CEO of Alliance Health Centers, discussing the critical issues facing rural hospitals and healthcare systems. They delve into the impacts of Medicaid cuts, the financial struggles of rural hospitals reliant on commercial insurance, and potential solutions like freestanding emergency rooms, telehealth, and the expanded roles of nurse practitioners.
The conversation also covers the complexities of maternity care and mental health services in rural areas, emphasizing the urgent need for systemic reforms to ensure equitable access to healthcare.
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08:14 How dire is the rural hospital situation right now?
08:33 How could freestanding ERs be a potential solution for rural hospitals?
09:56 Advice from CHQPR: Rural hospitals should not be forced to eliminate inpatient care.
11:22 Why is broadband a roadblock to telehealth as a solution for rural health access?
14:52 What are other potential rural health access solutions?
15:37 The “hot potato” of nurse practitioners in the healthcare world.
16:34 “The number of residencies for physicians each year is not increasing, but the population … is increasing.”
20:28 EP312 with Douglas Eby, MD, MPH, CPE, of the Nuka System of Care.
22:00 What’s the issue with maternity care in rural America?
24:09 “As healthcare becomes more and more specialized, [the] ability to treat high-risk cases is better, but access gets worse.”
27:57 How is mental health care affected in rural communities?
28:29 “Rural communities are trying very hard to hang on to what they have.”
29:52 “When you look at the one market plan that’s available in a rural community, you probably can’t afford it.”
31:37 What’s the
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Episode 470.
"Continuing the ER, Emergency Room,and Primary Care Through Line Over to
Rural Hospitals and Healthcare." A fewyears ago I had spoken with Nikki King.
(00:23):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentless Seeking Value.
So the show today, it's sort of anencore, but not really an encore because
I recorded this whole new introductionthat you are currently listening to.
And I also did a few inserts thatwe popped into the show itself.
(00:45):
Inserts from the future, you might say.
But why did I pull this episode from2021, you might be wondering, as an
immediate follow on to the show fromlast week about possible Medicaid cuts.
Well, for one thing, the show last weekabout Medicaid cuts were about how the
cuts might impact plan sponsors, andit left me feeling in a little bit like
(01:09):
part of the story was going unsaid.
So much of what happens in healthcare,we see numbers on a spreadsheet, but
can easily lose track of human beings.
I was reading something the other day.
It reminded me of thepeople behind these numbers.
I don't know if this happened in ruralAmerica, but it easily could have.
I'll link to it in the show notes.
Someone could not get a needed surgery.
(01:30):
This surgery had all of themedical necessity boxes checked
except, the hospital would notperform the needed surgery without
cash upfront in prepayment.
This patient, he did not have enoughmoney to cover the prepayment.
So somebody in the hospital financedepartment gave him a solution.
(01:51):
Just wait until the situation becomeslife-threatening, and then I guess
you can go to the ER with yournewly life-threatening condition,
and they will have to perform thesurgery without the money upfront.
And here we have the theme of people notbeing able to afford or not being able to
access primary care, or in this case, Iguess something more than that, a surgery
(02:13):
and they wind up in the emergency room.
As Dr. John Lee put it, the healthcaresystem in this country is like a balloon.
And the way we are currentlysqueezing it, everybody is getting
squeezed into the emergency room.
Which is the very most expensive placeto obtain care, of course, especially
when that care is non-emergent.
In rural America, thisis particularly true.
(02:34):
Now, by no means am I suggestingany kind of magic bullet
to this Medicaid situation.
As we all know, health and healthcareare not the same thing as health
insurance, and we all know enoughabout the issues with Medicaid.
That is not what the show is about.
The episode that follows with NikkiKing, who is my guest today, offers
(02:55):
some great advice when there's justsuch a scarcity of clinicians available
and she does a great job of it.
So I am going to spend my time withyou in this intro talking about
rural hospitals in rural areas.
The place where many patients windup when they cannot get primary care
in their community, just exacerbatingall of the issues we have with
(03:18):
Medicaid and affording Medicaid.
But yeah, even if there is adequateor even great primary care, you
still kind of need a hospital.
The thing is, if an economic situationemerges where, say for example, and,
and this is the case in a lot of ruralplaces, let's just say a factory or
two or a mine or whatever closes down.
(03:39):
It might mean the local hospital alsocloses down, if that local hospital was
dependent on commercial lives and costshifting to those commercial lives, like
this is not higher math or anything.
It's easy to see how a doomloop immediately gets triggered.
Recall that one big reason, andCynthia Fisher talked about this in
(04:00):
an episode from a few months ago.
One reason why employers in ruralareas are choosing to move facilities
somewhere else or overseas, isthat hospital costs, are too high
in the USA in these rural areas.
So they are closing their factory downbecause the hospital is charging too much.
The lower the volume of commerciallives, the higher the hospital
(04:21):
winds up raising their prices forthe other employers in the area.
Now there's a point that comes up alot in 2025 in conversations about
rural hospital financials or justhospital financials in general, I guess.
I had a conversation with BradBrockbank about this a while back, and
I've been mulling over it ever since.
There are many who strongly suggest thereason why rural and other hospitals
(04:42):
are in trouble is squarely becausethey don't have enough patients with
commercial insurance in their payer mix.
As Nathan Kaufman wrote on LinkedInthe other day, he wrote, "The tipping
point is the percent of commercialgross revenues. When most hospitals
hit 25%, if they don't have commercialrates in the high 300% over Medicare
(05:03):
range, things begin to unravel".
And look, I'm not gonnaargue any of the points here.
How would I know for any givenhospital, it could be a financial
imperative to try to get 300% overMedicare out of the local employers?
I don't doubt it.
The question I would ask, if someoneknows that hospital finances are
currently dependent on cost shifting,especially in a rural area with unstable
(05:25):
industry, what are the choices that aremade by hospital boards or leadership?
Is this current dependency used asa justification to level up the cost
shifting to local employers just asvolume diminishes keep charging more.
Which is ultimately going to causeeven more employers to leave the area.
Which seems to be kind of a default.
It's like the safety valve is,charge the local employers more.
(05:48):
The point I'm making here isnot all that profound actually.
It's just to point out thatsafety valve taking advantage of
it comes with downstream impactthat actually worsen a situation.
So what do we do now?
And similar to the Medicaid, whatI just said about Medicaid, I'm not
showing up with any silver bullet here.
And running a hospitalis ridiculously hard.
(06:11):
So I do not wanna minimize that.
And I certainly do not wanna minimizeMedicare advantage paying less than
Medicare going on and the mental healthcrisis and the just crippling issues
that a lot of rural hospitals face.
In the show notes, I will link to areally interesting report by the Center
for Healthcare Quality and Payment Reformabout the ways hospitals can restructure
(06:35):
and rethink how they deliver services butI will take a moment to point out some
case studies of success for what happenswhen people crossed off, go get more money
from the local employers off the list.
Then there's also FQHCs doing someamazing things even in rural areas.
Listen to the episode a whileback with Dr. Doug Eby about the
Nuka System of Care in Alaska.
(06:57):
Serving areas so rural, you need totake a prop plane to get to them.
Their patients, their members have some ofthe best outcomes in the entire country.
Their secret, yeah, great primary careteams that include behavioral health,
the doctor, the nurse, a whole crew.
And look at us.
We've come full circle.
Primary care, good primarycare I mean, is an investment.
(07:18):
Everything else is a cost.
Lastly, let me just offer a very largeupdate today, you cannot just say rural
hospital anymore and automatically meana hospital in dire financial straits
struggling to like make the rent.
Large consolidated hospital systems havebought up so many rural hospitals for
(07:39):
all kinds of reasons that may or maybenot have less to do with mission and more
to do with all the things I discussedwith Brennan Bilberry in the episode
entitled, "Consolidated Hospital Systemsand Cunning Anti-Competitive Contracts".
And with that, my name is Stacey Richter.
This podcast is sponsored byAventria Health Group and here is
(07:59):
the original episode with Nikki King.
Nikki, let me just mention, has gottena new job since she was on the pod.
She's now the CEO of AllianceHealth Centers in Indiana.
Nikki King, DHA.
Welcome to Relentless Health Value.
Thanks for having me.
How dire is the situation abouthospitals in rural America?
I wanna say that it's roughly50% of rural hospitals right
(08:23):
now are running in the red.
There's been, I wanna say,200 rural hospitals close
over the last 10 to 15 years.
It's very bad.
I know that freestanding ERs emergencyrooms is something that you've mentioned
before as a potential solution.
Freestanding ERs are a model thathas been thrown around as a way to
(08:45):
replace rural hospitals who close.
The general model for that to havea full service emergency room with a
helicopter pad and maybe one or twoinpatient beds that could be used
if you're waiting for a transfer.
If you're in a rural community that hasno access to healthcare after hours,
I think that that would be viable.
A real big con with that modelthough is it really flies to the
face of everything that we've triedto accomplish with value-based care.
(09:08):
Right now one of the major ills of thehealthcare system is how much primary care
has taken place in the emergency room.
When that happens, A, it's much moreexpensive care than it should have
been in the primary care office.
It's arguably not as good care.
So for example, I can think of veryfew emergency room physicians that
say that they are very well trainedto deal with mental health crises.
(09:28):
Yet that's the vast majority ofpeople's first access point into the
mental healthcare system, becausethey don't really have access to a
regular therapist or understandingthat they should have that.
When you look at that model now, theER is probably gonna be the biggest
provider of healthcare services.
And obviously the impact is thatpeople aren't getting colonoscopies or
(09:49):
other regular screenings, et cetera.
You know, like their bloodpressure's not getting checked
until they have a heart attack.
Cutting in from the future.
The advice in that C-H-Q-P-R documentreport that I mentioned in the intro
says that over the past few years,they've learned that rural hospitals
should not be forced to eliminateinpatient care in order to receive
(10:12):
higher payments for other services.
That is what is required under theFederal Rural Emergency Hospital Program.
Link to this report in the show notes.
It's actually pretty thought provoking.
Okay, back to the original interview.
Number two, telehealth has been proposedas a way to help with this lack of
access and the lack of providersthat are in the these rural areas.
(10:37):
There's a few proposals I knowthat are on the table relative
to telehealth and rural areas.
Do you have any insight into,you know, like, what are they.
Telehealth was almost universallynot reimbursed in the state of
Indiana prior to COVID, and it'sbeen almost universally reimbursed
since COVID, and we've had reallyimproved outcomes from my standpoint.
We've been able to really engage apatient population that we wouldn't have
(10:58):
been able to keep engaged during COVID,but honestly probably would've never
been able to get to in the first placehad the telehealth rules not changed.
I'll be interested tosee how that happens.
I believe where the state of Indiana leftoff is, we're gonna start looking into
it and really trying to track outcomesand see if this is worthwhile and if the
quality outcomes stack up to telehealth.
So I do know that those are some ofthe things that have been on the table.
(11:22):
One of the knocks on telehealth, whichis frequently cited, is that it can
further exacerbate disparities in care,especially in rural communities because
of the lack of access to broadband.
Right.
Is that something that with thepatients in your communities or
the ones that you see, how many ofthem have an issue with broadband?
(11:44):
Oh, just a lot of them.
There's tons of communities that havereally, really unreliable internet access.
Both in Indiana and Kentucky, there arepopulation centers that exist where the
only access are extremely expensive,satellite based plans that are just
unaffordable as well as having accesseven to a computer is not guaranteed.
What I have seen step into the gap thereand help a little bit is disposable
(12:08):
cell phones that have data plans.
So those have been really helpfulfor us during the pandemic, you know,
burner phones or whatever the, uh, goto Kroger, buy $30 pre-paid phone with
a data plan, and they're able to usetheir data minutes for, for telehealth.
And so we've had some success with that.
But you know, we have individuals whoare just never gonna be able to do that.
(12:30):
From a technological standpoint, itrequires a certain level of savvy.
If you've got a, 93-year-old ladyher ability to access a cell phone
with a data plan and figure out howto download an app and, you know,
use it for telehealth is not great.
Is it a local health system, itsactually buying the burner phones
and handing them out to patients.
(12:52):
Like, what did these programs look like?
I'm gonna be honest with you.
I bought 'em myself.
Oh wow.
Oh, back at the beginning of the pandemic,we didn't know what the future was gonna
look like and we didn't really havefunding or anything like that to do that.
So I just went out and I just boughta huge crate of burner phones and was
handing 'em out to patients and wehad a, we had some success with that.
They're surprisinglyaffordable for what you get.
(13:14):
So you personally, like you didn'teven have a grant, you just went
out and bought burner phones?
Yeah, it was kind of five alarmpanic, especially in Indiana because
it went, COVID went from a rumor tooverflowing the hospitals in a week.
Again, here's me from the future.
Listening to this made me remember vividlyin a way that I had nearly forgotten
(13:35):
just how heroic many clinicians andadministrators, just how valiant and
how many sacrifices, many who worked inhealthcare or work in healthcare made
during the pandemic for their patients.
It just brought back a huge senseof appreciation and gratefulness
that I really wanted to share.
I mean, I had no ideawhat to do, you know?
(13:56):
I just panicked the day beforewe went into quarantine and sent
everybody home with a burner phone.
Wow.
But subsequently, now they have a burnerphone and you actually know what the
phone number is 'cause you bought it.
So then you were able to have reimbursabletelehealth calls subsequently.
Yeah.
For people who would've been justcompletely alone, had you not done that.
(14:18):
You know, I especially worry about alot of our senior patients who live
at home, if they get sick or theygonna be able to get to the doctor,
or what if they need groceries?
So were you actually settingup telehealth appointments and
whatnot with rural patients?
Or was it more like, okay, ifyou need help, just gimme a call.
And then basically you were yourown twenty four seven call center.
Yeah, actually we were, wewere setting up appointments
(14:39):
at the time, again, pure panic.
We had no idea if it wasactually gonna be paid or not.
We just scheduled telehealth appointmentsthe same as, you know, we would
normal appointments, and that justindicated that they were telehealth.
And we just hoped and prayed thatthat worked out and it actually did.
So.
So we've come up with two potentialsolutions for rural health access.
One of them is freestanding ERs,which have the financial discipline
(15:02):
to not take advantage of the communitythat they are in, number one.
Number two, telehealth.
In particular, telehealthopportunities that recognize the
fact that there's broadband issues.
I'm gonna assume, though, unlessthere's another, you know, Nikki King
out there who takes it upon herself tospend her own money on her patients,
(15:24):
that it probably would take more of avalue-based reimbursement environment,
which is something that you also mentionedat the top of this conversation, to
inspire the health system to do thisinstead of a very concerned provider.
Would you agree?
Absolutely.
So another possibility that youhave talked about besides the
freestanding ER and the telehealth isto expand nurse practitioner rights.
(15:46):
So expanding NP rights.
Do you wanna talk about that a little bit?
This is a hot potato inthe healthcare world.
You know, a lot of strong feelingsabout it on both sides of the aisle,
but approaching it from purely adatabased standpoint, what we know
is that we've not really seen anysignificant changes in healthcare
outcomes for communities that have nursepractitioners who practice independently.
(16:08):
In fact, that model has been widelyutilized in the frontier states,
where they have very low per milepopulation and even lower number
of doctors serving large areas.
Utilizing APRNs to the top of theirlicense and really empowering them to
be independent providers, has increasedoutcomes as you would expect it to for
providing an area that didn't have accessto service, with access to service.
(16:31):
And the truth of the matter is withthe landscape being the way it is.
The number of residencies forphysicians each year is not
increasing, but the population ofthe United States is increasing.
And when you look at the placesthat it's increasing, it's
increasing in rural areas.
And we know that based offresearch, physicians are most
likely to practice within 40 mileswhere they completed residencies.
And the vast majority of residenciesare in urban communities.
(16:54):
So you have these doctors who mighthave started out in a rural community
with grand ambitions to go back home,but you know, they get out, they do the
residency, they get married, their kidsare in school, in the urban community,
they don't really feel like leaving.
So they just stay there.
And of course the demand'sthere and the pay is there and
the quality of life is there.
There's not a ton to entice themback to their home community
other than charitable spirit.
(17:16):
This creates an issue where we're gonnahave a huge bottleneck on the number of
available physicians and how far we canstretch 'em in the future, particularly
as the silver tsunami hits with thebaby boomers who are aging into a high
acuity age range, where they're gonnaneed much more intensive services.
When you look at how do we fill thatgap, disproportionately that gap has been
(17:36):
filled by nurse practitioners who migrateand gravitate to rural communities.
A, I think it's because of the peoplewho choose to be nurse practitioners
and the fact that they can oftencomplete their schooling a lot faster
and locally, so it doesn't reallymake it as hard for them to move after
they've completed their training.
But also, because a lot of themare attracted to the fact that they
(17:57):
can practice more independently andpractice at the top of their license.
So, like I said, I know that there'sa lot of feelings on both sides
about which providers are the bestor worst or who's got the strongest
skillset in one thing or another.
But the fact of the matter is, is thata lot of rural communities are gonna
be in the position where they have anurse practitioner or no doctor at all.
And I don't think anybody outthere thinks that no doctor is
(18:18):
better than a nurse practitioner.
I don't care how hard lineyou are on doctors' rights and
doctors maintaining control.
And so in those types of situations,we really need to revisit what the
supervision requirements are on nursepractitioners and if that's really the
way that we wanna go and do we reallysee the quality outcomes come out of
those supervision programs that wouldjustify their continued existence.
(18:40):
When again, you're facing a massivelack of access crisis nationally.
It's just another example of whatI would consider this sort of like
everything becomes this binary.
There is middle ground.
And it sounds like in some ofthese, you know, a lot of good
arguments are spoiled by some foolwho knows what he's talking about.
You know what I mean?
Like it just sounds like we need toactually look at the data and set our
(19:04):
ideologies aside and just figure outwhat's right for the patients here.
Right.
Well, you know, I've always wonderedwhat about something like a policy
where if there's no primary carephysician practicing within 30 miles,
nurse practitioners can practicewithin that radius independently,
or maybe it could go off the hipses.
If it's a health provider shortagearea designated by a HRSA within
those areas, the nurse practitionerscan practice independently.
(19:27):
Things like that, because that wouldalso help entice more nurse practitioners
to return to rural communities.
One thing that I thought wasreally interesting is I got the
opportunity to tour a hospital calledSeven Oaks in Winnipeg, Canada.
One of their administrators was niceenough to show me around the facility.
He made a comment that was really funny.
He's like, we've only got onegerontologist at this hospital.
(19:48):
I'm like.
You have a gerontologist.
I don't think I've ever even seenone, but when we started talking
about my community that I was workingin at the time, population 5,000,
obviously much smaller than the city ofWinnipeg, which is a very urban area.
I was like, yeah, we havefive OBGYNs, obstetricians.
And he's like, you have five OBGYNs.
He's like, what in the worldcould they possibly be doing?
(20:10):
And I'm like, what do you mean?
And he's like, we've got one for likethe entire greater Winnipeg area.
He is like, what do they do?
I'm like, deliver babiesand stuff, I guess.
And he's like, why would you nothave a nurse practitioner do that?
He's like, they do all of them here.
He is like, the only peoplethat the obstetricians see
here are the highest risk.
This reminds me of the Nuka systemof care, and I interviewed Dr.
(20:31):
Doug Eby on the show a bit ago.
So I, I definitely, if you haven'tlistened to that, would recommend
going back and listening to it.
But they also servevery rural communities.
I mean, ones that you have totake a prop plane to get to.
The way that they do it is with primarycare teams and a lot of telehealth.
Because if you have a primary careteam and you have the primary care
(20:53):
physicians that are interfacing withthese specialists and ensuring that
they're called in at the, at theright time, then you can do a lot
very efficiently and everyone gets towork at the, the top of their license.
I'm assuming that some of the stuff thatwe've been talking about relative to nurse
practitioners working at the top of theirlicense could be folded into a primary
(21:15):
care team like that in some fashion?
Oh yeah, absolutely.
To me, that's the top standard of care.
We did something similar atMargaret Mary with the Grow Program.
We didn't really have access to childpsychiatrists, but we had a need
for intensive trauma services foradolescent mental health patients.
What we ended up doing was puttingthe psychiatrist and the pediatrician
(21:36):
together and have them worktogether on a multidisciplinary
team and sort of offset one another.
And that worked really well.
So they were just simply workingtogether and collaborating together?
Or was it more official than that?
Yep, yep.
They would collaborate together and theywould have weekly multidisciplinary team
meetings with the therapist, the threeof them, and they would kind of all three
together come up with treatment plans.
Got it.
And the three are,
(21:57):
A pediatrician, apsychiatrist, and a therapist.
Alright, so let's talk aboutmaternity care in rural America,
which is becoming a huge issue.
First of all, what's the issue?
Let's start there.
What's the problem?
For many rural hospitals, again,and we said almost half of rural
hospitals are in danger of closing.
Maternity services are a losing prospect.
(22:18):
The payer mix is really bad.
The cost of malpracticeinsurance is really high.
The cost of just havingthat service is really high.
Most rural hospitals continue to dothat service A because they have a
mission to serve their community.
But B, because when you deliver a babyat your hospital, you have a really
good opportunity to engage them in thecontinuum of care for the rest of their
lives, which is a both good practiceand good quality for the patient.
(22:43):
But again, in an environment wherehalf the rural hospitals are closing,
their ability to maintain a losingservice line is dramatically decreased
regardless of the community need orif it's the right thing to do or not.
And so a lot of rural OBs are closing,so you have women who are hours and
hours away from the nearest hospitalwhere they could actually deliver a baby.
This is becoming a, a huge, huge crisis.
(23:05):
One of the things that you said thatI just wanna emphasize is that a lot
of hospitals, if you're in an urbansetting, it's like a loss leader.
You want people to deliver their babiesin your care setting, because then
chances are they're gonna stay there.
It's basically the health facilityfor the rest of their lives.
Right.
So if you're in the only game in town,anyway, you don't need to be doing that.
(23:28):
Obviously there's some really bigdownsides to being hours and hours
and hours away from the placewhere you can get maternal care.
Another huge issue is the lack ofobstetricians in rural communities.
When you look at, back in the day, thevast majority of care was being provided
by a general practitioner who just wentaround with a little black bag and he saw
(23:50):
everybody, and that made a lot of sense.
But the complexity of medical procedureshas really changed since then.
So back in the day, your little GP wasproviding oncology, women's services,
cardiology, psychiatry, you name it.
The general practitioner was doing it.
But now we know a lot more abouteach and every one of those services.
There's specialists who can do this,but as healthcare becomes more and more
(24:11):
specialized, our ability to treat highrisk cases is better, but access gets
worse because rural communities are, bydefinition, low volume and can't really
attract and retain that kind of talent.
That's a big problem.
And obstetrics is really no different.
It's become an increasinglyspecialized service.
So say you're an OBGYN who justgraduated from residency today.
For you to go out in rural communities,you're put in this Catch-22 where
(24:34):
these babies are so rude that theydon't come during office hours.
And so you have to be on callessentially twenty four seven.
And if you're not, then there'sno one to deliver the babies.
But say during the day or whatever,you have just enough patients to
keep you busy in the office duringthe day to give you a reason to be
there and to keep up your license.
But again, it's that call piece.
(24:54):
So then you hire two obstetricians who nowdon't have enough patients between the two
of 'em to keep their day practice full.
But now at least it's a one and two call.
So you can think about havinga beer every other week.
And you can maybe have a vacation,but that's just a very hard life
that a lot of doctors who arejust coming outta residencies.
Additionally, now you also havethe, the concept of a Laborist,
(25:15):
which is, you know, an OBGYN wholiterally just delivers babies.
They're really good at itbecause it's all they do.
They're a master of one tradeinstead of a jack of all trades.
And they have a great quality of lifebecause they work their 12 hour shift and
they go home at the end of it and nobodycalls 'em and they go, you know, wake up
the next day, work their 12 hour shift.
Again, that model is just untenable inrural communities where you might deliver
80 babies a year, if you're lucky.
(25:37):
They just sit around twiddle theirthumbs most shifts and they wouldn't see
enough action to even keep their license.
This is becoming a really heatedtopic too, as family practice
physicians who deliver babies anddo a great job are unfortunately
being forced out of the deliveryworld by higher malpractice rates.
A lot of insurance companies want thelaborist delivering babies because if
(25:58):
you've got a doctor who only deliversbabies, then that's the best care for
their patients and that they cover, ortheir insured lives that they cover.
And unfortunately they don't realizethe implications that that has on
access because again, this goes backto, the whole nurse practitioner debate.
Whatever you think of the quality ofa family practice physician delivering
versus a laborist delivering whateveryour personal opinions on that doesn't
(26:20):
super matter because everyone wouldagree that either of those things is
better than neither of those things.
And right now the dichotomy in ruralcommunity is neither of those things.
This has led to a full on systemiccollapse of obstetric services across
the country, and I don't think that itgets enough attention because we've sort
of internalized this idea that ruralAmerica is dying off and that the rural
(26:42):
population is decreasing every year.
So I don't think they're looking atservices that are disproportionately
affected by younger, you know,generations that are more likely to
live in an urban setting, but thatexists and it's creating a huge
access and health disparities issue.
It's like perfect beingthe enemy of the good.
If it's a question of having nobody,unless you're driving hours, because
(27:04):
you've got that sort of lead time.
Right
You're kind of left in a bit of a pickle.
Again when you don't have family practicedelivering babies, they might also
just elect to not do OBGYN servicesor women's health services at all,
which means that the folks who livein that community don't have access.
Because again, say you're a familypractice physician who's gonna go
(27:24):
practice in a rural community, afamily practice being one of the few
specialties that does disproportionatelypick rural communities to practice in.
For you to be trained in women'shealth, you would need to do additional
training to learn how to do deliveriesand to be really competent in that.
And so again, if you think that there'sa chance you're not gonna be allowed
to do deliveries, why would you takeall the extra work to train yourself up
(27:46):
in women's care when you can use thattime to prepare for something else?
It's not even just deliveries, it'sprenatal care period across the
board, but unfortunately women'shealth providers are being shoved out.
So, just last thing, let's talkabout mental health for a moment.
If there's not adequate primary careor patients don't realize that PCPs
can be their door into effectivemental health and patients wind
(28:09):
up beginning their mental healthjourney or their care journey in
these freestanding ERs, for example.
We are seeing a dramatic increasein diseases of despair across
the board in rural communities.
I saw a huge uptick in thismyself after the last election.
Without getting too political, Ithink that rural communities have
been on the decline for 60 plus years.
(28:29):
Rural communities are trying very hardto hang on to what they have, and for the
first time we saw some attention swingback towards the rural communities, and
it was this renewed sense of hope and thenthis sort of hard shift back to normalcy.
And normalcy was whererural health was dying.
That scares a lot of people who are veryculturally attached to their communities.
(28:50):
If you live in this little tiny communityand you don't see a future there with your
job, these things can really exasperatemental health and there's no access.
Obviously the pandemic dramaticallyaccelerated mental health issues
and there's still no access.
The economy really took a, a hardhit over the past four years in rural
(29:11):
communities and still no access.
Also, you're disproportionatelymore likely to A, have Medicaid.
You can't get providers who cantake more than a certain amount,
even if they're not for profit.
Or you have folks who are farmersor maybe they own an excavating
company, they don't have insurance,they can't afford insurance.
They make too much toqualify for the ACA plans.
(29:33):
They don't make enough to buy acommercial plan outright or to go to the
marketplace, which again, the marketplaceis disproportionately expensive in
rural communities because almost allof the insurers pulled out of the rural
marketplace because there wasn't avaried enough pool or a large enough
risk pool for the insurance companyto you know, make a profit off of it.
So when you look at the one marketplan that's available in a rural
(29:56):
community, you probably can't afford it.
And with no insurance, acourse comes, no access.
Obviously, diseases of despair,behavioral health, people are
starting to realize how much thatactually affects physical health,
that they're not two separate things,that it's just kind of like health.
Another thing that has been mentionedalong these lines is the evil cycle
(30:16):
that gets precipitated because ifyou have parents suffering from a
disease of despair, you tend to havechild abuse, which just perpetuates an
evil cycle, which I know is somethingthat you have studied and seen.
This goes back to the adversechildhood event study, which I think
we do not talk enough about in thehealthcare administration world.
(30:37):
We talk about a lot of it clinically.
I feel like a lot of clinical providersare acutely aware of the effects that
child abuse has on increasing riskof suicide, substance use disorders,
obesity, diseases related to obesity.
All these things, providers see that.
If you've got somebody who's justreally lived a rough life, chances
are they're overweight, they mayor may not have something like
(30:59):
type 2 diabetes or hypertension.
They probably havedepression, anxiety, or both.
As well as maybe something likePTSD, like you're seeing, them have
issues chronically with employmentand their ability to take negative
criticism or challenge themselves.
That's not everyone, likethat's not stereotyping.
I'm just saying that statisticallypeople who suffer from those things
have disproportionately experiencedchildhood trauma and that's why
(31:21):
they're having trouble coping.
But from the healthcare administrationside, we know that somebody who has
an elevated ACE score or adversechildhood event score has a 20 year
shorter life expectancy on the whole.
Their ability to meet population healthvalue-based markers, non-existent.
If you have a primary care providerwho's just trying to treat depression
in an office-based setting, andthis is somebody who has Complex
(31:44):
PTSD, that ain't gonna work.
This is gonna be something thatrequires intensive treatment.
And so, I think that this is thesingle biggest challenge to moving
to a model that really incentivizeskeeping people healthy versus
doing procedures in the hospital.
Because these people are gonna havesignificant and very specific barriers
to achieving physical health because oftheir lack of access to mental health.
(32:07):
You had said that a population healthmodels, having a reimbursement system
that's based on achieving better pophealth outcomes is, is gonna be essential.
And this is probably just anotherproof point to that being the case.
Yep.
If you had some advice for Medicaidand how that is structured, especially
given your experience in rural Americaand also with mental health and the
(32:30):
challenges there, what do you suggest?
The easiest low hanging fruit, first ofall, is having national Medicaid and have
that put under the same hood as Medicare.
Having Medicaid vastly different fromstate to state, both drives providers,
administrators, everybody insane.
You can implement a program that worksreally, really great at targeting
high risk people and thereforeMedicaid enrollees in the state of
(32:53):
Indiana and have it completely flopin California just because of the way
that the programs are administratored.
We can't even talk about, best practicesin a way that really makes sense
beyond the most very basic level.
That drives me insane.
There needs to be one rate all over thecountry, needs to be one set of rules,
all over the country, and it also reducesa lot of redundancy within the system.
(33:16):
That's just number one.
But additionally, looking at value-basedmodels for Medicaid and some states
have done this with great success.
I haven't looked into it personally,but I hear rave reviews about the
Pennsylvania model and what they didwith value-based care in that state.
So I know that some states havereally, really done this well, but
the vast majority of states are kindof pretending like Medicaid doesn't
(33:36):
exist and hoping it goes away.
And especially in light of thereally politicized nature of Medicaid
in states that did not expandwith the Accountable Care Act.
The truth is, is that we're gettingto a place where if we don't get
behind subsidizing health, we won'tbe able to pay what happens next.
And I can't think of any, any demographicwhere that's more important than high
(33:56):
risk Medicaid patients who oftentimesdon't have the resources that they
need to maintain their personal health.
We've just gotta completely look atthe way that we do this Medicaid thing.
It's untenable in every way imaginable.
The idea of paying for value seems to bedefinitely at least one leg in the stool
that's gonna transform healthcare here.
Right.
(34:16):
And particularly important forrural America that has all of
these additional challenges.
It's certainly a, aspider web of complexity.
Yep.
Nikki, if people are interestedin learning more about the work
that you're doing, where would youdirect them for more information?
You can let me up on LinkedIn, readilyavailable on most social media platforms.
(34:36):
Nikki King, thank you so much forbeing on Relentless Health Value today.
Thank you.
Hi, this is Cynthia Fisher,patientrightsadvocate.org.
We subscribe to Stacey's podcast and we'velearned so much from her podcast with all
the incredible individuals she interviewson healthcare and the opportunities
(34:59):
to affect change for the better.
I suggest everyone listen to thesegreat podcasts that Stacey provides.
So well informed for all ofus engaged in healthcare.
Episode 470.
"Continuing the ER, Emergency Room,and Primary Care Through Line Over to
Rural Hospitals and Healthcare." A fewyears ago I had spoken with Nikki King.
(00:23):
American Healthcare Entrepreneurs andExecutives You Want to Know, Talking.
Relentless Seeking Value.
So the show today, it's sort of anencore, but not really an encore because
I recorded this whole new introductionthat you are currently listening to.
And I also did a few inserts thatwe popped into the show itself.
(00:45):
Inserts from the future, you might say.
But why did I pull this episode from2021, you might be wondering, as an
immediate follow on to the show fromlast week about possible Medicaid cuts.
Well, for one thing, the show last weekabout Medicaid cuts were about how the
cuts might impact plan sponsors, andit left me feeling in a little bit like
(01:09):
part of the story was going unsaid.
So much of what happens in healthcare,we see numbers on a spreadsheet, but
can easily lose track of human beings.
I was reading something the other day.
It reminded me of thepeople behind these numbers.
I don't know if this happened in ruralAmerica, but it easily could have.
I'll link to it in the show notes.
Someone could not get a needed surgery.
(01:30):
This surgery had all of themedical necessity boxes checked
except, the hospital would notperform the needed surgery without
cash upfront in prepayment.
This patient, he did not have enoughmoney to cover the prepayment.
So somebody in the hospital financedepartment gave him a solution.
(01:51):
Just wait until the situation becomeslife-threatening, and then I guess
you can go to the ER with yournewly life-threatening condition,
and they will have to perform thesurgery without the money upfront.
And here we have the theme of people notbeing able to afford or not being able to
access primary care, or in this case, Iguess something more than that, a surgery
(02:13):
and they wind up in the emergency room.
As Dr. John Lee put it, the healthcaresystem in this country is like a balloon.
And the way we are currentlysqueezing it, everybody is getting
squeezed into the emergency room.
Which is the very most expensive placeto obtain care, of course, especially
when that care is non-emergent.
In rural America, thisis particularly true.
(02:34):
Now, by no means am I suggestingany kind of magic bullet
to this Medicaid situation.
As we all know, health and healthcareare not the same thing as health
insurance, and we all know enoughabout the issues with Medicaid.
That is not what the show is about.
The episode that follows with NikkiKing, who is my guest today, offers
(02:55):
some great advice when there's justsuch a scarcity of clinicians available
and she does a great job of it.
So I am going to spend my time withyou in this intro talking about
rural hospitals in rural areas.
The place where many patients windup when they cannot get primary care
in their community, just exacerbatingall of the issues we have with
(03:18):
Medicaid and affording Medicaid.
But yeah, even if there is adequateor even great primary care, you
still kind of need a hospital.
The thing is, if an economic situationemerges where, say for example, and,
and this is the case in a lot of ruralplaces, let's just say a factory or
two or a mine or whatever closes down.
(03:39):
It might mean the local hospital alsocloses down, if that local hospital was
dependent on commercial lives and costshifting to those commercial lives, like
this is not higher math or anything.
It's easy to see how a doomloop immediately gets triggered.
Recall that one big reason, andCynthia Fisher talked about this in
(04:00):
an episode from a few months ago.
One reason why employers in ruralareas are choosing to move facilities
somewhere else or overseas, isthat hospital costs, are too high
in the USA in these rural areas.
So they are closing their factory downbecause the hospital is charging too much.
The lower the volume of commerciallives, the higher the hospital
(04:21):
winds up raising their prices forthe other employers in the area.
Now there's a point that comes up alot in 2025 in conversations about
rural hospital financials or justhospital financials in general, I guess.
I had a conversation with BradBrockbank about this a while back, and
I've been mulling over it ever since.
There are many who strongly suggest thereason why rural and other hospitals
(04:42):
are in trouble is squarely becausethey don't have enough patients with
commercial insurance in their payer mix.
As Nathan Kaufman wrote on LinkedInthe other day, he wrote, "The tipping
point is the percent of commercialgross revenues. When most hospitals
hit 25%, if they don't have commercialrates in the high 300% over Medicare
(05:03):
range, things begin to unravel".
And look, I'm not gonnaargue any of the points here.
How would I know for any givenhospital, it could be a financial
imperative to try to get 300% overMedicare out of the local employers?
I don't doubt it.
The question I would ask, if someoneknows that hospital finances are
currently dependent on cost shifting,especially in a rural area with unstable
(05:25):
industry, what are the choices that aremade by hospital boards or leadership?
Is this current dependency used asa justification to level up the cost
shifting to local employers just asvolume diminishes keep charging more.
Which is ultimately going to causeeven more employers to leave the area.
Which seems to be kind of a default.
It's like the safety valve is,charge the local employers more.
(05:48):
The point I'm making here isnot all that profound actually.
It's just to point out thatsafety valve taking advantage of
it comes with downstream impactthat actually worsen a situation.
So what do we do now?
And similar to the Medicaid, whatI just said about Medicaid, I'm not
showing up with any silver bullet here.
And running a hospitalis ridiculously hard.
(06:11):
So I do not wanna minimize that.
And I certainly do not wanna minimizeMedicare advantage paying less than
Medicare going on and the mental healthcrisis and the just crippling issues
that a lot of rural hospitals face.
In the show notes, I will link to areally interesting report by the Center
for Healthcare Quality and Payment Reformabout the ways hospitals can restructure
(06:35):
and rethink how they deliver services butI will take a moment to point out some
case studies of success for what happenswhen people crossed off, go get more money
from the local employers off the list.
Then there's also FQHCs doing someamazing things even in rural areas.
Listen to the episode a whileback with Dr. Doug Eby about the
Nuka System of Care in Alaska.
(06:57):
Serving areas so rural, you need totake a prop plane to get to them.
Their patients, their members have some ofthe best outcomes in the entire country.
Their secret, yeah, great primary careteams that include behavioral health,
the doctor, the nurse, a whole crew.
And look at us.
We've come full circle.
Primary care, good primarycare I mean, is an investment.
(07:18):
Everything else is a cost.
Lastly, let me just offer a very largeupdate today, you cannot just say rural
hospital anymore and automatically meana hospital in dire financial straits
struggling to like make the rent.
Large consolidated hospital systems havebought up so many rural hospitals for
(07:39):
all kinds of reasons that may or maybenot have less to do with mission and more
to do with all the things I discussedwith Brennan Bilberry in the episode
entitled, "Consolidated Hospital Systemsand Cunning Anti-Competitive Contracts".
And with that, my name is Stacey Richter.
This podcast is sponsored byAventria Health Group and here is
(07:59):
the original episode with Nikki King.
Nikki, let me just mention, has gottena new job since she was on the pod.
She's now the CEO of AllianceHealth Centers in Indiana.
Nikki King, DHA.
Welcome to Relentless Health Value.
Thanks for having me.
How dire is the situation abouthospitals in rural America?
I wanna say that it's roughly50% of rural hospitals right
(08:23):
now are running in the red.
There's been, I wanna say,200 rural hospitals close
over the last 10 to 15 years.
It's very bad.
I know that freestanding ERs emergencyrooms is something that you've mentioned
before as a potential solution.
Freestanding ERs are a model thathas been thrown around as a way to
(08:45):
replace rural hospitals who close.
The general model for that to havea full service emergency room with a
helicopter pad and maybe one or twoinpatient beds that could be used
if you're waiting for a transfer.
If you're in a rural community that hasno access to healthcare after hours,
I think that that would be viable.
A real big con with that modelthough is it really flies to the
face of everything that we've triedto accomplish with value-based care.
(09:08):
Right now one of the major ills of thehealthcare system is how much primary care
has taken place in the emergency room.
When that happens, A, it's much moreexpensive care than it should have
been in the primary care office.
It's arguably not as good care.
So for example, I can think of veryfew emergency room physicians that
say that they are very well trainedto deal with mental health crises.
(09:28):
Yet that's the vast majority ofpeople's first access point into the
mental healthcare system, becausethey don't really have access to a
regular therapist or understandingthat they should have that.
When you look at that model now, theER is probably gonna be the biggest
provider of healthcare services.
And obviously the impact is thatpeople aren't getting colonoscopies or
(09:49):
other regular screenings, et cetera.
You know, like their bloodpressure's not getting checked
until they have a heart attack.
Cutting in from the future.
The advice in that C-H-Q-P-R documentreport that I mentioned in the intro
says that over the past few years,they've learned that rural hospitals
should not be forced to eliminateinpatient care in order to receive
(10:12):
higher payments for other services.
That is what is required under theFederal Rural Emergency Hospital Program.
Link to this report in the show notes.
It's actually pretty thought provoking.
Okay, back to the original interview.
Number two, telehealth has been proposedas a way to help with this lack of
access and the lack of providersthat are in the these rural areas.
(10:37):
There's a few proposals I knowthat are on the table relative
to telehealth and rural areas.
Do you have any insight into,you know, like, what are they.
Telehealth was almost universallynot reimbursed in the state of
Indiana prior to COVID, and it'sbeen almost universally reimbursed
since COVID, and we've had reallyimproved outcomes from my standpoint.
We've been able to really engage apatient population that we wouldn't have
(10:58):
been able to keep engaged during COVID,but honestly probably would've never
been able to get to in the first placehad the telehealth rules not changed.
I'll be interested tosee how that happens.
I believe where the state of Indiana leftoff is, we're gonna start looking into
it and really trying to track outcomesand see if this is worthwhile and if the
quality outcomes stack up to telehealth.
So I do know that those are some ofthe things that have been on the table.
(11:22):
One of the knocks on telehealth, whichis frequently cited, is that it can
further exacerbate disparities in care,especially in rural communities because
of the lack of access to broadband.
Right.
Is that something that with thepatients in your communities or
the ones that you see, how many ofthem have an issue with broadband?
(11:44):
Oh, just a lot of them.
There's tons of communities that havereally, really unreliable internet access.
Both in Indiana and Kentucky, there arepopulation centers that exist where the
only access are extremely expensive,satellite based plans that are just
unaffordable as well as having accesseven to a computer is not guaranteed.
What I have seen step into the gap thereand help a little bit is disposable
(12:08):
cell phones that have data plans.
So those have been really helpfulfor us during the pandemic, you know,
burner phones or whatever the, uh, goto Kroger, buy $30 pre-paid phone with
a data plan, and they're able to usetheir data minutes for, for telehealth.
And so we've had some success with that.
But you know, we have individuals whoare just never gonna be able to do that.
(12:30):
From a technological standpoint, itrequires a certain level of savvy.
If you've got a, 93-year-old ladyher ability to access a cell phone
with a data plan and figure out howto download an app and, you know,
use it for telehealth is not great.
Is it a local health system, itsactually buying the burner phones
and handing them out to patients.
(12:52):
Like, what did these programs look like?
I'm gonna be honest with you.
I bought 'em myself.
Oh wow.
Oh, back at the beginning of the pandemic,we didn't know what the future was gonna
look like and we didn't really havefunding or anything like that to do that.
So I just went out and I just boughta huge crate of burner phones and was
handing 'em out to patients and wehad a, we had some success with that.
They're surprisinglyaffordable for what you get.
(13:14):
So you personally, like you didn'teven have a grant, you just went
out and bought burner phones?
Yeah, it was kind of five alarmpanic, especially in Indiana because
it went, COVID went from a rumor tooverflowing the hospitals in a week.
Again, here's me from the future.
Listening to this made me remember vividlyin a way that I had nearly forgotten
(13:35):
just how heroic many clinicians andadministrators, just how valiant and
how many sacrifices, many who worked inhealthcare or work in healthcare made
during the pandemic for their patients.
It just brought back a huge senseof appreciation and gratefulness
that I really wanted to share.
I mean, I had no ideawhat to do, you know?
(13:56):
I just panicked the day beforewe went into quarantine and sent
everybody home with a burner phone.
Wow.
But subsequently, now they have a burnerphone and you actually know what the
phone number is 'cause you bought it.
So then you were able to have reimbursabletelehealth calls subsequently.
Yeah.
For people who would've been justcompletely alone, had you not done that.
(14:18):
You know, I especially worry about alot of our senior patients who live
at home, if they get sick or theygonna be able to get to the doctor,
or what if they need groceries?
So were you actually settingup telehealth appointments and
whatnot with rural patients?
Or was it more like, okay, ifyou need help, just gimme a call.
And then basically you were yourown twenty four seven call center.
Yeah, actually we were, wewere setting up appointments
(14:39):
at the time, again, pure panic.
We had no idea if it wasactually gonna be paid or not.
We just scheduled telehealth appointmentsthe same as, you know, we would
normal appointments, and that justindicated that they were telehealth.
And we just hoped and prayed thatthat worked out and it actually did.
So.
So we've come up with two potentialsolutions for rural health access.
One of them is freestanding ERs,which have the financial discipline
(15:02):
to not take advantage of the communitythat they are in, number one.
Number two, telehealth.
In particular, telehealthopportunities that recognize the
fact that there's broadband issues.
I'm gonna assume, though, unlessthere's another, you know, Nikki King
out there who takes it upon herself tospend her own money on her patients,
(15:24):
that it probably would take more of avalue-based reimbursement environment,
which is something that you also mentionedat the top of this conversation, to
inspire the health system to do thisinstead of a very concerned provider.
Would you agree?
Absolutely.
So another possibility that youhave talked about besides the
freestanding ER and the telehealth isto expand nurse practitioner rights.
(15:46):
So expanding NP rights.
Do you wanna talk about that a little bit?
This is a hot potato inthe healthcare world.
You know, a lot of strong feelingsabout it on both sides of the aisle,
but approaching it from purely adatabased standpoint, what we know
is that we've not really seen anysignificant changes in healthcare
outcomes for communities that have nursepractitioners who practice independently.
(16:08):
In fact, that model has been widelyutilized in the frontier states,
where they have very low per milepopulation and even lower number
of doctors serving large areas.
Utilizing APRNs to the top of theirlicense and really empowering them to
be independent providers, has increasedoutcomes as you would expect it to for
providing an area that didn't have accessto service, with access to service.
(16:31):
And the truth of the matter is withthe landscape being the way it is.
The number of residencies forphysicians each year is not
increasing, but the population ofthe United States is increasing.
And when you look at the placesthat it's increasing, it's
increasing in rural areas.
And we know that based offresearch, physicians are most
likely to practice within 40 mileswhere they completed residencies.
And the vast majority of residenciesare in urban communities.
(16:54):
So you have these doctors who mighthave started out in a rural community
with grand ambitions to go back home,but you know, they get out, they do the
residency, they get married, their kidsare in school, in the urban community,
they don't really feel like leaving.
So they just stay there.
And of course the demand'sthere and the pay is there and
the quality of life is there.
There's not a ton to entice themback to their home community
other than charitable spirit.
(17:16):
This creates an issue where we're gonnahave a huge bottleneck on the number of
available physicians and how far we canstretch 'em in the future, particularly
as the silver tsunami hits with thebaby boomers who are aging into a high
acuity age range, where they're gonnaneed much more intensive services.
When you look at how do we fill thatgap, disproportionately that gap has been
(17:36):
filled by nurse practitioners who migrateand gravitate to rural communities.
A, I think it's because of the peoplewho choose to be nurse practitioners
and the fact that they can oftencomplete their schooling a lot faster
and locally, so it doesn't reallymake it as hard for them to move after
they've completed their training.
But also, because a lot of themare attracted to the fact that they
(17:57):
can practice more independently andpractice at the top of their license.
So, like I said, I know that there'sa lot of feelings on both sides
about which providers are the bestor worst or who's got the strongest
skillset in one thing or another.
But the fact of the matter is, is thata lot of rural communities are gonna
be in the position where they have anurse practitioner or no doctor at all.
And I don't think anybody outthere thinks that no doctor is
(18:18):
better than a nurse practitioner.
I don't care how hard lineyou are on doctors' rights and
doctors maintaining control.
And so in those types of situations,we really need to revisit what the
supervision requirements are on nursepractitioners and if that's really the
way that we wanna go and do we reallysee the quality outcomes come out of
those supervision programs that wouldjustify their continued existence.
(18:40):
When again, you're facing a massivelack of access crisis nationally.
It's just another example of whatI would consider this sort of like
everything becomes this binary.
There is middle ground.
And it sounds like in some ofthese, you know, a lot of good
arguments are spoiled by some foolwho knows what he's talking about.
You know what I mean?
Like it just sounds like we need toactually look at the data and set our
(19:04):
ideologies aside and just figure outwhat's right for the patients here.
Right.
Well, you know, I've always wonderedwhat about something like a policy
where if there's no primary carephysician practicing within 30 miles,
nurse practitioners can practicewithin that radius independently,
or maybe it could go off the hipses.
If it's a health provider shortagearea designated by a HRSA within
those areas, the nurse practitionerscan practice independently.
(19:27):
Things like that, because that wouldalso help entice more nurse practitioners
to return to rural communities.
One thing that I thought wasreally interesting is I got the
opportunity to tour a hospital calledSeven Oaks in Winnipeg, Canada.
One of their administrators was niceenough to show me around the facility.
He made a comment that was really funny.
He's like, we've only got onegerontologist at this hospital.
(19:48):
I'm like.
You have a gerontologist.
I don't think I've ever even seenone, but when we started talking
about my community that I was workingin at the time, population 5,000,
obviously much smaller than the city ofWinnipeg, which is a very urban area.
I was like, yeah, we havefive OBGYNs, obstetricians.
And he's like, you have five OBGYNs.
He's like, what in the worldcould they possibly be doing?
(20:10):
And I'm like, what do you mean?
And he's like, we've got one for likethe entire greater Winnipeg area.
He is like, what do they do?
I'm like, deliver babiesand stuff, I guess.
And he's like, why would you nothave a nurse practitioner do that?
He's like, they do all of them here.
He is like, the only peoplethat the obstetricians see
here are the highest risk.
This reminds me of the Nuka systemof care, and I interviewed Dr.
(20:31):
Doug Eby on the show a bit ago.
So I, I definitely, if you haven'tlistened to that, would recommend
going back and listening to it.
But they also servevery rural communities.
I mean, ones that you have totake a prop plane to get to.
The way that they do it is with primarycare teams and a lot of telehealth.
Because if you have a primary careteam and you have the primary care
(20:53):
physicians that are interfacing withthese specialists and ensuring that
they're called in at the, at theright time, then you can do a lot
very efficiently and everyone gets towork at the, the top of their license.
I'm assuming that some of the stuff thatwe've been talking about relative to nurse
practitioners working at the top of theirlicense could be folded into a primary
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care team like that in some fashion?
Oh yeah, absolutely.
To me, that's the top standard of care.
We did something similar atMargaret Mary with the Grow Program.
We didn't really have access to childpsychiatrists, but we had a need
for intensive trauma services foradolescent mental health patients.
What we ended up doing was puttingthe psychiatrist and the pediatrician
(21:36):
together and have them worktogether on a multidisciplinary
team and sort of offset one another.
And that worked really well.
So they were just simply workingtogether and collaborating together?
Or was it more official than that?
Yep, yep.
They would collaborate together and theywould have weekly multidisciplinary team
meetings with the therapist, the threeof them, and they would kind of all three
together come up with treatment plans.
Got it.
And the three are,
(21:57):
A pediatrician, apsychiatrist, and a therapist.
Alright, so let's talk aboutmaternity care in rural America,
which is becoming a huge issue.
First of all, what's the issue?
Let's start there.
What's the problem?
For many rural hospitals, again,and we said almost half of rural
hospitals are in danger of closing.
Maternity services are a losing prospect.
(22:18):
The payer mix is really bad.
The cost of malpracticeinsurance is really high.
The cost of just havingthat service is really high.
Most rural hospitals continue to dothat service A because they have a
mission to serve their community.
But B, because when you deliver a babyat your hospital, you have a really
good opportunity to engage them in thecontinuum of care for the rest of their
lives, which is a both good practiceand good quality for the patient.
(22:43):
But again, in an environment wherehalf the rural hospitals are closing,
their ability to maintain a losingservice line is dramatically decreased
regardless of the community need orif it's the right thing to do or not.
And so a lot of rural OBs are closing,so you have women who are hours and
hours away from the nearest hospitalwhere they could actually deliver a baby.
This is becoming a, a huge, huge crisis.
(23:05):
One of the things that you said thatI just wanna emphasize is that a lot
of hospitals, if you're in an urbansetting, it's like a loss leader.
You want people to deliver their babiesin your care setting, because then
chances are they're gonna stay there.
It's basically the health facilityfor the rest of their lives.
Right.
So if you're in the only game in town,anyway, you don't need to be doing that.
(23:28):
Obviously there's some really bigdownsides to being hours and hours
and hours away from the placewhere you can get maternal care.
Another huge issue is the lack ofobstetricians in rural communities.
When you look at, back in the day, thevast majority of care was being provided
by a general practitioner who just wentaround with a little black bag and he saw
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everybody, and that made a lot of sense.
But the complexity of medical procedureshas really changed since then.
So back in the day, your little GP wasproviding oncology, women's services,
cardiology, psychiatry, you name it.
The general practitioner was doing it.
But now we know a lot more abouteach and every one of those services.
There's specialists who can do this,but as healthcare becomes more and more
(24:11):
specialized, our ability to treat highrisk cases is better, but access gets
worse because rural communities are, bydefinition, low volume and can't really
attract and retain that kind of talent.
That's a big problem.
And obstetrics is really no different.
It's become an increasinglyspecialized service.
So say you're an OBGYN who justgraduated from residency today.
For you to go out in rural communities,you're put in this Catch-22 where
(24:34):
these babies are so rude that theydon't come during office hours.
And so you have to be on callessentially twenty four seven.
And if you're not, then there'sno one to deliver the babies.
But say during the day or whatever,you have just enough patients to
keep you busy in the office duringthe day to give you a reason to be
there and to keep up your license.
But again, it's that call piece.
(24:54):
So then you hire two obstetricians who nowdon't have enough patients between the two
of 'em to keep their day practice full.
But now at least it's a one and two call.
So you can think about havinga beer every other week.
And you can maybe have a vacation,but that's just a very hard life
that a lot of doctors who arejust coming outta residencies.
Additionally, now you also havethe, the concept of a Laborist,
(25:15):
which is, you know, an OBGYN wholiterally just delivers babies.
They're really good at itbecause it's all they do.
They're a master of one tradeinstead of a jack of all trades.
And they have a great quality of lifebecause they work their 12 hour shift and
they go home at the end of it and nobodycalls 'em and they go, you know, wake up
the next day, work their 12 hour shift.
Again, that model is just untenable inrural communities where you might deliver
80 babies a year, if you're lucky.
(25:37):
They just sit around twiddle theirthumbs most shifts and they wouldn't see
enough action to even keep their license.
This is becoming a really heatedtopic too, as family practice
physicians who deliver babies anddo a great job are unfortunately
being forced out of the deliveryworld by higher malpractice rates.
A lot of insurance companies want thelaborist delivering babies because if
(25:58):
you've got a doctor who only deliversbabies, then that's the best care for
their patients and that they cover, ortheir insured lives that they cover.
And unfortunately they don't realizethe implications that that has on
access because again, this goes backto, the whole nurse practitioner debate.
Whatever you think of the quality ofa family practice physician delivering
versus a laborist delivering whateveryour personal opinions on that doesn't
(26:20):
super matter because everyone wouldagree that either of those things is
better than neither of those things.
And right now the dichotomy in ruralcommunity is neither of those things.
This has led to a full on systemiccollapse of obstetric services across
the country, and I don't think that itgets enough attention because we've sort
of internalized this idea that ruralAmerica is dying off and that the rural
(26:42):
population is decreasing every year.
So I don't think they're looking atservices that are disproportionately
affected by younger, you know,generations that are more likely to
live in an urban setting, but thatexists and it's creating a huge
access and health disparities issue.
It's like perfect beingthe enemy of the good.
If it's a question of having nobody,unless you're driving hours, because
(27:04):
you've got that sort of lead time.
Right
You're kind of left in a bit of a pickle.
Again when you don't have family practicedelivering babies, they might also
just elect to not do OBGYN servicesor women's health services at all,
which means that the folks who livein that community don't have access.
Because again, say you're a familypractice physician who's gonna go
(27:24):
practice in a rural community, afamily practice being one of the few
specialties that does disproportionatelypick rural communities to practice in.
For you to be trained in women'shealth, you would need to do additional
training to learn how to do deliveriesand to be really competent in that.
And so again, if you think that there'sa chance you're not gonna be allowed
to do deliveries, why would you takeall the extra work to train yourself up
(27:46):
in women's care when you can use thattime to prepare for something else?
It's not even just deliveries, it'sprenatal care period across the
board, but unfortunately women'shealth providers are being shoved out.
So, just last thing, let's talkabout mental health for a moment.
If there's not adequate primary careor patients don't realize that PCPs
can be their door into effectivemental health and patients wind
(28:09):
up beginning their mental healthjourney or their care journey in
these freestanding ERs, for example.
We are seeing a dramatic increasein diseases of despair across
the board in rural communities.
I saw a huge uptick in thismyself after the last election.
Without getting too political, Ithink that rural communities have
been on the decline for 60 plus years.
(28:29):
Rural communities are trying very hardto hang on to what they have, and for the
first time we saw some attention swingback towards the rural communities, and
it was this renewed sense of hope and thenthis sort of hard shift back to normalcy.
And normalcy was whererural health was dying.
That scares a lot of people who are veryculturally attached to their communities.
(28:50):
If you live in this little tiny communityand you don't see a future there with your
job, these things can really exasperatemental health and there's no access.
Obviously the pandemic dramaticallyaccelerated mental health issues
and there's still no access.
The economy really took a, a hardhit over the past four years in rural
(29:11):
communities and still no access.
Also, you're disproportionatelymore likely to A, have Medicaid.
You can't get providers who cantake more than a certain amount,
even if they're not for profit.
Or you have folks who are farmersor maybe they own an excavating
company, they don't have insurance,they can't afford insurance.
They make too much toqualify for the ACA plans.
(29:33):
They don't make enough to buy acommercial plan outright or to go to the
marketplace, which again, the marketplaceis disproportionately expensive in
rural communities because almost allof the insurers pulled out of the rural
marketplace because there wasn't avaried enough pool or a large enough
risk pool for the insurance companyto you know, make a profit off of it.
So when you look at the one marketplan that's available in a rural
(29:56):
community, you probably can't afford it.
And with no insurance, acourse comes, no access.
Obviously, diseases of despair,behavioral health, people are
starting to realize how much thatactually affects physical health,
that they're not two separate things,that it's just kind of like health.
Another thing that has been mentionedalong these lines is the evil cycle
(30:16):
that gets precipitated because ifyou have parents suffering from a
disease of despair, you tend to havechild abuse, which just perpetuates an
evil cycle, which I know is somethingthat you have studied and seen.
This goes back to the adversechildhood event study, which I think
we do not talk enough about in thehealthcare administration world.
(30:37):
We talk about a lot of it clinically.
I feel like a lot of clinical providersare acutely aware of the effects that
child abuse has on increasing riskof suicide, substance use disorders,
obesity, diseases related to obesity.
All these things, providers see that.
If you've got somebody who's justreally lived a rough life, chances
are they're overweight, they mayor may not have something like
(30:59):
type 2 diabetes or hypertension.
They probably havedepression, anxiety, or both.
As well as maybe something likePTSD, like you're seeing, them have
issues chronically with employmentand their ability to take negative
criticism or challenge themselves.
That's not everyone, likethat's not stereotyping.
I'm just saying that statisticallypeople who suffer from those things
have disproportionately experiencedchildhood trauma and that's why
(31:21):
they're having trouble coping.
But from the healthcare administrationside, we know that somebody who has
an elevated ACE score or adversechildhood event score has a 20 year
shorter life expectancy on the whole.
Their ability to meet population healthvalue-based markers, non-existent.
If you have a primary care providerwho's just trying to treat depression
in an office-based setting, andthis is somebody who has Complex
(31:44):
PTSD, that ain't gonna work.
This is gonna be something thatrequires intensive treatment.
And so, I think that this is thesingle biggest challenge to moving
to a model that really incentivizeskeeping people healthy versus
doing procedures in the hospital.
Because these people are gonna havesignificant and very specific barriers
to achieving physical health because oftheir lack of access to mental health.
(32:07):
You had said that a population healthmodels, having a reimbursement system
that's based on achieving better pophealth outcomes is, is gonna be essential.
And this is probably just anotherproof point to that being the case.
Yep.
If you had some advice for Medicaidand how that is structured, especially
given your experience in rural Americaand also with mental health and the
(32:30):
challenges there, what do you suggest?
The easiest low hanging fruit, first ofall, is having national Medicaid and have
that put under the same hood as Medicare.
Having Medicaid vastly different fromstate to state, both drives providers,
administrators, everybody insane.
You can implement a program that worksreally, really great at targeting
high risk people and thereforeMedicaid enrollees in the state of
(32:53):
Indiana and have it completely flopin California just because of the way
that the programs are administratored.
We can't even talk about, best practicesin a way that really makes sense
beyond the most very basic level.
That drives me insane.
There needs to be one rate all over thecountry, needs to be one set of rules,
all over the country, and it also reducesa lot of redundancy within the system.
(33:16):
That's just number one.
But additionally, looking at value-basedmodels for Medicaid and some states
have done this with great success.
I haven't looked into it personally,but I hear rave reviews about the
Pennsylvania model and what they didwith value-based care in that state.
So I know that some states havereally, really done this well, but
the vast majority of states are kindof pretending like Medicaid doesn't
(33:36):
exist and hoping it goes away.
And especially in light of thereally politicized nature of Medicaid
in states that did not expandwith the Accountable Care Act.
The truth is, is that we're gettingto a place where if we don't get
behind subsidizing health, we won'tbe able to pay what happens next.
And I can't think of any, any demographicwhere that's more important than high
(33:56):
risk Medicaid patients who oftentimesdon't have the resources that they
need to maintain their personal health.
We've just gotta completely look atthe way that we do this Medicaid thing.
It's untenable in every way imaginable.
The idea of paying for value seems to bedefinitely at least one leg in the stool
that's gonna transform healthcare here.
Right.
(34:16):
And particularly important forrural America that has all of
these additional challenges.
It's certainly a, aspider web of complexity.
Yep.
Nikki, if people are interestedin learning more about the work
that you're doing, where would youdirect them for more information?
You can let me up on LinkedIn, readilyavailable on most social media platforms.
(34:36):
Nikki King, thank you so much forbeing on Relentless Health Value today.
Thank you.
Hi, this is Cynthia Fisher,patientrightsadvocate.org.
We subscribe to Stacey's podcast and we'velearned so much from her podcast with all
the incredible individuals she interviewson healthcare and the opportunities
(34:59):
to affect change for the better.
I suggest everyone listen to thesegreat podcasts that Stacey provides.
So well informed for all ofus engaged in healthcare.
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