AHA's Rural Podcast Series

00;00;00;28 - 00;00;27;14
Tom Haederle
Ask any hospital leader to name the biggest challenges facing their organization, and their answers are pretty much the same, regardless of size. But for rural care providers, the workforce and financial issues found everywhere are harder to solve, and they're looking to their boards of trustees for help.

00;00;27;17 - 00;00;49;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Join us for this brief but on-point discussion of the role board members can play in helping their hospitals and health systems navigate today's pressing problems, and how the AHA's resources and educational materials can assist board members in turn.

00;00;49;23 - 00;01;12;28
Sue-Ellen Wagner
I'm Sue Ellen Wagner, vice president of trustee engagement and strategy for the American Hospital Association. I'm here at the AHA Rural Conference in Orlando, Florida with Barbara Sowada, who's the president of the board of trustees for Memorial Hospital of Sweetwater County in Rock Springs, Wyoming. Barbara, thank you for joining me today.

00;01;13;00 - 00;01;16;14
Barbara Sowada, Ph.D.
Thank you for inviting me. It's a pleasure to be here.

00;01;16;16 - 00;01;23;02
Sue-Ellen Wagner
Barbara, can you highlight the top three challenges that rural hospital boards are experiencing?

00;01;23;05 - 00;01;58;16
Barbara Sowada, Ph.D.
Obviously, workforce stability, including physician recruitment. That is difficult in rural areas. The financial challenges Medicare and Medicaid do not cover the cost of care right now. And then the commercials are, what should I say,  providing their own challenges with pre-authorization and denials. The other part with the commercials is we're just starting to experience in Wyoming narrow networks through Medicare Advantage.

00;01;58;18 - 00;02;18;00
Sue-Ellen Wagner
Thank you for citing those challenges that we've heard at the conference a lot about the financial and the workforce challenges. So given the challenges that you just talked about, rural hospitals do serve a tremendous value to their communities, and trustees represent these communities. So can you expand a little bit more on that?

00;02;18;02 - 00;02;49;06
Barbara Sowada, Ph.D.
Yeah, the challenges, as you know, the no mission, no margin or no margin, no mission. One of the tricks anymore is to find that balance between what is affordable and what are the community's needs. One of the things that I forgot to mention, but is a challenge nationwide, is behavioral health. And again, in rural areas that I don't know whether it's worse in some areas of the country

00;02;49;06 - 00;02;57;03
Barbara Sowada, Ph.D.
yes, mental health is more challenging than in the urban areas. And again, it's a dearth of resources.

00;02;57;05 - 00;03;15;00
Sue-Ellen Wagner
Absolutely. Yeah. We hear a lot about the behavioral health challenges. My colleague Rebecca Chickey spearheads the behavioral health issues for AHA And we do a lot of collaboration with her. So what can AHA trustee services do to help boards, specifically the rural boards?

00;03;15;02 - 00;03;46;01
Barbara Sowada, Ph.D.
I think the things that you are doing right now, the continuing education...the newsletters...you have a fabulous webinar archival board, the education is fabulous. What was really fun today, is one of the AHA - and I cannot remember her name - employees is working with our hospital to become critical access. So your resources are widespread and greatly appreciated.

00;03;46;07 - 00;04;11;11
Sue-Ellen Wagner
Oh that's good to hear. We aim to help our members. Our website is trustees with an "S" trustees.aha.org. As Barbara mentioned, we do have a wealth of information, including some boardroom briefs, which are 2 or 3 pagers, which also includes some questions that board members can ask about specific issues. We do have a brief on behavioral health, so I encourage folks to listen to that.

00;04;11;14 - 00;04;25;27
Sue-Ellen Wagner
As Barbara mentioned, we do have some great recorded webinars on quality and some other issues. Anything else you want to talk about, Barbara? Maybe something at the rural conference that you learned about or heard about that could be helpful to our listeners?

00;04;25;29 - 00;05;01;19
Barbara Sowada, Ph.D.
One of the things that really delighted me and surprised me are there are several presentations on, I would say, building relationships, having more civil conversations, the need to repair community relationships, sometimes even relationships within an organization. That is part of the focus of this week's conference is truly delightful, and I actually encourage you to do more of that, whether it's written or webinars or what have you, because that communication is just key.

00;05;01;22 - 00;05;11;09
Sue-Ellen Wagner
Well, for folks who weren't able to join us at the conference, hopefully they'll visit our website and utilize some of our podcast and webinars. Thank you for being with us today, Barbara.

00;05;11;11 - 00;05;15;09
Barbara Sowada, Ph.D.
Oh, thank you, Sue Ellen. This is delightful and I love the conference.

00;05;15;12 - 00;05;17;24
Sue-Ellen Wagner
Great. Thank you.

00;05;17;26 - 00;05;26;06
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;26 - 00;00;32;23
Tom Haederle
Where will tomorrow's health care workforce come from? How can we recruit and encourage young people today to pursue careers in this critically important field? These questions face every hospital and health system in the country and are particularly challenging for rural care providers. Big challenges demand innovative solutions and one health care provider in rural Missouri has really stepped up to the plate.

00;00;32;25 - 00;01;05;12
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Signing bonuses and tuition payments are familiar tools many health care employers use when recruiting young people for current and future workforce needs. Hannibal Regional Health Care System offers those things, too. But as we hear in this podcast recorded at the AHA's 2024 Rural Health Care Leadership Conference, Hannibal does much more, such as offering apprenticeships that provide on the job training for people with no health care experience.

00;01;05;14 - 00;01;27;27
Elisa Arespacochaga
I’m Elisa Arespacochaga, AHA's vice president for clinical affairs and workforce. And today, really excited to be joined by Susan Wathen, vice president, Human Resources, Hannibal Regional Health Care System in Hannibal, Missouri, and getting a chance to talk to her about recruiting and encouraging the next generation of the health care workforce. So, Susan, first, thanks for all the work you've done, and tell me a little bit about yourself and your role.

00;01;27;29 - 00;01;50;09
Susan Wathen
Hannibal Regional is an independent health care system located in northeast corner of Missouri. My role is vice president of Human Resources, which means all of the HR functions roll up to me. Training or development, physician recruitment, employee health. And we have a child care center that has to report somewhere. So that is mine as well. You know, I'm part of the senior leadership team.

00;01;50;11 - 00;01;58;13
Susan Wathen
And for an independent health care system, being a part of that team means that we need to be very nimble and collaborative as well. And so that's a bit about my role.

00;01;58;16 - 00;02;27;22
Elisa Arespacochaga
It sounds like you've got a number of hats in your closet to fill. So like all hospital and health systems, you're facing recruitment challenges and not only recruitment challenges for today, but really thinking about the next generation of the health care workforce, which is even harder to do in a rural area. Can you share some of the great programs that you've got underway, both with your local educational system, your high schools, and then some of the opportunities you're putting together going forward?

00;02;27;25 - 00;02;49;13
Susan Wathen
Sure. So we're doing a lot of the same things most of the listeners are doing. We are offering sign-on bonuses for hard to recruit positions such as nursing and radiology positions. We are paying for students' tuition. We're paying tuition for nursing students in exchange for coming to work force after graduation. You know, a certain level of commitment post-graduation.

00;02;49;15 - 00;03;13;09
Susan Wathen
We're paying tuition for some hard to fill radiology positions. We are an official patient care tech apprenticeship program. So for those that have absolutely no health care experience but are interested and maybe even potentially down the road becoming a nurse, they can come in without any health care experience and go through our on the job training to become a patient care tech.

00;03;13;11 - 00;03;31;25
Susan Wathen
And in the state of Missouri, that's just essentially an unlicensed CNA. So they're paid on the job. They're able to work full time in that role afterwards. If at some point they decide they want to go into nursing and further their education, we can help pay their tuition to do that as well. And we have partnerships with the local nursing schools.

00;03;31;28 - 00;04;14;00
Susan Wathen
We have no cap on our tuition payments for one of the local universities there in Hannibal for their nursing programs, and we get a number of nurses for them. And then we have a little bit of a unique program called Work and Learn, where someone in any sort of university or community college, any accredited post-graduate level education...and they don't have to be going into health care. But if they will work in some of our frontline positions, such as dietary, EVS, phlebotomist and even some pharmacy tech one positions depending on how many hours they work each quarter, then we pay them a stipend for their going to school and work in those frontline jobs.

00;04;14;02 - 00;04;38;21
Susan Wathen
So again, those are pretty similar to what a lot of places are doing. One of my favorite unique programs to help fill some non-clinical positions is what we call the BEST program. It's basic employment skills training. It's a partnership with our local high school, and it is for seniors in high school who have disabilities. They're either physically disabled or they're challenged.

00;04;38;27 - 00;05;05;06
Susan Wathen
And honestly, for these students, their families plan for them before this program came to existence was probably going to be going on disability after they graduated high school if they graduated high school. So this is our eighth year for that program, and it places these seniors in internship roles on our campus. They learn soft skills, but then they are in positions such as environmental services and dietary materials management.

00;05;05;13 - 00;05;25;08
Susan Wathen
And then we have that child care center. And so we've actually this year had our first intern in that child care center. We have been able to recruit and retain seven of those throughout the past years. And I'm sure we'll probably have the opportunity to recruit and retain 1 or 2 of those this year as well. So that's been, for the frontline non-clinical

00;05;25;08 - 00;05;31;01
Susan Wathen
that's probably one of my favorite programs. It's just been life-changing for those high school students and their families.

00;05;31;07 - 00;05;51;28
Elisa Arespacochaga
It gives them such a great opportunity to understand health care and be able to, you know, find a role that makes sense for them. That's wonderful. Let me ask and we'll get to your rural residency program that your personal mission to get done. But work like this doesn't exist in a vacuum. Obviously, you talked about a number of partnerships that you have already in place.

00;05;52;00 - 00;05;55;07
Elisa Arespacochaga
How did you build some of those and how do you sustain them now?

00;05;55;09 - 00;06;20;18
Susan Wathen
That's a great question. Relationships are key, and I think if you talk to anyone in rural health care, you're talking about rural areas. Those people have to have relationships to trust you. And so it's relationships internal but external as well. It's with the school districts. It's with the chamber. It's with your local governments. It's really building those partnerships and maintaining those relationships.

00;06;20;20 - 00;06;32;04
Susan Wathen
You know, we're taking care of those same people in our health care system. And so they often will get to see both sides of that. But it's a lot about the relationships, any place in rural health care.

00;06;32;06 - 00;06;40;11
Elisa Arespacochaga
I know you have on your plate building a rural residency, but you're not building that from nothing. You've got a program already in place. Can you tell me a little bit about where you're going with that work?

00;06;40;15 - 00;07;01;22
Susan Wathen
Sure. So this is the eighth year that we have had third and fourth year medical students doing their clinical rotations at Hannibal Regional. We're a formal training site for the University of Missouri out of Columbia, Missouri, and for A.T. Still University out of Kirksville, Missouri. And we'll have some one off clinical rotations for people that maybe are in other medical schools across the country but have ties to the area.

00;07;01;24 - 00;07;18;11
Susan Wathen
But those third and fourth year medical students do all of their third year rotations with us and then a number of their fourth year. And that has really been good for the physicians. I think our physicians were a little gun shy at first. It was change. It was new. It looked like it was going to be a lot of work for them.

00;07;18;14 - 00;07;37;14
Susan Wathen
But what they have found is that these students really compliment the work they do. And the students keep these physicians very sharp. You know, the students are being trained. They're asking questions that sometimes cause the physicians to have to go look something up. So then just organically, our next step is to bring residents into the setting.

00;07;37;17 - 00;07;57;04
Elisa Arespacochaga
That's awesome. So as you're, you know, based on your experience in building all these programs and your deep HR background, what's some advice you'd give for those who are saying from, you know, are in clinical departments or other departments, they're trying to figure out how to approach you - HR - and say, I want to build a program. What's your advice to them?

00;07;57;06 - 00;08;26;02
Susan Wathen
I'm going to go back to relationships. You know, we have a little over 1,600 team members. I can't say now like I could when I started working there, that I really know everyone, I know their names. But I work hard to know people and build relationships with them. I think keeping that open door, doing rounding in all of the locations and areas so they at least see who we are gives them the opportunity to feel comfortable coming, instead of just going from the HR perspective, instead of just going in some place

00;08;26;02 - 00;08;34;20
Susan Wathen
when you're coming in with bad news, come in with good news and build those relationships. I think that's true for any leader in rural health care.

00;08;34;22 - 00;08;45;26
Elisa Arespacochaga
And I guess the flip side of that is all the folks listening should know that they can go talk to their HR folks, and especially when they've got a good point, you know, a plan to try something new.

00;08;46;01 - 00;09;08;25
Susan Wathen
Right. Well, and I think with all of these programs we've talked about, it is not just HR. This crosses, it breaks down the silos, and it really crosses a lot of different areas in rural health care settings. Nursing is involved in many of these and nursing education. If our chief medical officer weren't on board for having medical students or residents, these programs wouldn't be going. Operations is impacted

00;09;08;25 - 00;09;14;21
Susan Wathen
when we bring these interns on site and we need a classroom. It is not just HR.

00;09;14;24 - 00;09;19;00
Elisa Arespacochaga
I'm glad you're leading the charge for Hannibal. And thank you so much for joining me today.

00;09;19;05 - 00;09;20;28
Susan Wathen
Yeah. Thank you Elisa.

00;09;21;01 - 00;09;29;12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:13 - 00:00:24:07
Tom Haederle
Changing demographics and financial pressures pose challenges for hospitals, especially those in rural communities, to maintain obstetric services. In the last five years, more than 300 birthing units across the country have shut down.

00:00:24:09 - 00:01:06:18
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Despite today's many challenges, some hospitals are implementing creative strategies to maintain necessary obstetric services for their communities. San Luis Valley Hospital in rural central Colorado is cross-training its clinical staff and partnering with community stakeholders to keep serving their community. Julia Resnick, AHA's director of Strategic Initiatives, recently spoke with Monica Hinds, an RN and director of Emergency Services and Obstetrics and Stephanie Posorske, a certified nurse midwife, about their approach to maternal care for the San Luis Valley community.

00:01:06:20 - 00:01:15:02
Julia Resnick
So, Monica, Stephanie, thank you both so much for joining me. Let's start with some background about each of you and San Luis Valley Health. Monica, I'll start with you.

00:01:15:04 - 00:01:40:14
Monica Hinds, R.N.
I am new to nursing. I've been a nurse for about ten years. This is my second career. and I attribute my nursing drive to OB, actually. When I had my kids, the OB nurses here at San Luis Valley Health were awesome, and I felt like that's what I wanted to give back to the community. So that was a little bit about myself.

00:01:40:16 - 00:01:58:11
Monica Hinds, R.N.
I have been overseeing the OB department for the last 4 to 5 years, I think is when I took over. I was, originally, an emergency room nurse. Became director of the emergency department, and then just sort of, fell into the OB leadership position as well.

00:01:58:14 - 00:02:03:02
Julia Resnick
So can you tell me a just a little bit about the community that is in the Valley?

00:02:03:04 - 00:02:22:28
Monica Hinds, R.N.
Alamosa is the central hub of the Valley. We do service several communities throughout the area, the San Luis Valley. And we are the only location that does labor and delivery. And so everyone does come to us, or they go outside of the valley for their OB needs.

00:02:23:05 - 00:02:26:21
Julia Resnick
Got it. And what kind of pregnancy care does your hospital provide?

00:02:26:23 - 00:02:44:24
Monica Hinds, R.N.
We pretty much do everything. Because even if we cannot manage the patients here, we make sure that we get them to that higher level of care. So we do have the C-sections, we do induce, we do have a local midwife that does deliver outside that we do support as well for her needs.

00:02:44:27 - 00:02:52:06
Julia Resnick
And tell me a little bit about the community stakeholders and partners that you work with, both for prenatal care and postpartum care.

00:02:52:08 - 00:03:11:07
Monica Hinds, R.N.
So we do have valley wide. They are also part of our labor and delivery department. They do manage their own patients. Do their own deliveries, do their postpartum care as well. And then we do have our ObGyn clinic here that, manages our patients for our hospital.

00:03:11:10 - 00:03:24:28
Julia Resnick
So turning to you, Stephanie. I know that there are a lot of challenges faced by rural communities, especially in terms of maternal care. So can you talk about some of the challenges, that expectant and postpartum moms are facing in your community?

00:03:25:00 - 00:03:49:18
Stephanie Posorske
So, interestingly enough, I think that social media has changed this significantly in the last ten years in the sense that everybody knows what's out there, and then what's that availability here? So they're, you know, they want to know, like, can I have an epidural? And yes, they totally can. And being able to meet those needs.

00:03:49:18 - 00:04:19:25
Stephanie Posorske
I think that we do a really good job of finding the niches that are really important. For example, women really worry about being able to have a lactation consultation. And while we don't have a specific lactation counselor, that that's just what they do. I'm our hospital's lactation counselor, on top of being a certified nurse midwife, so that we can still meet those needs without, you know, having to expend our resources.

00:04:19:27 - 00:04:41:08
Julia Resnick
Got it. And, you know, every day we're hearing about more OB units closing down unlimited access in rural communities. But you all are some of the rare ones who are managing to keep yours up and running and serving your community. So can you tell me about what strategies you're implementing that's able to keep your maternity unit open and thriving?

00:04:41:11 - 00:05:05:18
Monica Hinds, R.N.
We are seeing a decrease in, deliveries per year as well. And to be able to make our department managable as far as financial, we've really had to think outside of the box on what we're going to put on that unit. So we have expanded our unit to that surge overflow unit. We have implemented pediatric patients on part of our unit.

00:05:05:21 - 00:05:26:00
Monica Hinds, R.N.
We do some post-surgicals that are not Ob-Gyn related on our unit. So we really have grown our OB nurses into well-rounded nurses that do everything. And so we give them a lot of credit for the knowledge that they've had to obtain over these last few years just to be able to care for our patients in our community.

00:05:26:03 - 00:05:29:02
Julia Resnick
That's really wonderful. Stephanie, anything else you want to add?

00:05:29:04 - 00:05:57:03
Stephanie Posorske
Yeah, I think that there has come a lot of flexibility and changing our expectations of what works for people, and that that's what like all these units that have been able to stay open have had to do...is that we've had to become more flexible as an employee, but also the employer has had to become more flexible on what meeting the needs of everybody's situation so that we can keep this resource available.

00:05:57:05 - 00:06:17:14
Julia Resnick
That's great and wonderful that you're all willing to be so adaptable as you're trying to make your way through this. So besides clinical services, we know that a lot of rural women are also experiencing challenges around behavioral health, such as substance use, and other issues related to social determinants of health. So how are you addressing those issues in your community

00:06:17:16 - 00:06:20:29
Julia Resnick
especially for pregnant and postpartum women?

00:06:21:01 - 00:06:44:19
Stephanie Posorske
I think I can answer that. So I prescribe Suboxone, which is for people that use opiates. And on top of that, like being a great resource for people that use opiates so that they can hopefully get off opiates, it also opens the door for all avenues of people knowing that we're open to doing that and what we can do to help.

00:06:44:21 - 00:07:08:00
Stephanie Posorske
I think we really want to get out there this idea of like, we want you to come in, we want you to get care. Despite all of these challenges, whether it's for behavioral health or because you use some substance, we want to be the doors are open because this is an opportunity for us to capture people that are using

00:07:08:03 - 00:07:20:18
Stephanie Posorske
and it's when they're going to be most motivated to make a change in their lives. And so keeping that door wide open is the best way to do that and hopefully is working.

00:07:20:21 - 00:07:22:17
Julia Resnick
Monica, anything you want to add?

00:07:22:19 - 00:07:48:27
Monica Hinds, R.N.
So I would really like to add we do depression screening on all of our patients - no matter if they're observation patients or inpatients, postpartum in the middle of their pregnancy - just so we can try to catch these patients early enough to be able to give them the resources that they need. We have also really focused on our social determinants and making sure that we're asking those hard questions of patients, you know, do they need some help with housing?

00:07:48:27 - 00:08:06:16
Monica Hinds, R.N.
Do they need transportation? Is food a difficulty for them at this point in time? And we have great care coordination that actually will follow up on all of those patients prior to them being discharged to make sure that they're providing them the resources in the community that they need.

00:08:06:18 - 00:08:29:09
Julia Resnick
And yeah, I think you're both really getting at this idea that, like, these are sensitive questions and sensitive topics for people and keeping that door open so that they feel comfortable coming to you and asking for the support they need is just so crucial. So we always love stories that can really bring this to life. Do you have any stories from your hospital or patient stories, that can help bring to life the work you're doing?

00:08:29:12 - 00:09:02:03
Stephanie Posorske
I have a patient. She's had a baby already. Her and her partner have had times where they've used either fentanyl or opiates. And that door has stayed open to them, despite their not always being as compliant as we would like them to be. But they continue to come see us. Another provider in my clinic sees her husband so that we are both taking care of both of them and their substance use.

00:09:02:05 - 00:09:25:18
Stephanie Posorske
It's just lovely for them, like to have their baby, and for us to be continuing to work on this medical problem that they have. And it's not black and white and it's not it's not super easy. But every time they bring that little baby in and that they're still together and that they're still coming is exactly why that that door has to stay open.

00:09:25:21 - 00:09:34:08
Julia Resnick
Absolutely. And clearly the motivation is there. Yeah. And it's wonderful that you embrace them. Monica, any stories from your world?

00:09:34:10 - 00:09:58:00
Monica Hinds, R.N.
I don't have any specific patients. I mean, we do see when those those patients come in that have that substance use and and we're able to, you know, get them the resources that they need and be able to get them reunited with their baby, even if they aren't able to leave with them at discharge. But to be able to help them get that custody back.

00:09:58:02 - 00:10:06:07
Monica Hinds, R.N.
We see it, you know, not daily, but we see it a lot. It warms our heart that we can help those patients get back with their babies.

00:10:06:09 - 00:10:17:15
Julia Resnick
That is wonderful. So for other rural hospitals that are considering different creative avenues for providing maternal care, what advice do you have for them? What have you learned along the way?

00:10:17:17 - 00:10:56:10
Monica Hinds, R.N.
I'm going to say that you have to listen to your staff. It's been very difficult making that transition from just being a labor and delivery nurse and moving into other fields. It's definitely a lot easier with the newer nurses that are coming out, because that has expectations set forth on employment. But for those those experienced labor and delivery nurses, taking that time to listen to them, about their concerns and what kind of education that they need to make sure that they feel comfortable in providing the care to patients that they haven't cared for, you know, since nursing school, probably.

00:10:56:12 - 00:11:05:03
Monica Hinds, R.N.
So just stopping and listening to concerns is something that I feel that we can really learn throughout this transition.

00:11:05:05 - 00:11:05:27
Julia Resnick
Stephanie?

00:11:06:00 - 00:11:25:09
Stephanie Posorske
I mean I think that's really important. And like listening to your staff is how we will make changes together and not be like get all that pushback. And just like the adaptability like we talked about, we have to all be adaptable. We had to be adaptable in the sense that we brought these patients to our unit,

00:11:25:12 - 00:11:46:09
Stephanie Posorske
that we sometimes have some med surge patients on our unit. But depending on what's going on on labor and delivery, we have to be able to change that. And I think all of our expectations have changed, and we've all learned to evolve with the situation. And that's the true heart of nursing and medicine is that we have to be able to evolve and change based on the patient.

00:11:46:09 - 00:11:54:15
Stephanie Posorske
But big picture: How we evolve and have adapted and changed for our unit as a whole has been really how this has worked.

00:11:54:18 - 00:12:09:22
Julia Resnick
That is an incredibly powerful message that I think we all need to to take in to the work that we do, that, you know, the world changes and we need to change along with it to make things work. So to wrap up, what's next for you all? And SLVH's is work in maternal health?

00:12:09:25 - 00:12:12:06
Monica Hinds, R.N.
I'll let you go first, Stephanie.

00:12:12:09 - 00:12:35:18
Stephanie Posorske
Well, you know, I mean, Monica knows that I always have all kinds of ideas and some of them work and some of them don't. But we, you know, we all move forward and with our ideas and, you know, like, I'd like it if we had nitrous is an option for our patients. And I think we're totally on the brink of getting that. We want to meet to the need of everybody

00:12:35:21 - 00:12:53:28
Stephanie Posorske
which is a wide variety of people really here. And so finding ways that keep us safe and financially feasible, but also our meetings and needs and make us also feel like maybe we aren't as Podunk as sometimes we think, even.

00:12:54:00 - 00:13:10:08
Monica Hinds, R.N.
Yeah. And I would definitely agree with what Stephanie is saying. We we do try to stay up with the times, but making sure that we are providing that safe environment for our patients and for our staff as well, and giving them those opportunities to continue to learn and grow in the field.

00:13:10:10 - 00:13:27:00
Julia Resnick
Well, it's clear how dedicated you all are to your patients and your community and really making sure that door stays open to them. So I just want to thank you for the great work that you're doing to to support moms in your community and really appreciate your taking the time to talk with us today about your work.

00:13:27:01 - 00:13:28:15
Julia Resnick
Thank you so much.

00:13:28:17 - 00:13:29:24
Stephanie Posorske
Thank you for having us.

00:13:29:26 - 00:13:31:28
Monica Hinds, R.N.
Yeah, thank you for sure.

00:13:32:01 - 00:13:40:12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:25 - 00:00:33:19
Tom Haederle
Being a new parent is challenging in the best of circumstances, but it's even harder for expecting and new moms struggling with social and behavioral health needs. And living in a rural community means that the resources available to support new parents may be limited. The first 1,000 days from pregnancy to age two offers a crucial window of opportunity to create brighter, healthier futures.

00:00:33:21 - 00:01:17:00
Tom Haederle
Welcome to Rural, a yearlong series devoted to rural hospitals and health systems in America. I'm Tom Haederle with AHA Communications. St. James Health Care in Butte, Montana, now part of Intermountain Health, is designing care around new moms who need the extra support not just during pregnancy, but during the first two years of the baby's life. At this year's AHA Rural Health Care Leadership Conference, Julia Resnick, director of strategic initiatives at the AHA, spoke with April Ennis Keippel, community health director, Montana/Wyoming Market at Intermountain Health, and Joslin Hubbard, social worker at Intermountain Health at St.James Hospital, about how their first 1,000 Days program provides wraparound services for at risk new moms.

00:01:17:03 - 00:01:25:18
Tom Haederle
They were joined by Lacey Starcevich, a former program participant who shares her powerful journey to build a healthy life for herself and her family.

00:01:25:21 - 00:01:42:25
Julia Resnick
April and Joslin and Lacey, thank you so much for recording this podcast with us. We're here at the AHA Rural Health Care Leadership Conference. I'm really pleased to have all of you. So to kick things off, let's get a little background on your health care system. So can you tell us about Intermountain Health, St.James Hospital, and the community that you serve?

00:01:43:02 - 00:01:44:27
Julia Resnick
April, do you want to kick things off?

00:01:45:00 - 00:02:12:19
April Ennis Keippel
Sure. So we are a part of a large system, Intermountain Health, that includes hospitals in Montana, Colorado, Utah, clinics in Nevada as well. And St. James is located in southwest Montana. It's a community of about 35,000 residents, is a level three emergency department and really provides services for all the surrounding counties, which are primarily rural counties.

00:02:12:21 - 00:02:15:12
Julia Resnick
Anything else you both want to add about the hospital and your community?

00:02:15:12 - 00:02:30:04
Joslin Hubbard
Butte is a really proud community. It has a long history of mining and people are proud to be from Butte. They help each other out. They come together to support one another. And it's just a beautiful place to live.

00:02:30:07 - 00:02:44:00
April Ennis Keippel
And Butte was known as the richest hill on earth at one point and at one time was the largest city between Chicago and San Francisco in its heyday. So rich history in the community.

00:02:44:00 - 00:02:58:01
Julia Resnick
That is quite a history. And I love that piece about community because I think that's really what we're here to talk about. And our focus today is really on maternal health. So, Jocelyn, can you talk at all about the maternal population that you're serving and where your patients come from?

00:02:58:07 - 00:03:23:00
Joslin Hubbard
Yeah. So most of our patients live in Butte or Silver Bow County. We do serve the women from the surrounding counties as well. Our payor mix at our hospital is, you know, around 85% Medicare and Medicaid. And we have women primarily of Caucasian descent. And we serve ages, you know, teen age to later maternal - advanced maternal age, they call it.

00:03:23:01 - 00:03:26:06
Joslin Hubbard
So but just a really great mix of.

00:03:26:09 - 00:03:33:27
Julia Resnick
And even though most of your patient population does identify as white, are there any disparities that you've identified between like different subsections?

00:03:33:29 - 00:03:53:15
April Ennis Keippel
So a lot of the disparities we see in our community health needs assessment are actually related to socioeconomic status. Individuals living in poverty across all health outcomes have poorer outcomes. So anyone 200% or less of the federal poverty level just scores worse on a number of health outcomes.

00:03:53:18 - 00:03:58:29
Joslin Hubbard
April, Do you know what population of our patients fall within that 200% below poverty level?

00:03:59:04 - 00:04:05:24
April Ennis Keippel
The residents, I would say about 20% of overall residents. So one in five are below the poverty level.

00:04:05:27 - 00:04:19:22
Julia Resnick
Got it. And when you're thinking about these new parents in your community, are there any particular challenges that you've been seeing them experience? I know you touched on their socioeconomic status of needs, but in terms of behavioral health and how those challenges are impacting them.

00:04:19:24 - 00:04:46:18
Joslin Hubbard
So we have limited resources for our behavioral health and substance use. So those definitely impact our patients' access to care. When we're talking our socioeconomic struggles, it's even transportation to those appointments. It's housing, working with women and families. It's hard to talk about getting to appointments when they're not sure where they're going to live, you know, or stay that night or how they're going to get to that appointment.

00:04:46:21 - 00:04:53:07
Joslin Hubbard
You know, we have to take in all of that into consideration when we're dealing with people with substance and mental health needs.

00:04:53:10 - 00:05:01:00
Julia Resnick
Absolutely. So we're really here to talk about the Meadowlark Initiative. So can you talk to our listeners about what that is?

00:05:01:03 - 00:05:28:08
April Ennis Keippel
I can maybe start and then you can fill in as needed. So the Meadowlark Initiative is funded through the Montana Health Care Foundation. And it's really focused on providing intensive case management to the most at-risk patients prenatal and then following through til the second year of life. So, really helping to guide and support both prenatally and then also postnatal.

00:05:28:10 - 00:05:30:07
April Ennis Keippel
What else would you add, Jocelyn?

00:05:30:09 - 00:06:05:15
Joslin Hubbard
Yeah, so the initiative initially was funded by the Montana Health Care Foundation, but St.James has continued that, recognizing the need and the importance of this work. And so our program was the first 1,000 Days, which is from conception to age two, recognizing that it is the most critical and crucial time in human development. And when the brain develops, you know, it's just really using that care coordination piece to kind of bridge the gaps between those services, whether it's housing, food issues, transportation, mental health, substance use and the clinic or the hospital and how to connect patients when they come in for prenatal care with those outside resources, and then to continue to be

00:06:05:15 - 00:06:12:02
Joslin Hubbard
a resource and a support for them as they not only through their pregnancy, but as they embark on parenthood.

00:06:12:04 - 00:06:22:08
Julia Resnick
That's amazing that you have such a long perspective on it and not just, you know, a specific part of pregnancy or postpartum. So who are you partnering with or coordinating with to bring this all to life.

00:06:22:14 - 00:06:46:16
Joslin Hubbard
In terms of community resources? Yeah, Perfect. Yeah. So we have lots of you know, we partner with all of our resources in the community, whether that's private therapists. We partner with our Southwest Montana Community Health Center to provide mental health services as well as primary care following delivery. You know, our mental health centers and parenting agencies in the community as well.

00:06:46:18 - 00:06:53:24
Julia Resnick
So talk me through it...like someone finds out they're pregnant: how do they get enrolled in the program? Like, what happens next? What does that look like?

00:06:53:26 - 00:07:15:00
Joslin Hubbard
The hope is that they would seek prenatal care and come to an appointment. And at that appointment they would be screened for social determinants of health. So we would be screening for transportation issues, food insecurities, housing, as well as mental health and substance use. We would also be screening the partner or whoever is supportive of that woman in pregnancy.

00:07:15:02 - 00:07:28:25
Joslin Hubbard
So that we can really help the whole unit. And then they would meet with a care coordinator. And that care coordinator then would connect with resources and help identify needs, provide education, and then support throughout the pregnancy.

00:07:28:27 - 00:07:32:27
Julia Resnick
It's wonderful. And are there any stories you can share that can really bring this to life?

00:07:33:04 - 00:07:43:25
Joslin Hubbard
Well, I'm fortunate to have Lacey here today. Lacey was one of our moms in our program, and I think that she can speak to her story better than I could ever.

00:07:43:27 - 00:07:46:05
Julia Resnick
Great. Lacey, over to you.

00:07:46:07 - 00:08:11:12
Lacey St.arcevich
I'm Lacey. I just, on the 22nd of February, recently celebrate five years clean. I originally attended my first prenatal appointment actively using drugs. I was screened and obviously made the requirements for the program. At the time, I was homeless and still using. I left that first prenatal appointment not sure if I was going to get clean or not.

00:08:11:17 - 00:08:26:09
Lacey St.arcevich
Not even sure if I wanted to keep Bradon. That's my son's name. He'll be five in August, actually. So with the help of Jocelyn and the Meadowlark Initiative, I was able to connect with these resources and get help. And today I'm present for my children.

00:08:26:12 - 00:08:32:02
Julia Resnick
That's amazing. I'm just so glad you're here to share your story and that you've been involved in the program since, is that?.. Yes.

00:08:32:03 - 00:08:41:09
Lacey St.arcevich
Yeah. So anything I can do to help? There are just so many mothers out there who are in the same position I am. And it's an unfortunate situation. But with things like this, we can try to lower that number.

00:08:41:12 - 00:08:46:06
Julia Resnick
And I'm sure having contact with you helps them feel less alone and that, you know, there is a light at the end of the tunnel.

00:08:46:12 - 00:08:50:19
Lacey St.arcevich
You know, there's nothing more therapeutic than another addict helping another addict.

00:08:50:21 - 00:09:03:09
Julia Resnick
Wonderful. And I know that, you know, we have a great personal story of the impact of this work, but have you been measuring what the impact is on the women that are in the program? Yes. Yes, we have. Is there anything you can share?

00:09:03:11 - 00:09:06:28
April Ennis Keippel
If I look at my notes...I don't know off the top of my head.

00:09:07:00 - 00:09:31:28
Joslin Hubbard
We have found that women who participate in this program are more likely to have consistent prenatal care. They're more likely to take their child home at delivery. And that means from a lower involvement of the Child Protective Services Removals, women have better health outcomes to higher birth weights, lower complications, less hospital stays that are involved in the care as well.

00:09:32:01 - 00:09:44:24
Joslin Hubbard
And a lot of that's probably attributed to the more consistent prenatal care, as well as changing a lot of their lifestyle and ensuring that they have the food and resources that they need,  as well as you know, hopefully not using substances.

00:09:44:26 - 00:10:01:19
Julia Resnick
So to wrap us up, I love your words of advice for other rural hospitals that are really thinking about what they can do to improve their maternal and child health outcomes. What have you learned along the way that you can share with them? And Lacey, you'll have a slightly different version of that question.

00:10:01:22 - 00:10:30:04
Joslin Hubbard
You know, when we're dealing with rural, it's hard to find people to fill spots, right? And I think the most important thing is that we realize that this is just has to be someone who cares and who understands the community and the resources out there and who can show understanding and love and kindness to patients. There's not a magic wand. This is hard work, but it's, you know, it's done in partnerships and relationships that are built not only with the patient but with the community.

00:10:30:07 - 00:10:40:10
Joslin Hubbard
And, you know, just really taking time, stepping back, understanding what the needs of your community are and, you know, just addressing it one day at a time.

00:10:40:13 - 00:10:41:21
April Ennis Keippel
Well said.

00:10:41:23 - 00:10:43:26
Julia Resnick
Very well said, April.

00:10:43:28 - 00:11:10:09
April Ennis Keippel
I don't know if I could really add anything more to that. I think it just in looking at having a connector and a go-to person, I think is probably the most important thing so that there's a single point of contact that can help move forward any of the needs and make connections. And I'm not sure that that always would need to be a particular type of training to do that work.

00:11:10:10 - 00:11:22:25
April Ennis Keippel
So I think in a rural community you could customize it to really fit what you have available. But the key piece would be just to have that single person who can really help be the connector.

00:11:22:27 - 00:11:41:11
Julia Resnick
That human connection piece really just came out strongly in both of your answers. And Lacey, from being on the participant side of this and, you know, having been one of the moms in the program, what do you wish that hospitals knew about working with new moms who might need additional social or emotional support?

00:11:41:13 - 00:11:59:16
Lacey St.arcevich
We just need, you know, a setting that's not judgmental. We do not have a village. And programs like this help us create that village, and that sets us up for success. They help me create my family. They help not only me get clean and deliver a healthy baby, but my husband followed ensued because they provided us the resource to be able to do that.

00:11:59:19 - 00:12:00:22
Julia Resnick
It's wonderful.

00:12:00:25 - 00:12:16:03
Joslin Hubbard
I just wanted to call out Lacey. You know, not only does she have Bradon, but she now has a two year-old, Parker. She's married, has bought her own home, and is a role model for other women in our community and just so proud of where she is.

00:12:16:06 - 00:12:20:06
Julia Resnick
I'm so glad we can lift up your story and share it with the world.

00:12:20:09 - 00:12:21:03
Lacey St.arcevich
Thank you.

00:12:21:05 - 00:12:30:07
Julia Resnick
So, Lacey, Joslyn, April, thank you so much for joining this podcast. I look forward to seeing your presentation later today. And just congratulations on the fantastic work you're doing.

00:12:30:09 - 00:12:30:22
Joslin Hubbard
Thank you.

00:12:30:28 - 00:12:31:27
Lacey St.arcevich
Thank you.

00:12:32:00 - 00:12:40:12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and read us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;25 - 00;00;22;23
Tom Haederle
Today, half of all Medicare beneficiaries get their benefits through Medicare Advantage or "MA" plans. They're offered by private companies and supposed to provide at least the same level of coverage that traditional Medicare does. That's in theory, anyway. In practice, an alarming number of MA private insurers have made the process of getting a claim covered a nightmare for patients.

00;00;00;25 - 00;00;22;23
Tom Haederle
Today, half of all Medicare beneficiaries get their benefits through Medicare Advantage or "MA" plans. They're offered by private companies and supposed to provide at least the same level of coverage that traditional Medicare does. That's in theory, anyway. In practice, an alarming number of MA private insurers have made the process of getting a claim covered a nightmare for patients.

00;00;22;26 - 00;00;45;24
Tom Haederle
Policyholders report facing ever-higher administrative hurdles that resulted in long delays and inappropriate denials, while hospitals and other caregivers are being overwhelmed by all of the red tape. What can be done?

00;00;45;26 - 00;01;18;00
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA Communications. In recent years, the growth of MA plans in rural areas has especially impacted rural and critical access hospitals, who already face a host of serious challenges as they strive to meet the health care needs of their communities. It's not overstating things to say that prior authorization, payment audits and delays and denials of patient care by some MA plans is threatening the financial solvency of our nation's rural safety net.

00;01;18;03 - 00;01;32;13
Tom Haederle
In this podcast, hosted by Michelle Millerick, AHA's senior associate director of health insurance coverage policy, one CEO of a rural health system describes the impact of the growth of MA plans on the communities it serves. Let's join them.

00;01;32;15 - 00;01;58;24
Michelle Millerick
Thanks, Tom. This is Michelle Millerick from the AHA Policy team and a senior associate director of health insurance coverage policy. And today, I'm joined by Chris Barber, who's the president and chief executive officer of St. Bernards Health Care in Jonesboro, Arkansas. Chris has been part of the leadership team at St. Bernards for over 30 years. So there's been tremendous on the ground experience and insight from the field to our conversation today about Medicare Advantage and some of the unique challenges facing our rural health care providers.

00;01;58;26 - 00;02;07;28
Michelle Millerick
So, Chris, I'm hoping we can start there. If you can tell us a little bit about yourself and more about St. Bernards and the types of patients and communities that you serve in Arkansas and Missouri.

00;02;08;00 - 00;02;32;09
Chris Barber
Thanks for having us, Michelle. During the malaria outbreak in the late 1890s, the brave women of the Olivetan Benedictine sisters followed their faith and responded to a desperate need by reaching out and inviting the sick into what was at that time was a six-room house referred to as St. Bernards to began a journey of sacrifice and unwavering service to others that has spanned over 123 years.

00;02;32;11 - 00;03;10;23
Chris Barber
Over that time, this small hospital has been transformed into the most extensive regional health system serving rural communities in northeast Arkansas and southeast Missouri, with a catchment area of approximately 624,000 individuals. The largest tertiary facility in the region of Saint Bernard Medical Center, which is a 454-bed facility, including a 74-bed behavioral health facility with multiple critical access hospitals under the umbrella, and recently transitioned a low-volume PPS hospital to the first Rural Emergency Hospital in Arkansas and one of the first rural pace programs in the country.

00;03;10;27 - 00;03;18;08
Chris Barber
The organization looks much different than it did in 1900, but our primary purpose and mission have transcended through time.

00;03;18;10 - 00;03;33;13
Michelle Millerick
Thanks, Chris. It's really helpful to hear more about your organization and especially the mission part of the work that you do and taking care of patients in your community. So as we think about Medicare Advantage and diving into our topic for today, you know, I think one of the reasons that this is so top of mind is that MA enrollment has been growing rapidly.

00;03;33;13 - 00;03;53;05
Michelle Millerick
As you now, you know, traditional Medicare for a long time was the predominant delivery system for Medicare coverage where most people were getting their Medicare coverage options. And now we've hit that tipping point this year where 50% of all Medicare beneficiaries are getting that care through Medicare Advantage and that enrollment is growing at about 8 to 10% per year nationwide.

00;03;53;08 - 00;04;15;01
Michelle Millerick
And I think, as you know, you know, we're really seeing sort of some of that growth in rural areas, in particular in a big way and perhaps as well some of the delays and denials and insurer practices that can be problematic for providers and patients that are following that. So I wonder if you can just tell us more about what you're seeing in Arkansas and Missouri in terms of MA growth and the impact that it's having on your organization?

00;04;15;03 - 00;04;50;25
Chris Barber
Sure. Similar to what's occurring nationally, we experience a rapid increase in Medicare eligible people choosing Medicare Advantage plans. These ongoing challenges with insurance companies over negotiations on reimbursement, prior authorization claims, denial and delayed payments have placed extreme financial pressures on hospitals in the state. The center of health care quality and payment reports revealed recently that 37 of our 49 rural hospitals, or 76%, are losing money in day-to-day operations of hospital services in Arkansas.

00;04;50;27 - 00;05;23;14
Chris Barber
Additionally, as more of these Medicare eligible population has transitioned to Medicare Advantage plans, our hospitals are reimbursed well below the rate of Medicare, resulting in a material financial impact on organization. This development of the shift in payer mix from Medicare to MA has had a profound effect on our organizations. For example, we have seen significant increases in our labor costs by just adding personnel to combat the massive number of claims, denials, pursue appeals and prior authorization.

00;05;23;16 - 00;05;32;13
Chris Barber
We are experiencing challenges just transferring patients to the appropriate level of care, often increasing length of stay in some of our acute care facilities.

00;05;32;15 - 00;05;50;07
Michelle Millerick
That's really striking, Chris, and especially some of the details you just shared on some of the financial impact of these shifts in the market. Do you have any data you can share with us just to help paint a picture as well about the environment and what you're seeing in MA? You know, certainly we're seeing some national trends with huge growth, but anything from from your market that you can share data wise?

00;05;50;14 - 00;06;19;19
Chris Barber
Yes, In our market, for St. Bernard’s Medical center, if you look at a ten year comparison of our percentage of charges for Medicare versus Medicare Advantage, it has changed dramatically. In 2015, Medicare represented 43% versus 9.5% of Medicare for our book of business. Our most recent records - 2024 percentage that Medicare Advantage is now more significant book of business than traditional Medicare.

00;06;19;21 - 00;06;46;19
Chris Barber
Medicare Advantage represents 29.8% versus Medicare, now 28.4%. Again, we've experienced these increased denials and payment delays and appeals. Our inpatient reimbursement for this population is roughly 7 to 9% below Medicare for this Medicare Advantage population. Additionally, we seeing an increase in self-pay with higher co-pays and deductibles in our market.

00;06;46;22 - 00;07;07;27
Michelle Millerick
That's really interesting, Chris, and I think consistent with what we're hearing from our members across the country. You know, I also think when you look at MA growth over the last decade or so, you see in rural areas, you know, ten years ago the uptake was pretty low. And it seems like in the last five or so years we've just seen a lot of dramatic growth, especially, you know, nationwide, but especially in rural areas, it's growing faster.

00;07;08;05 - 00;07;29;14
Michelle Millerick
And so I think some of the reasons that we're starting to see some of these pain points that that you alluded to, you know, really is correlated, especially with some increased growth and MA penetration in rural areas. So I wonder as we think about, you know, the bigger picture of what does this growth mean? You know, you've provided sort of an outline of some of the impacts on your organization, but I think a lot of this comes back to, especially for mission driven organizations like St. Bernards

00;07;29;18 - 00;07;46;17
Michelle Millerick
you know, what does this mean for patients and families? You know, there's real people behind delays and denials and, you know, people who are waiting for an authorization to be transferred to a rehabilitation facility or people who are told that they have cancer but need to wait for the treatment that might save their life while their insurer decides if they're going to cover it.

00;07;46;24 - 00;07;56;21
Michelle Millerick
And so I wonder if you can just talk a little bit about, you know, what some of these challenges translate to for patients and families that you serve and also for the clinicians and the nurses and doctors who are taking care of them.

00;07;56;23 - 00;08;21;08
Chris Barber
Absolutely. In terms of patients and their families, they can have a more exhausting experience when shopping for health insurance policies these days. They still have to educate themselves on common terms that we're all familiar with co-insurance, co-pays, deductibles and then what network. But these newer policies, however, may include some additional qualifiers or terms that may affect where and how individuals can receive care.

00;08;21;10 - 00;08;47;24
Chris Barber
If they don't meet all the criteria, they may have to pay more out-of-pocket penalties or a number of other requirements that were not present in older and more traditional policies. Anecdotally, many older individuals enroll in an MA   plan when they're healthy, seeing lower premium costs and additional benefits like dental and vision insurance. I know a recent report on NPR said those enrollees start feeling trapped as they encounter more health problems.

00;08;47;26 - 00;09;18;05
Chris Barber
They don't get to choose any doctor or hospital they want, like the traditional Medicare. To make matters worse, a recent federal review cited that more than half of MA plan directories contain inaccurate information on which providers they could see. You know, on the clinical side, we believe some insurance companies conduct business and write their clinical policies that has made it difficult for organizations to provide medical care and could jeopardize how, when and where individuals receive future care.

00;09;18;07 - 00;09;48;24
Chris Barber
Frequently, patients and families feel caught in the middle and really need trusted resources to provide honest and transparency and guidance. Clinicians are highly frustrated with the time required on the phone to receive a much needed test that has to be pre-authorized, thus creating unnecessary delays in determining a working diagnosis and appropriate treatment course. Again, we hear concerns about delays in transferring patients from the acute care setting to other levels of care.

00;09;48;26 - 00;10;14;11
Chris Barber
Finally, I would just add and underscore this point: these roadblocks to patient care really demonstrate the importance of community benefit and programs that not-for-profit hospitals and health systems play in addressing how rates of smoking, inadequate nutrition, substance abuse, help counter health risk assessments that we have in our communities. So it's imperative for us to continue to navigate these waters.

00;10;14;14 - 00;10;41;28
Michelle Millerick
Thanks, Chris, and I really appreciate your perspective on how some of these issues and trends affect patients. There's something you said that I want to just drill down on for a second. You know, particularly around some of the impact on clinicians and caregivers and how these policies are adding cost and burden to the health care system. You know, particularly as a system with rural presence, you know, workforce issues and shortages of health care providers is a national issue all over the country, but certainly something that's especially pronounced in rural areas.

00;10;42;00 - 00;11;01;10
Michelle Millerick
And as we think about, you know, peer-to-peers and the burden of prior authorization and clinician documentation and some of the things that play into insurer delays and denials or excessive use of prior authorization for things that are pretty routine. Can you talk a little bit more just about some of the workforce issues that you're seeing and maybe how some of your policies might play a role?

00;11;01;13 - 00;11;25;06
Chris Barber
Yes, this has certainly been a challenge, one, recruiting talent to rural communities. As you know, physicians primarily trained in urban markets. And we have to compete nationally on compensation, but also you have to have amenities to go along with that. So it is a challenge. We want to get physicians as well as clinicians to move to rural communities.

00;11;25;09 - 00;11;47;08
Chris Barber
So if they have a rural payback or program with physician training, that has certainly benefited some of our communities. It's also good to have a medical school, a residency that believes in rural medicine and encompasses that and provides rotations in a community. What we've found, if we can get them to the community, they can see what kind of quality medicine you can provide, an impact that you can have.

00;11;47;10 - 00;12;15;24
Chris Barber
It can be meaningful on a fulfilling career here, but is a challenge when you're trying to recruit to rural communities. Let me say some of the other aspects and critical access hospitals in regard to MA...timely payment in the payer mix of patients are essential to hospital survival. In many of these rural communities, we see less commercial insurance and more Medicaid and Medicare and now a significant percentage of Medicare advantage in our rural communities.

00;12;15;26 - 00;12;57;11
Chris Barber
You know, recently in the American Hospital Survey on Medicare Advantage plans, they have the highest denial rate at 19.1%. This significant operational challenges places organizations and exacerbate issues in smaller rural facilities that do not have either a dedicated resource for ongoing monitoring and continuously fighting to overturn these high number of denials. In many instances, Medicare plans are paying much less for critical access hospitals and Medicare, and we have one critical access facility that is receiving 37% less for inpatient reimbursement premiums for MAs, compared to Medicare, which is significant.

00;12;57;13 - 00;13;28;04
Chris Barber
Additionally, in specific markets, rural critical access hospitals are limited in their ability to negotiate a reasonable agreement with these large national insurers effectively. And as we all know, the margins on rural hospitals are extremely thin. And this shift in payer mix has dramatically impacted the financial deterioration of many hospitals with limited cash reserves. In our case, we're fortunate to have a system that helps some of these resources in alignment with our critical access hospitals.

00;13;28;06 - 00;13;38;01
Chris Barber
But in general, if there's no changes in the near future, unfortunately, I think we'll continue to see the deterioration of services and the number of providers in rural communities.

00;13;38;04 - 00;13;58;19
Michelle Millerick
Chris, that's really striking. And you know, I think when you describe one of your critical access hospitals getting 37% less than they would have under traditional Medicare...you know, you think back to 1997...Congress made a special payment designation for critical access hospitals to make sure in recognition of their unique status and their ability to ensure that people get access to health care services.

00;13;58;26 - 00;14;20;23
Michelle Millerick
I mean, rural areas that they get paid at 101% of their costs under Medicare. And so it's really striking, I think, an important policy question for us to think about, too, as Medicare Advantage continues growing and is rapidly becoming the predominant way that people get Medicare coverage. You know, it's really striking that that need perhaps isn't being met on the MA side in terms of what the reimbursement that critical access hospitals are getting.

00;14;20;23 - 00;14;36;12
Michelle Millerick
It doesn't match what Congress wanted them to get on the fee for service side. And then you add some of the other things that you're talking about in delays and denials of care and prior authorization. And that's that's really helpful perspective, Chris. You know, I want to think about sort of solutions and, you know, where do we go from here?

00;14;36;12 - 00;14;56;06
Michelle Millerick
And I think you've laid out what some of the issues are really well. You know, I think from a federal perspective, there's some good news, which is that these issues are getting a lot of attention from policymakers, from the media, and frankly, just from the public and people who are really worried about what's happening, you know, in open enrollment the last couple of months as people are out there making choices about Medicare coverage.

00;14;56;09 - 00;15;25;05
Michelle Millerick
There's been a lot of stories and attention on the impact on patient access to care for services that should be covered in MA and inappropriate denials. You know, in the last year or so, we've started to see a major government reports from the HHS Office of Inspector General raising concerns about inappropriate denials. The Centers for Medicare and Medicaid Services, which oversees the operation of the Medicare program, finalized a major new rule in April of this year that just went into effect January 1st

00;15;25;08 - 00;15;54;02
Michelle Millerick
that's really trying to better align coverage in May with traditional Medicare. So I think our voice is being heard and I think these perspectives are really being elevated and that there's consensus that something needs to be done. And, you know, I think from the AHA perspective this is really a full court press issue where we're actively working to develop policy solutions to help rural critical access hospitals and urging federal policymakers to continue increasing oversight and really focusing on enforcement and compliance of some of the new rules that just went into effect.

00;15;54;04 - 00;16;15;02
Michelle Millerick
But I wonder if, from your perspective, in leading a health system, Chris, you know, what else do you think was needed in terms of solutions? You know, what does your system, you know, need as you contemplate how to move forward and tackle this sort of new world that we live in and for rural hospitals in general, to be able to continue to be viable in serving their communities as this MA shift continues to take place?

00;16;15;05 - 00;16;38;17
Chris Barber
Well, first and foremost, I'd like to begin by applauding the AHA for the work done to date and the continued effort to advance this meaningful policy and regulatory oversight of the MA. And as you stated, it's important to let our voice be heard often and frequently. Please keep up the pace regarding the enforcement and compliance in calendar year 2024 of Medicare Advantage rule.

00;16;38;20 - 00;17;10;09
Chris Barber
We believe there are significant outstanding public policy issues and problems that need to be rectified for past underpayments to hospitals by MA, specifically the 340B remedy from 2018 to 2022. And as you stated, I want to underscore the significance. It'll be imperative to continue to explore payment mechanisms to secure essential services in rural communities while providing some organizational flexibility and selected markets where strategies that might work well in their area.

00;17;10;11 - 00;17;39;15
Chris Barber
Initially, when establishing the Critical Access Hospital designation, CMS recognized the need for cost plus payment mechanism for rural hospitals. In light of the current environment, we believe CMS should consider similar approaches to preserve our essential services in rural America. They need to be mindful of where we are and what's at risk at this point in time. We all are supportive of tighter alignment of the administration of these Medicare Advantage plans similar to that of traditional Medicare program.

00;17;39;18 - 00;17;51;19
Chris Barber
One example that has been identified is the appeal process, not having the plan conduct the appeal process, that you haved that QIO which would provide some benefit.

00;17;51;22 - 00;18;16;16
Michelle Millerick
Those are some great suggestions, Chris, And I think, you know, anything is on the table these days and totally agree that this is an area where this is ripe for opportunity. I think that's about all the time that we have for today. So I just want to thank you so much, Chris, for joining us on the Advancing Health AHA podcast and for all the work that you're doing on behalf of patients and families, especially for your willingness to tell your story about your organization and some of the challenges that you're facing.

00;18;16;16 - 00;18;30;15
Michelle Millerick
And, you know, I think as we try to tackle some of the big challenges of our time that our health care system is facing, it truly takes a village. So we look forward to our continued partnership with all of you and with your team at St. Bernards in 2024. So thanks again, Chris.

00;18;30;17 - 00;18;40;28
Chris Barber
Thanks, Michelle , for having us. And it's our pleasure to provide some contribution to the discussion. Please continue all the great work that you guys are doing. We look forward to an exciting 2024.