Advancing Health Podcast

00:00:00:04 - 00:00:36:12
Tom Haederle
During the past several years, a growing number of hospitals and health systems have ramped up their diversity, equity, and inclusion efforts with focus and intentionality. While each organization charts its own unique DEI path, most of them, like New Jersey's Hackensack Meridian Health, have found that being able to track their effectiveness at the intersection of quality, patient safety, and health equity with measurable, reliable data is making a big difference.

00:00:36:14 - 00:01:09:22
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Hackensack Meridian Health's DEI effort has made good use of several important tools, including guidance provided by the AHA's Health Equity Roadmap. It's also developed advanced metric dashboards that allow it to precisely gauge what's working and what can be improved. We learn more in today's podcast hosted by Joy Lewis, senior vice president of health equity strategies and executive director of Institute for Diversity and Health Equity.

00:01:09:25 - 00:01:21:13
Tom Haederle
Joy is joined by two experts from Hackensack Meridian Health. Avonia Richardson Miller is senior vice president and chief diversity officer and Dr. Rajan Gurunathan is a vice president.

00:01:21:16 - 00:01:46:29
Joy Lewis
Why don't we talk about how you got started? How did your organization begin its health equity journey? Essentially with a leaning towards what prompted you to even want to launch this work, and maybe a little bit in your response about how you initially identified where there were gaps, where those inequities existed across patient populations in your system?

00:01:47:02 - 00:01:50:25
Avonia Richardson-Miller
Hello, Joy, and thank you so much for this opportunity.

00:01:50:28 - 00:02:20:16
Avonia Richardson-Miller
First, let me say that I am so proud of the strides that Hackensack Meridian Health has made through years to address health equity. I want to say we've been on this journey for some time. We continue to build on the great work that has happened historically across our organization. But what has changed is our degree of strategic focus and intentionality around this work.

00:02:20:19 - 00:03:08:14
Avonia Richardson-Miller
And I attribute that change to several things occurring, including some very key external factors. In 2020, unfortunately, as a nation, as a world, we witnessed the brutal murder of George Floyd while in police custody, playing out on television before our eyes, sparking a global movement that spanned 60 countries in seven continents. This was the largest racial justice movement since the civil rights movement. And this took place in the backdrop of Covid, a global pandemic that laid bare the critical health disparities existing in our marginalized and under-resourced and underrepresented communities.

00:03:08:16 - 00:03:44:06
Avonia Richardson-Miller
And Hackensack Meridian Health, located in New Jersey, which is one of the most diverse states in the nation - we were at the epicenter of this pandemic, right? In 2021, the CDC declares racism is a serious threat to public health. Also in 2021, 60 Minutes actually aired a special segment on race and health, and they were highlighting a research from Harvard University where the findings revealed that more than 200 Black Americans died each day because of the corrosive impact of racism.

00:03:44:07 - 00:04:07:21
Avonia Richardson-Miller
So all of this really resonated with our leadership, strengthening our commitment to make a difference and address health equity through living our mission. Our mission is to transform health care and be a leader of positive change. So here's just a few of the actions that was taken. One of the first things is that our CEO, Robert Garrett, signed the CEO Action Pledge.

00:04:07:26 - 00:04:32:10
Avonia Richardson-Miller
He joined over 2,500 CEOs across the nation. It's the largest business initiative that's focusing on advancing DEI. And then within HMH created the role of the chief diversity officer and elevated that reporting structure to be a direct report to himself, the CEO. So I'm proud to be the first to serve in that capacity. We were formerly diversity and inclusion.

00:04:32:14 - 00:04:57:28
Avonia Richardson-Miller
So our scope also expanded with that to include equity. And so we would then have leadership and oversight to drive a network level health equity strategy, which I will add was an area of opportunity that had been identified in the most recent AHA survey. With that we created first thing, an effective DEI governance structure with stakeholders from all across the organization.

00:04:58:03 - 00:05:26:18
Avonia Richardson-Miller
That included a committee that was focused on health equity and our collaboration with our quality team, which Dr. Gurunathan leads a great deal of that work. AHA at the time also launched the Equity Roadmap, and we had the privilege to collaborate with you to actually pilot the health equity transformation assessment. And we partnered through our flagship hospital, Hackensack University Medical Center.

00:05:26:25 - 00:05:32:10
Avonia Richardson-Miller
At that time, we were able to recognize the great value that that tool provides.

00:05:32:17 - 00:05:44:06
Joy Lewis
I guess I just wanted to interject and really call out those accelerators that you pointed to over the 2020, 2021, but also how mission aligned.

00:05:44:07 - 00:05:44:19
Avonia Richardson-Miller
Yes.

00:05:44:19 - 00:05:55:00
Joy Lewis
this work is right. Absolutely. And having the sponsorship from the highest levels within your health system that it's really that trifecta.

00:05:55:00 - 00:06:03:01
Joy Lewis
The combination of all of that that has probably been really instrumental. And then having the support from the association.

00:06:03:01 - 00:06:03:06
Avonia Richardson-Miller
Yeah.

00:06:03:13 - 00:06:16:11
Joy Lewis
With the development, I mean, you got in on the ground floor helping us to actually craft that assessment to benefit the field. So thanks again for that. But it sounds like it's really this multi-factor...you know,

00:06:16:17 - 00:06:17:08
Avonia Richardson-Miller
It is.

00:06:17:11 - 00:06:33:11
Avonia Richardson-Miller
Let me just say that it started even at the highest level of our organization at the level of our board. That's critical. So that is really where it starts. And then our CEO.. and really do believe that it has to be top down and bottom up, inclusive of everyone.

00:06:33:13 - 00:06:41:24
Joy Lewis
So Dr. Gurunathan, I guess I would ask, how has the strategy that Avonia just walked us through

00:06:41:29 - 00:07:05:21
Joy Lewis
How is that evolved over time? And maybe since quality is a key area, a cornerstone, and we are often talking about the intersection of quality, patient safety and health equity. How do you leverage data? I know our point of view at the AHA is that data is an important starting point. You need to know your organizational story as it pertains to the data.

00:07:05:23 - 00:07:26:16
Rajan Gurunathan, M.D.
Yeah, I think data has been a central issue for us for a couple of different reasons, right? So number one really is understanding that in this context of the DEI quality landscape, you need a lot of context. And so just one set of numbers without any context can really actually be off-putting in some ways. Right. And throw people sort of that general track.

00:07:26:16 - 00:07:56:18
Rajan Gurunathan, M.D.
Right. So one thing we accepted very early on from a data perspective is we needed some sort of governance and quality mechanism in the beginning to make sure that data was collected in a reasonable and appropriate way. And there was training and competency around some of the things that we wanted to capture. And then we also wanted to make sure that once that information came in, that we were able to use it, first off, to understand our populations, like you said, because many of our interventions are really organized around the needs of our sites and their communities.

00:07:56:25 - 00:08:22:22
Rajan Gurunathan, M.D.
So they're heavily influenced by demographics and they're heavily influenced by the community needs assessment framework of the social determinants of health. And so once we established let's get good data, right, then it was what type of data? And that data again started with just understanding who we're serving. And that really helped frame out a lot of our efforts because we realized, you know, as a network we're over 50% women in terms of patient mix.

00:08:22:24 - 00:08:43:24
Rajan Gurunathan, M.D.
We have several sites that are highly geriatric, and we have several pockets of real diverse language levels, and we have several pockets which are much more homogeneous, but means that it's even more critical that data framework of understanding who we are was really important. And the last piece I think that really helps make it actionable is to make it as self-service as possible.

00:08:43:26 - 00:09:09:20
Rajan Gurunathan, M.D.
And so we really were very intentional, as Avonia said, about figuring out how we could make our data platforms, which are cloud platforms, be able to stratify all of our information. So anything we want to be able to look at, we should be able to look at with this particular type of lens. And so as we build out our data platform, having that in there and having it self-service where any leader in their department could be able to click through their quality metrics and goals and be able to stratify them immediately and see their population.

00:09:09:27 - 00:09:16:03
Rajan Gurunathan, M.D.
That's been very powerful and helping promote what we want to work on, how you can follow it, and tools to do it.

00:09:16:06 - 00:09:40:10
Joy Lewis
No that makes sense. I think the ability to self-interrogate and slice and dice your data across what you just described gender, age, language preferences, race and ethnicity and all of those dimensions of diversity. And also looking at the social drivers of health. That's exactly the direction that we've got to take this work. You mentioned that you've made it self-service.

00:09:40:10 - 00:09:47:27
Joy Lewis
So does this mean you've created dashboards or some way to track and monitor the progress?

00:09:48:00 - 00:10:09:11
Rajan Gurunathan, M.D.
Yeah, absolutely. So we've created a series of dashboards actually. And so some of them are large scale dashboards which again let us look at the whole network, right. Demographics of the network, right. Race, ethnicity payer etc.. And then there's some specific ones that relate to cultural competence, right? To be able to look at that. And so how often are we properly documenting preferred language,

00:10:09:11 - 00:10:30:09
Rajan Gurunathan, M.D.
For example? How often are we offering interpreter services, documenting interpreter services in the right fashion, and how often are we providing discharge instructions, for example, or other materials in preferred language? So there's a set of cultural competence dashboards that are also very relevant. And lastly, I think, you know, the idea that we look at this as a care for all kind of initiative, right?

00:10:30:09 - 00:10:46:13
Rajan Gurunathan, M.D.
But at the same time, you can't ignore the fact that there are certain populations which in the literature are full of disparities. And so for us to have eyes on those populations of maternal health, behavioral health, pediatrics and cancer. And for those, I think it's looking at the process of care as well as the outcome.

00:10:46:15 - 00:10:55:24
Avonia Richardson-Miller
Dr. Gurunathan, maybe speak a little bit about the one link dashboard too, because that was a major advancement with us too, looking at health equity.

00:10:55:26 - 00:11:14:07
Rajan Gurunathan, M.D.
100%. And that was really driven by Avonia and several other high level leaders in our organization to be able to start bringing equity and safety into the same conversation. In terms of our event reporting system, we should be able to have the same visibility and the same lenses on those events, just as we do on other types of outcomes and goals.

00:11:14:11 - 00:11:30:15
Rajan Gurunathan, M.D.
And so again, we can now stratify our event reporting system with similar fashion. And so there's a lot of power in that, you know, both on the front end and the back end, right. So bringing all those data points together helps round out our view on where we need to improve and where are the gaps, as you were describing.

00:11:30:18 - 00:11:35:25
Joy Lewis
And creating that larger context. As you mentioned earlier.

00:11:35:28 - 00:12:03:20
Chris DeRienzo, M.D.
Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, AHA’s chief physician executive and a champion of the AHA Patient Safety Initiative. AHA's Patient Safety Initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

00:12:03:22 - 00:12:35:21
Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1,500 other hospitals already involved, visit aha.org/patientsafety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA's Patient Safety Initiative.

00:12:35:23 - 00:12:42:17
Chris DeRienzo, M.D.
Remember - together, we can make health care safer for everyone.

00:12:42:19 - 00:13:04:22
Joy Lewis
Before I move back, Avonia, are you reporting out these data and your progress to internal stakeholders? How does it bubble up to the board level at the board table? And have you gone as far as sharing any of these data with your community partners as well? Just curious about that.

00:13:04:24 - 00:13:07:25
Avonia Richardson-Miller
Absolutely. It does get shared with the board

00:13:07:25 - 00:13:31:25
Avonia Richardson-Miller
and actually Dr. Gurunathan coordinates presents to the quality committee. And then we also have an executive DEI council that's chaired by our CEO has many stakeholders across the organization a part of that. So it's regularly reported out there as well. And then whenever we're speaking we may reference some of it not, you know, not our whole dashboard report, but certain things that we're speaking to.

00:13:31:25 - 00:13:33:26
Avonia Richardson-Miller
We may speak to some of that data there.

00:13:33:28 - 00:13:40:27
Joy Lewis
What a strong signal of support, though, to have your CEO as the chair of your DEI council.

00:13:40:27 - 00:13:43:24
Avonia Richardson-Miller
Absolutely. He is our biggest champion.

00:13:43:28 - 00:13:48:19
Joy Lewis
Yes. This is what you need. Okay. Over to you, Dr. Gurunathan.

00:13:48:21 - 00:14:11:14
Rajan Gurunathan, M.D.
No, I completely agree. And I think having that level of leadership, acceptance and accountability and the empowerment of the rest of us to operationalize that strategy has really allowed the organization, I think, to take this battleship in an ocean kind of issue. I think, you know, really with a lot of steam. So I think, to the point that Avonia was making about all the way, you know, the governance structure and the data, certainly it goes all the way to the board.

00:14:11:15 - 00:14:31:26
Rajan Gurunathan, M.D.
And what I especially like is that we've been able to align all of it, right? And so it's not just random data at random meetings. It's information about the same kinds of things. It's information about the same kinds of populations that we're interested in. Information about the same processes of care around cultural competence and communication with patients in the same way.

00:14:31:28 - 00:14:44:03
Rajan Gurunathan, M.D.
So I think what's been especially valuable for me in this is, is seeing how when you stack all those things together, that you can actually move the needle, and it doesn't seem so much like a series of one-offs.

00:14:44:05 - 00:15:05:16
Avonia Richardson-Miller
I think to what Dr. Gurunathan was saying, what the beauty of it is it's not the check the box of the extra thing that we need to do to say that we're doing health equity, right. Our aim is that it's the lens by which we approach all things. And also the fact that it's everybody's work and everybody has accountability for this.

00:15:05:21 - 00:15:12:18
Avonia Richardson-Miller
Whatever role you have in an organization, whatever department, there is a DEI lens on it, too.

00:15:12:20 - 00:15:19:05
Joy Lewis
Sounds consistent with the way we think about it at the AHA both on the clinical side and the operational side.

00:15:19:06 - 00:15:20:14
Avonia Richardson-Miller
Absolutely.

00:15:20:19 - 00:15:27:02
Joy Lewis
Because to your point, everyone should begin to see him or herself as an equity influencer from wherever they sit.

00:15:27:05 - 00:15:27:24
Avonia Richardson-Miller
Absolutely.

00:15:27:27 - 00:15:38:22
Joy Lewis
Inspire others to take action and to really coalesce around that, that North Star, which is equitable care, safe care for all.

00:15:38:24 - 00:16:04:26
Joy Lewis
We didn't talk much about the role of community and how you're collaborating with your community partners to ensure that whatever the solutions are that you're developing are being done in a collaborative, very intentional way. I think that's amiss, Dr. Gurunathan, when you said the secret sauce, you know, you just described, I think another component of that secret sauce is the collaboration with the community.

00:16:04:28 - 00:16:34:28
Avonia Richardson-Miller
Absolutely. And so we have defined at the highest level four pillars to drive our efforts for DEI and health equity. Number one: being focus on patient care and outcomes. Number two: on community. Number three: on our workforce, right? We want to make sure representation matters. And then supplier diversity is a fourth one. And that one because that drives jobs.

00:16:35:01 - 00:16:59:23
Avonia Richardson-Miller
That drives wealth. That drives sustainable communities. And that's just the four high level buckets. We are doing some work in the space of community and for example, our community health needs assessment. The most recent one that was done has been done completely through the lens of health equity. And then our social determinants of health space, where Dr. Nicole Harris-Hollingsworth leads this area -

00:17:00:00 - 00:17:20:23
Avonia Richardson-Miller
over 4 million screenings have been conducted. Five million referrals. And what has been incorporated now is the closed loop reporting for that system. And so those are referrals that are going out to agencies that are aligned with the type of work that we do. And that's driving where some of our focus is around those community collaborations.

00:17:20:25 - 00:17:46:18
Rajan Gurunathan, M.D.
I would look at those community aspects again with two sort of buckets. Right? I think certainly the community needs assessment helps frame out our data context in a particular way, right. Because it establishes links between the services and the services provided and needed. And I think also we've got a robust network of community health workers that actually partner with us, who are actively out in the community and engaged not only with our patients, but with, you know, patients that don't even follow with us.

00:17:46:20 - 00:18:04:00
Joy Lewis
That's right. We're learning more and more about the value of the role of the community health worker as a real, integral part of the care team. Are there any final thoughts you want to leave with our audience today? Because I've been inspired by the good work that you're leading on the ground there in New Jersey.

00:18:04:03 - 00:18:11:29
Avonia Richardson-Miller
I think it's important to just know that you have to start the work and you start wherever you are.

00:18:12:00 - 00:18:44:19
Avonia Richardson-Miller
That's where you start. Your journey is going to be unique to you in your system, right? We're all at different places on this journey and across different domains and areas. And the engagement of others, and also understanding that this work cannot be done alone, and definitely not by any one particular department. And so for us in 2021, we started as basic in one of the areas, as far as doing training around how to collect real and social data.

00:18:44:21 - 00:19:08:18
Avonia Richardson-Miller
But in the short amount of time, Dr. Gurunathan has really described where we've come along that continuum with data, because I believe in our baseline assessments of the HETA we were exploring, we fell in the category of exploring consistent with where most of our hospitals are. So yeah, you're not alone. But now we are far beyond that to get mission accreditation in a very short time.

00:19:08:18 - 00:19:09:27
Joy Lewis
Yes. So it's doable.

00:19:10:01 - 00:19:13:02
Avonia Richardson-Miller
And that's due to partnership with our IT department.

00:19:13:05 - 00:19:15:19
Joy Lewis
Great. And you Dr. Gurunathan.

00:19:15:21 - 00:19:35:16
Rajan Gurunathan, M.D.
Yeah, I think Avonia said it very well. I think you know my three words or three lines of advice - hashtags would be, you know, just start for sure. I think that's just, you know, the number one. I think the idea of being collaborative, as Avonia mentioned, because it affects all aspects of the organization. And then lastly, be intentional because you don't have to cut it off all at once.

00:19:35:16 - 00:19:40:27
Rajan Gurunathan, M.D.
And then I think, just figure out what's important to you and the people you serve. And there's clearly room for gains.

00:19:41:00 - 00:19:45:00
Joy Lewis
Excellent. So thank you, thank you, thank you for being here.

00:19:45:02 - 00:19:46:09
Avonia Richardson-Miller
Joy, can I add one more thing?

00:19:46:09 - 00:19:47:01
Joy Lewis
Sure.

00:19:47:03 - 00:20:02:13
Avonia Richardson-Miller
Don't think that you have to reinvent the wheel. Use the resources that are out there. Yes. And I'm talking about the Equity Roadmap. And then all of the resources that Joint Commission has also identified.

00:20:02:15 - 00:20:10:23
Joy Lewis
I think you're spot on. That's one of our key lessons that we want to leave with our audience is you don't have to feel like you're alone in this.

00:20:10:25 - 00:20:32:21
Joy Lewis
There are others who you can beg, borrow and steal from. The AHA has done a lot of the heavy lifting for you, so please, this is a member benefit, frankly. So why not lean into the Health Equity Roadmap and other tools and resources that might be there at your disposal from, as you mentioned, Avonia to the Joint Commission and other spaces.

00:20:32:21 - 00:20:35:25
Joy Lewis
So thank you again and keep up the good work.

00:20:36:01 - 00:20:41:03
Avonia Richardson-Miller
Thank you. And you too, because we are, as you say, borrow, steal. We're doing that from AHA.

00:20:41:05 - 00:20:43:08
Joy Lewis
We're in this together.

00:20:43:10 - 00:20:43:28
Avonia Richardson-Miller
Thank you.

00:20:44:00 - 00:20:44:10
Rajan Gurunathan, M.D.
Thank you.

00:20:44:12 - 00:20:45:24
Joy Lewis
Take care.

00:20:45:27 - 00:20:54:07
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:05 - 00:00:28:06
Tom Haederle
Every parent wants their child to be healthy. But that is not always the case. Some kids are considered to have medical complexity, multiple conditions that require a lot of health care. Meeting the needs of those kids and their families can be challenging, especially when trying to coordinate care between several providers and specialists.

00:00:28:08 - 00:00:47:28
Tom Haederle
Welcome to another episode of Caring for Our Kids, a limited podcast series from Advancing Health. I'm Tom Haederle with AHA communications. Today you'll hear how Children's Hospital Colorado has designed team-based, coordinated care to make care seamless for medically complex kids and their families.

00:00:48:00 - 00:00:48:27
SFX
Children playing

00:00:49:04 - 00:00:50:01
SFX
Children talking

00:00:50:02 - 00:00:54:04
SFX
Children talking

00:00:54:07 - 00:01:17:10
Julia Resnick
Having a child is an act of optimism. We go into parenthood with the highest expectations. We imagine them running, jumping. And above all else, we hope that our kids will be born healthy so that they can fulfill all the dreams we have for them. But that dream is not the reality for many families that have children with special medical needs.

00:01:17:12 - 00:01:44:12
Julia Resnick
19% of kids living in the United States, more than 14 million children total, have health care needs that require specialized care. That is where pediatric hospitals come in. The U.S. has over 200 pediatric hospitals that are dedicated to advancing the health of the nation's 73-million children. Welcome to Caring for Our kids. I'm Julia Resnick, director of strategic initiatives at the American Hospital Association.

00:01:44:14 - 00:02:11:25
Julia Resnick
In today's episode, we're focusing on caring for children with medical complexity. About 1% of kids are considered to have medical complexity, which means they have multiple severe chronic health conditions resulting in significant health service needs, functional limitations and high health care use. Caregivers of kids with medical complexity often struggle with the fragmentation of their children's medical services. Children's Colorado is aiming to change that.

00:02:11:28 - 00:02:39:19
Julia Resnick
They are dedicated to making care seamless and coordinated for medically complex kids and their families through their multidisciplinary clinic located at the Anschutz Medical Campus in Aurora, Colorado. To learn more, I spoke with two leaders from Children's Colorado. Suzy Jaeger is the chief patient experience and access officer. She was joined by Dr. Glenn Furuta, a pediatric gastroenterologist who serves as the section head of pediatric gastroenterology and hepatology.

00:02:39:21 - 00:02:41:07
Julia Resnick
Here's Suzy.

00:02:41:10 - 00:03:05:05
Suzy Jaeger
We opened our multidisciplinary clinic back in 2015, and this was after we had conducted an exhaustive search around the country, working with other children's hospitals and adult hospitals and trying to figure out what is the best way to care for highly complex patients in a multidisciplinary setting, especially patients who travel a long distance to visit with us and then go back to their own communities.

00:03:05:05 - 00:03:26:11
Suzy Jaeger
How can we provide that array of services in a way that's convenient for families? That we are able to provide them with timely access to care, and certainly the latest cutting edge type of care that's based upon evidence-based research. So, we settled on the model that we have in place today. It's about a 24,000 square foot clinic facility.

00:03:26:13 - 00:03:50:00
Suzy Jaeger
It includes 26 exam rooms and ten consult rooms. It also includes two large provider teamwork areas, where there are more than 20 workstations in each of those areas, so accommodates a large number of staff. We also have two observation and evaluation rooms. We provide a really nice family lounge to families. They're here for a long time. When they're here for a visit, and it's usually a full day, if not more.

00:03:50:07 - 00:04:14:02
Suzy Jaeger
And so we provide some space for them to get away from the clinical setting and relax and be with their families. They also can use that space to interact with other families who are there for similar reasons. And then of course because we're a children's hospital, we have to include play areas. So there's three really nice play areas for kids to be able to utilize, not just our patients, but the siblings that often times will travel with patients for this type of care.

00:04:14:04 - 00:04:33:08
Suzy Jaeger
So we really designed this space around trying to provide an optimal way to coordinate care for children that have complex needs. We have 78 different multidisciplinary clinics that currently meet in that space, and in 2023, we provided care to more than 12,500 patients and their families.

00:04:33:10 - 00:04:35:07
Julia Resnick
Here's Dr. Faruta

00:04:35:10 - 00:05:15:27
Glenn Furuta, M.D.
2006 I imagined in Boston that we really needed to do better, and how can we take better care of our patients who have a group of diseases called eosinophilic GI diseases? And those patients suffer from not only intestinal inflammation  with allergic problems, but food allergies, and they have feeding problems and nutritional problems. If you can imagine someone would need to come in and out to different offices over a number of different visits, 8 to 10 visits, and then have probably more importantly, all of those providers communicate to establish a centralized plan to help take care of that,

00:05:15:27 - 00:05:45:16
Glenn Furuta, M.D.
that's challenging. And so when I met with Suzy and others here at the hospital, I was like, this is what I would like to do. And they're like, well, guess what? We're doing that right now. And we have been able to care for patients from 40 states, from four different countries now who come here to receive that kind of care where we can really have an immediate discussion to share the expertise in providing the best care that we can.

00:05:45:18 - 00:05:49:22
Jill Tappert
Do you want to try to say that again more clearly, or do you want me to repeat after you?

00:05:49:24 - 00:05:50:21
Abigail Tappert
After me.

00:05:50:23 - 00:05:51:12
Jill Tappert
Yeah. You sure?

00:05:51:16 - 00:05:52:25
Abigail Tappert
I sure.

00:05:52:27 - 00:06:05:29
Julia Resnick
This is Abigail Tappert and her mom, Jill. Abigail is now 20 years old with complex medical needs. She's a patient at the multidisciplinary clinic at Children's Colorado. Here's Jill, Abigail's mom.

00:06:06:01 - 00:06:21:17
Jill Tappert
Abigail's voice sometimes is harder to understand than others. She wants me to repeat what she said. So Abigail said that she is humorous, courageous, adventurous, and mischievous.

00:06:21:19 - 00:06:30:06
Abigail Tappert
I like to do Pokémon Go walks and drives with Geneva and Mom.

00:06:30:09 - 00:06:35:24
Jill Tappert
I like to do Pokémon Go walks and drives with Geneva and Mom.

00:06:39:18 - 00:06:44:02
Abigail Tappert
I wish everybody had a chance to go to Children’s.

00:06:44:04 - 00:07:07:00
Jill Tappert
I wish everybody had a chance to go to Children's. We are family of four from Boulder. So we're fortunate to be able to have just a one hour drive to receive care at Children's Colorado. We've known since Abigail was very young, certainly before grade school, that she didn't seem the same as her peers with autism. There was another layer, but we didn't have the words, we didn't have the vocabulary.

00:07:07:03 - 00:07:27:01
Jill Tappert
And then when she was a young teen, her medical status deteriorated. And at the time, we didn't know why. And there were a lot of things happening all at one time. In the beginning of that time period, we had trouble getting the care she needed. No one knew what was going on. No one could see the big picture except me, and I didn't necessarily have all the words in the vocabulary.

00:07:27:03 - 00:07:46:27
Jill Tappert
And then Abigail got into the special care clinic here at Children's, and I do not think it's exaggerating to say it was literally life saving. Got a pediatrician at a very high level who was looking at me with all of this - at all the symptoms that were crossing a whole bunch of different disciplines and needed to be looked at together.

00:07:46:29 - 00:08:09:17
Jill Tappert
And then she got all of those different specialties, all those different doctors literally in one room. I'll tell you from the patient care perspective, it made all the difference. One of the things that was happening was dysphasia or difficulty swallowing, and that got Abigail to see Dr. Furuta and the diagnosed with eosinophilic esophagitis. It's quite a mouthful, EOE.

00:08:09:19 - 00:08:33:17
Jill Tappert
And then ultimately to be seen in the GEDP multidisciplinary clinic. After her EOE was in remission, she still had a number of symptoms throughout the day, all day. The dysphagia, the difficulty swallowing. And by bringing in those other specialties, the allergist recommended just a regular plain old over-the-counter allergy medication when those symptoms were spiking in the spring and fall.

00:08:33:19 - 00:08:58:05
Jill Tappert
Those additional eyes looking at it from a different perspective - that made a significant difference. Along the same lines, having access to a nutritionist and feeding specialist have also made a big difference, both in safety and in her overall nutrition. That pediatrician at the top of that, at the top of the triangle with me trying to see the big picture connecting dots as she always was, was well, have you looked at this yet?

00:08:58:07 - 00:09:25:25
Jill Tappert
No, we hadn't. And we pursued a new possibility. And it turned out Abby does have something called POTS: positional orthostatic tachycardia syndrome, which in her case is relatively simple to treat. And when we figured that out and started treating that, Abigail's migraines went away. And that had not been simple to treat. And there's no way we would have figured that out without someone who was doing that team approach,

00:09:25:27 - 00:09:32:06
Jill Tappert
looking at all of the things across the different specialties and troubleshooting right beside me.

00:09:32:09 - 00:09:58:01
Julia Resnick
All kids deserve the best care, and Children's Colorado has made the investment in designing a system that can meet the needs of even the most medically complex children. By co-locating specialists and building a culture of team-based care, they're improving outcomes and the patient experience for the children and families they serve. Since Doctor Furuta and Suzy have been there from the start, they shed light onto what it takes to get a clinic like this off the ground.

00:09:58:04 - 00:10:24:11
Glenn Furuta, M.D.
Every other month, someone comes from somewhere else to visit us to see what we do and how we do it. Before they come, I always tell them, make sure you've had a conversation with your institution because what you're going to see it's...it's really fantastic, but it's going to require some infrastructure and dedication. One of the things that I thought about when we were starting this was you need to have institutional commitment and you need to have leadership.

00:10:24:13 - 00:10:57:15
Glenn Furuta, M.D.
And those two things together really will help make this happen. It's just kind of dreamlike, to be honest, because it's exactly what I've always thought about wanting to do, to make sure that we could serve patients in a way that they had the expertise present and available, that the providers themselves were able to feel fulfilled in what they're doing in a way they had not been able to do before, that we're able to have that immediate impact but then also create some really innovative research studies that can be impactful afterwards also.

00:10:57:15 - 00:11:08:22
Glenn Furuta, M.D.
So it's not just the four walls of Children's. We want to spread care outside of here, too, in a way that's going to be impactful other places. It's yeah, exactly what I had always wanted to do.

00:11:08:24 - 00:11:31:09
Suzy Jaeger
If you think about this from a patient family perspective, it's so much better. The outcomes are so much better. The costs are reduced. The amount of time that they have to spend in the hospital is reduced. It provides the primary care physician who's going to be responsible for this child once they return home with the comprehensive plan, detailed information about the results of the consult and the next steps and so forth.

00:11:31:09 - 00:11:53:03
Suzy Jaeger
So, I mean, it's the kind of program that may not make the most sense financially, but from the perspective of patient family experience, it clearly is the right approach to take. And it also requires, you know, a big commitment, 24,000 square feet. We wish we had more space. We're lucky we have 24,000. We're making, good use of every inch of that space.

00:11:53:03 - 00:12:16:00
Suzy Jaeger
But that's a big commitment of space within our facility to, dedicate to this type of care. But we think it's the right thing to do, and we continue to hear from patients and families and their providers out in the community how much they appreciate and value the service, so that's our guiding light. And, that is what will keep us committed to continuing to provide these types of services well into the future.

00:12:16:02 - 00:12:41:29
Julia Resnick
Thank you to Suzy Jaeger and Dr. Glenn Furuta for your efforts to provide the highest quality team-based care for medically complex kids. And to Abigail and Jill Tappert, so appreciate you sharing your family's story with us. AHA's growing library of resources on child and adolescent health can be found at aha.org/mch.

00:12:42:01 - 00:12:50:13
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:13 - 00:00:24:06
Tom Haederle
Improving patient safety is every caregiver's concern. While each hospital customizes its patient safety efforts and strategies to best meet the needs of the patients and communities it serves, certain practices hold promise to help just about everyone.

00:00:24:09 - 00:01:00:04
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this month's Leadership Dialogue series podcast hosted by Dr. Joanne Conroy, CEO and president of Dartmouth Health and 2024 board chair of the American Hospital Association, we hear from Dr. Steven Diaz, chief medical officer at MaineGeneral Health in Augusta and an AHA board member, about how things like accountability, prioritizing teamwork, overcoming barriers and using artificial intelligence are helping to deliver quality care that is safer than ever.

00:01:00:07 - 00:01:01:21
Tom Haederle
Let's join them.

00:01:01:24 - 00:01:34:25
Joanne Conroy, M.D.
Thank you for joining us today for another AHA Leadership Dialogue discussion. It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and the current chair of the American Hospital Association Board of Trustees. You can tell that I have some laryngitis, but I am delighted that I don't have to do a lot of the talking because I'm going to be joined by Dr. Steve Diaz, who is chief medical officer of MaineGeneral Health.

00:01:34:27 - 00:02:20:11
Joanne Conroy, M.D.
MaineGeneral Health is a comprehensive, nonprofit health system located in Augusta, Maine. And in addition to serving as chief medical officer, Steve is an emergency medicine physician by training and is deeply involved in many of MaineGeneral's health care quality and safety initiatives. Earlier this month, the AHA released a new report showing that hospital and health system performance on key patient safety and quality measures was better in the first quarter of 2024 than it was before the COVID-19 pandemic, and that hospitals made these improvements while caring for patients with more significant health care needs.

00:02:20:13 - 00:02:52:18
Joanne Conroy, M.D.
Last year, the AHA launched a national initiative to reaffirm our leadership and commitment to patient safety. AHA's Patient Safety Initiative is guided by a clinical advisory panel and a strategic advisory group. They focus on reducing patient harms, increasing health equity, and improving public trust. But before we jump into our discussion and my questions, Steve, our audience really wants to know about our speakers.

00:02:52:19 - 00:03:02:23
Joanne Conroy, M.D.
So can you share some information about your background and how you got to MaineGeneral, and how that's affected your approach to patient safety?

00:03:02:25 - 00:03:22:13
Steven Diaz, M.D.
Thank you. Joanne. Glad to join you today. I started in healthcare prior to medical school. I was an EMS at work in Sacramento, Sacramento Ambulance and decided I would take the plunge going to medical school. And I, growing up in California, I decided to have an East Coast experience. I went to Cornell New York hospital

00:03:22:15 - 00:03:45:26
Steven Diaz, M.D.
thinking after that, I go back to California. I was somewhat wayward, took a year off and taught there, and then decided to do family medicine training to start with and would go to a rural area -  again, to grow up and figure out what I wanted to do for my life. So I said that I would go to Maine for three years 31 years ago. Finished my training and then went into emergency medicine and grandfathered into that a long time ago.

00:03:45:28 - 00:04:19:01
Steven Diaz, M.D.
And then became involved in disaster EMS and emergency medicine on my way to becoming an administrator for MaineGeneral. It's interesting. I think prior to medical school, having that EMS experience was key. We worked in teams. We've always thought we worked in teams, we've really strived to work in teams. And I see the thing that I focused on at MaineGeneral is flattening the hierarchy and moving things so that we're all taking care of patients in a coordinated fashion rather than everybody having a different care plan, if you will.

00:04:19:04 - 00:04:38:21
Joanne Conroy, M.D.
So, Steve and I share an affection for the state of Maine. My family grew up in rural Maine. But why patient safety? Because emergency medicine...you know, you can take many paths after training in that specialty. But why was safety such a passion for you?

00:04:38:23 - 00:05:03:13
Steven Diaz, M.D.
Safety is such as a passion because in emergency medicine, the times that we get involved in high acuity situations, it's not as common as taking care of amateur sense of conditions or even intermediate medical conditions. Because of that, when we do critical care in emergency medicine, it's not the most common thing we do. With our central line intubations, using vasoactive drugs or other things that are very aggressive

00:05:03:20 - 00:05:25:05
Steven Diaz, M.D.
you have to be sure that the whole team is ready for that. Today, of course, we all have, you know, care bundles and team practice in Stemi care, sepsis, stroke and trauma  - all the time sensitive conditions. But that was not the way it was 30 years ago. One of the roles I had early in my career here in Maine was I was the medical director for Maine Emergency Medical Services,

00:05:25:07 - 00:05:46:16
Steven Diaz, M.D.
so the state medical director. And we worked to have state protocols for Stemicare for ER to cath lab. We work to have state protocols for stroke care. Prior to my time there, we had state protocols for trauma care. And now sepsis care. Again having state protocols or state initiatives that starts with  EMS will hopefully change that curve as well.

00:05:46:18 - 00:05:59:11
Steven Diaz, M.D.
So it appealed to me because you have to plan for it. You have to have teamwork. Be critical of yourselves, both individually and as a team in order to improve the care and the outcomes of the patients we serve. So that's why emergency medicine, it called to me.

00:05:59:13 - 00:06:20:19
Joanne Conroy, M.D.
Now, you trained in a rural area. You know, that's gotta be different than delivering emergency care in an urban area. What are the challenges that you've run into really in rural Maine, where most of the hospitals are critical access hospitals, except for a handful of quaternary care facilities?

00:06:20:21 - 00:06:44:04
Steven Diaz, M.D.
I think the biggest issue in rural emergency medicine care is you don't have the consultants at your fingertips, if you will. Whether it's trauma, stroke, heart attacks or Stemis, you might have to be creative on how you get those patients the care they need and find your consultants. I think in many ways, I was fortunate that I was EMS medical director for Maine early on because I met a lot of people across all the systems.

00:06:44:06 - 00:07:03:29
Steven Diaz, M.D.
And again, the goal here was to have a system of care so no matter where you went, you'd have the same care. So let me give you an example. When I was a young ER doctor and I had somebody with a SD elevation, myocardial infarction or a heart attack in front of me, that referral centers of cath labs who did interventional cardiology had three different protocols.

00:07:04:01 - 00:07:25:21
Steven Diaz, M.D.
And so I had different colored folders - we all did in our E.R., depending on which tertiary care center they chose. And so, and heaven forbid that you picked the wrong folder color and someone changed their mind or there wasn't bed availability. Nuances were no significant, but they were nuances. And so, we work to have that really ironed out.

00:07:25:24 - 00:07:47:04
Steven Diaz, M.D.
And I think that is the same discussion you have with stroke care, although that have been helped by other entities having some standardized protocols, but then having the consultants know who you are and where you call them. Interestingly enough, my preferred shift was the weekend overnight shifts in the ER, it just seemed to be a shift that went by quickly.

00:07:47:06 - 00:08:04:05
Steven Diaz, M.D.
Lots of teamwork. No offense, less suits around. But also made it so that I really had to know my consultants and know where I was going. In rural emergency medicine, rural states and or rural health care in general, again, you have to know where you're going to go because you may not have a lot of things in-house.

00:08:04:07 - 00:08:13:03
Steven Diaz, M.D.
And that was true 30 years ago as and it's still true today. Making it more important that we know our networks of care and our consultants.

00:08:13:06 - 00:08:23:12
Joanne Conroy, M.D.
So, you know, there's a lot of conversation about AI. Is AI going to improve safety, do you think, or is it going to jeopardize that?

00:08:23:14 - 00:08:52:20
Steven Diaz, M.D.
It's funny when you talk about AI and or even machine language, I think of "2001 A Space Odyssey." How the computer taking over everything or, Star Trek with the little device. I don't think that's how I see AI helping us. We spend a lot of time outside of the diagnostic and patient-facing time to get people on a care plan, talking about things over and over again in order to help them.

00:08:52:20 - 00:09:25:00
Steven Diaz, M.D.
And I think that's where AI could help us. If you have somebody getting a procedure or going on chemotherapy or who has other complex medical conditions, informed consent to ongoing education could be a boon for AI that identifies, you know, people with heart failure and which class they're in what they need as education. AI could say well, hold on, once you're done with them in the office, you know, you can send them this or they'll be identified by AI to receive these education, either online or print, depending on how they learn best.

00:09:25:03 - 00:09:39:21
Steven Diaz, M.D.
And it's always available to them. And we'll check in with them. It sounds like it'll be perhaps a cure management, but it's even beyond that because it'll speak to them in a way or then you can test them so they get the information the best way they get it. Right now all those things are done by people.

00:09:39:23 - 00:09:59:07
Steven Diaz, M.D.
You know, it's not the decision, it's the NPA or it's the nurse or the care manager. And they're all, we're all happy to do it. But none of us had that conversation once. Oncology is my favorite example of this. If you see an oncologist and you're told you have something that usually happens in the first few minutes and the next 15, 20 minutes, no offense,

00:09:59:07 - 00:10:18:09
Steven Diaz, M.D.
the patient and family don't hear anything else. Yeah, and that'll be me, if I remember. You know, there's no way I'm gonna remember anything past whatever they tell me that just shifted my whole world. But wouldn't it be great, though, if someone had a link, that was identified for them? Or AI can help answer their questions and gets information back from them

00:10:18:09 - 00:10:30:03
Steven Diaz, M.D.
that's given to the care team to help create the right message for them. That'd be incredible. That would be role changing, giving people back time, to not be burdened by the admission.

00:10:30:08 - 00:11:02:06
Joanne Conroy, M.D.
So it's almost personalizing their treatment plan. You know, we actually do videotape on your phone, our visits. So patients actually can refer to the conversation later 'cause you're absolutely right, Steve. After they hear that they have a diagnosis of cancer, they don't hear anything else. And all that important information is lost. Let's talk a little bit about AI in like, record abstraction.

00:11:02:09 - 00:11:27:25
Joanne Conroy, M.D.
Remember when we started using algorithms to oversee our ICU care? We identified that there were some early warning signs so we could anticipate when somebody might be unstable before they actually became unstable. What do you think about using AI for chart abstraction and kind of identifying things that are very difficult for our chart of structures currently pick up?

00:11:27:27 - 00:11:46:24
Steven Diaz, M.D.
I think they'd be ideal. Right now, you know, we spend a lot of administrative time either at the physician level MPPA coder, biller, trying to find those magic words that people are looking for in order to determine your risk stratification and thus your billing and even quality metrics at the back end. It shouldn't be a game, right?

00:11:47:01 - 00:12:03:02
Steven Diaz, M.D.
We should be able to say, I remember early on as a young doctor when I kept saying, urosepsis. I got the nastygram saying, no, you mean UTI with sepsis? You know, very specific words. So AI should be able to help with that, to be able to take the human element out of it.

00:12:03:02 - 00:12:32:04
Steven Diaz, M.D.
Let us practice and talk and then make the crosswalk so that it gets categorized the correct way and in the correct format. To me, that's a yeah, another easy lift. I've seen the products, I've been demo'ed by some of our younger medical staff who have me as a patient, and they're the doctor, and we just have a conversation and they hit a button and it can either generate a consult note, the agent P, the soap note, you know, and it's better than anything we could have delivered or dictated.

00:12:32:06 - 00:12:42:06
Steven Diaz, M.D.
And so, yeah, we do think there's a way coming that will make it more compliant and hopefully, again, get some of that red tape, some of the administrative burden out of health care.

00:12:42:09 - 00:13:05:02
Joanne Conroy, M.D.
Let's talk a little bit about safety and how we create community partners. Because patient safety is of great interest to people in our communities. And you live in a community like mine that people come up to you in the grocery store and in a coffee shop, and safety is probably one of the number one things that our patients worry about.

00:13:05:04 - 00:13:14:08
Joanne Conroy, M.D.
How do you actually engage the community so you have internal and external partners that are working on safety across the community?

00:13:14:11 - 00:13:39:17
Steven Diaz, M.D.
I will take an example in the behavioral health addiction medicine realm. When I was a young ER doc here, again, decades ago, the contract in the community for behavioral health is very strong. And today all those community partners are under duress. We actually surveyed them about two years ago on the Pediatric Realm Tracker. How we bolster more, resources for people who would need help in either mental health or addiction medicine services.

00:13:39:19 - 00:13:59:12
Steven Diaz, M.D.
And I would just say that everybody needs more help. And so we convened from that discussion, a small conference, that it's now an ongoing symposium where we try to bring all our partners together to discuss this openly. How are we sharing patients, what's the best way to go forward? Where should we go speak to the community,

00:13:59:18 - 00:14:33:26
Steven Diaz, M.D.
who's our audience? And so that's one small example of taking a piece of what we have to try to do more with it. It's not surprising that was spurned by the adolescent mental health crisis that's sweeping the nation that's also linked to suicide. So that was sort of the call to arms for that. I take that same paradigm, and that is sort of how we go out there to meet people where they live, whether it's behavioral health, CHF, COPD, there's a lot of community partners that we need to intersect with in order for the people to have the care they need, because we can't do it all alone.

00:14:33:28 - 00:14:45:15
Joanne Conroy, M.D.
Especially in rural America. We figured out that, our external partners are really important in actually keeping our community healthy and keeping our community safe.

00:14:45:18 - 00:14:46:08
Steven Diaz, M.D.
Right.

00:14:46:10 - 00:15:06:13
Joanne Conroy, M.D.
I want to thank you, Steve, and I want to apologize for our audience for having laryngitis today. But Steve did most of the talking, and I thank him for that. We appreciate you sharing your valuable expertise and insights. Thank you very much from rural Hanover, New Hampshire, to rural Augusta, Maine.

00:15:06:16 - 00:15:14:26
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.

00:00:00:09 - 00:00:21:21
Tom Haederle
Distance and lack of transportation. Obtaining a prescription and then paying for it. These are just some of the challenges that make accessing mental health and addiction services especially difficult in rural communities.

00:00:21:24 - 00:00:43:01
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Access to quality care in rural communities often presents problems that defy easy solutions. Still, there are workarounds, as we learn in this podcast hosted by Rebecca Chickey, the AHA's senior director for clinical affairs and workforce.

00:00:43:04 - 00:01:06:17
Rebecca Chickey
Indeed, it's an honor to be here today with Brenda Romero. I have known her for over a decade now. She is a past member of AHA's Committee on Behavioral Health, our national advisory committee that helps us with our advocacy and policy, as well as resource work. And that's why Brenda is here today as a CEO of a small rural hospital in New Mexico.

00:01:06:19 - 00:01:31:21
Rebecca Chickey
She has a great deal of experience, some of which she's going to share with you here today about improving access to mental health and addiction services in a small rural community. So, Brenda, welcome. Thank you for sharing your time and expertise. My first question to you is, what are a couple of the biggest challenges to accessing behavioral health in a rural community?

00:01:31:25 - 00:01:37:09
Rebecca Chickey
For those many, many listeners who live in an urban, metropolitan area, help them understand.

00:01:37:11 - 00:02:09:20
Brenda Romero
The first issue is access to the care in that rural communities don't usually have taxis. Transportation is an issue. And for people who are suffering from this illness, they're usually couch surfing or living out in the streets. And so finding them and getting them to the care is usually the first issue that we encounter. And the second is getting them the medication. The cost

00:02:09:20 - 00:02:38:15
Brenda Romero
of the medication can be up to $500 a month. And getting them the prescriptions is one thing, but then getting them the medications is another. Usually people with that presentation don't have a payor source, and so then it would require somebody giving them that money and willing to support that every single month. In order to increase compliance with medication treatment

00:02:38:20 - 00:03:03:26
Brenda Romero
we have started using some medications, like Brixadi, that we can give in the ER or in our infusion center, and it'll last a whole month. And we're using that type of medication for pregnant women that present and that we're not sure if we're going to see again for some time. And so that's been helpful.

00:03:03:28 - 00:03:27:15
Rebecca Chickey
So I'm going to hit home with a couple of things that you said for people who live in Chicago or New York or even Nashville, Tennessee, where I lived for a number of years. The fact that there's not a taxi is really sort of like, what? And I suppose that same lack of transportation services, you don't have an abundance of Uber drivers or Lyft drivers in your community either, right?

00:03:27:16 - 00:03:53:11
Brenda Romero
No, it's not available. And when you're talking about where these patients need to come from, we are in Espanola and there's about, there's less than 10,000 people that actually live in the city. And then there's Rio Arriba county, and it can be 100 miles to one of the borders. So we're talking about they come from surrounding communities. So it's not like somebody can walk there.

00:03:53:13 - 00:03:55:13
Brenda Romero
They need to find a ride.

00:03:55:15 - 00:04:18:17
Rebecca Chickey
And so that means relying on family or friends who may or may not also have transportation services. So just that physical capability of getting to the hospital or the emergency room is a challenge that many of our listeners probably can't imagine, but I can. Having grown up in rural Alabama, when EMS tried to get to my father, they couldn't find the house because there was no GPS at that time.

00:04:18:19 - 00:04:49:26
Rebecca Chickey
The next thing that you mentioned is the cost of the medications. So that's not unique to mental health. There always seems to be an article in the news or a discussion somewhere about the cost of medications, but these medications are for our most fragile patient populations because they often, and please correct me if I'm wrong, but they often have physical comorbidities as a result of or perhaps one of the reasons that they may be self-medicating with substances.

00:04:50:03 - 00:04:56:29
Rebecca Chickey
So their physical health and their mental health are often fragile and being challenged. Is that an accurate statement?

00:04:57:01 - 00:04:58:09
Brenda Romero
Yes.

00:04:58:11 - 00:05:16:02
Rebecca Chickey
And so because of that, tell me why it's so important to be able to provide a medication that lasts for a month. Is that to know that you don't have to worry after that because of compliance issues, because the patients are actually going to, they don't have to worry about that then.

00:05:16:05 - 00:05:48:23
Brenda Romero
Yes, it's not only compliance, but it's actually getting the medication. And so usually they don't have a payor source so they don't have Medicaid. And if they have Medicare due to a disability, they usually haven't signed up for part D or any of the other parts that they need to get payment for the medications, for prescriptions. And so if they were to try to go get their medications and be compliant with that, most times they wouldn't even get the medications because they can't pay for them.

00:05:48:26 - 00:06:07:24
Brenda Romero
And if a family member is willing to start them on it, like pay for the first month, it's pretty hard to get somebody to commit to just continue to pay for that. In order to get them on Medicaid, they would have to then get all the paperwork in order to apply. And they can apply online.

00:06:07:24 - 00:06:28:24
Brenda Romero
But some of these older folks don't have the capacity to be able to do that. They don't have the phone. They don't have the experience with getting on a website and filling in all the information that they need. And some of that information that they might need is to upload a copy of the birth certificate, and they might not have the birth certificate.

00:06:28:26 - 00:06:37:12
Brenda Romero
So the barriers are huge for them. They can't get there. And so I think that...

00:06:37:15 - 00:06:40:28
Rebecca Chickey
So what's your solution? What have you been creating, what have you been innovating.

00:06:40:28 - 00:07:01:18
Brenda Romero
So what we've done is we've started the treatment in the emergency room and then following them up in the clinic. And if we can get them started on medication, then we can buy more time to work with peer counselors, to work with case managers to help them get what they need in place in order to continue the treatment.

00:07:01:21 - 00:07:29:00
Brenda Romero
We are also encouraging the homeless shelters to work with the homeless population and to get them to our E.R. if they can do that. Presbyterian Healthcare Services, organization I work for, is now also asking if our paramedics can start giving out some of the medication when they respond to a call, if the patient is willing to start the treatment at the time.

00:07:29:07 - 00:07:37:17
Brenda Romero
So we're trying to figure out how to get the medications to folks where we can, even if they can't afford to do it.

00:07:37:19 - 00:08:04:08
Rebecca Chickey
So it sounds like you're taking advantage of every opportunity where there's a touchpoint with a patient that has this need. Yes. That's phenomenal. It's, I think, a broader sense of patient-centered care. You're going to where the patients are and providing the services. So do you think this innovative idea is replicable? Can it be implemented by other organizations in a similar crisis situation?

00:08:04:08 - 00:08:11:23
Rebecca Chickey
I would say because the challenges that you described almost seem insurmountable. But do you think others could replicate it?

00:08:12:00 - 00:08:35:21
Brenda Romero
Yes. Also, keeping in mind that, especially at the beginning, they're not going to have a payor source, right? So we're going to have to start that and not be reimbursed for that. But it makes a huge difference, not only most importantly to that person's life. Right? Like, who wants to be suffering like that? And then it starts improving their participation in society

00:08:35:21 - 00:09:02:27
Brenda Romero
and with their family members. And in our area it's a very family-oriented area, and most people who don't have a place to live will have a place to live if they sober up. And so reuniting those patients with their families is just, it would be an amazing thing to do. And then their reentry into their communities would be another win for everybody, right?

00:09:03:00 - 00:09:25:08
Brenda Romero
And makes it a safer place for the patient and for the communities that they live in. And so I think it's very, very important. I think it's worth it to everybody. There's something in it for everyone. And I think that one way to start is to assess what the barriers are, what are the barriers that those patients in your community are experiencing.

00:09:25:08 - 00:09:37:07
Brenda Romero
Because as you said, bigger communities have transportation. They have other ways to get around. So the patients in their community might not have the same barriers that we have in ours.

00:09:37:14 - 00:09:59:26
Rebecca Chickey
Yeah. As you were describing the long-term impact of this, if an individual gets on a medication that helps them remain sober for a month, then that gives them hope, then they may be able to get traction to go back and live with their family. Then they may be able to get a job. And that is something that is priceless, right?

00:09:59:29 - 00:10:26:15
Rebecca Chickey
You can't really put a price on giving someone their humanity back. But at the same time, the reality is that often no margin, no mission. So I realized that this is a new innovative initiative that you undertake, and so you probably haven't, you don't have hard data on that. But I would assume that what you're hoping is that you're going to see fewer emergency room visits, which we all know are costly.

00:10:26:17 - 00:10:54:12
Rebecca Chickey
I assume that you're going to have less use of emergency services outside, sending someone out to rescue someone who is in a crisis from a substance use disorder. And perhaps even you will see a reduction long term in things like cirrhosis, in things like congestive heart failure, in wound care for individuals, depending upon what the substance is. Is that what you're hoping for in the long run?

00:10:54:15 - 00:11:21:19
Brenda Romero
Yes. But most importantly, saving people, saving people's lives, right? They are at risk of death every day, premature death every day. And there's a lot of violence that's, you know, associated with this diagnosis. And so not only the patient's life, but their family and friends and other community members walking around. I mean, it would improve all of that also.

00:11:21:21 - 00:11:33:08
Rebecca Chickey
So it's a population health approach, I agree. Thank you. So much, one, for the work that you're doing. Boots on the ground, making a difference in individuals' lives. And thank you for sharing that inspiration with us here today.

00:11:33:10 - 00:11:34:27
Brenda Romero
Thank you.

00:11:35:00 - 00:11:43:10
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:16 - 00:00:33:28
Tom Haederle
Clinical validation audits are a new tactic that certain commercial insurers are adopting to reduce or deny payment to health care providers for diagnoses they treated in patients. It can take months or even years for these audits to be adjudicated and resolved, adding tremendous cost and burden to the health care system. And at the end of the day, some insurers are getting away with not paying their bills as a result of these audits.

00:00:34:00 - 00:00:54:00
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Clinical validation audits are growing rapidly and increasingly straining the financial viability of hospitals and health systems and the resources they need to care for their communities. What's happening and what can be done?

00:00:54:02 - 00:01:23:02
Michelle Millerick
This is Michelle Millerick from the AHA policy team. I'm joined by Richelle Marting who's the director of managed care contracting from North Kansas City Hospital in Kansas City, Missouri. Richelle is an attorney by training, a registered health information administrator and a certified coder. She has spent her career focused on the legal aspects of health information management and reimbursement issues for health care providers and has helped overturn millions of dollars in clinical validation audit findings through developing systems to effectively appeal payers’ inappropriate denials.

00:01:23:04 - 00:01:43:29
Michelle Millerick
Second, I'm joined by Christine or Chris Thompson, who's the executive director of reimbursement and compliance for managed care at AdventHealth in Altamonte Springs, Florida. Chris is an accountant and CPA by training and directs teams responsible for contract negotiations, reimbursement and financial analysis in a large health system. So, let's just dive into the meat of it. So, maybe Richelle, you can start.

00:01:44:05 - 00:01:47:09
Michelle Millerick
Can you explain what the heck a clinical validation audit is?

00:01:47:12 - 00:02:22:29
Richelle Marting
Sure. Well, I can try my best. Clinical validation audits are almost a derivative of a type of inpatient audit that looks at diagnostic-related group coding. In the past, looking at DRGs and the way that we bill as inpatient accounts used to be focused on coding guidelines. We looked at the way principal diagnosis codes were sequenced and coding additional diagnoses, all of your coding rules and concepts, and clinical validations sort of stemmed from that concept that has a very different focus.

00:02:23:02 - 00:02:59:03
Richelle Marting
Rather than looking at documentation and the medical record to determine if coding guidelines allow us to assign the codes that we reported, that in turn dictate what that DRG is, clinical validation recognizes that these conditions were documented by medical providers typically, but instead examines clinically whether a health plan believes that the diagnosis is supported based on signs and indicators and different underlying conditions within the record.

00:02:59:09 - 00:03:35:24
Richelle Marting
In other words, we see that the patient's physician diagnosed this condition and documented it, but do we believe that the patient actually had that condition, or is it clinically supported to report? The result of the clinical validation audit, if a plan believes that a documented diagnosis like sepsis or acute respiratory failure is not clinically valid, we almost ignore or omit that diagnosis code, as if it were not there on the claim, to derive a new DRG for payment purposes.

00:03:35:27 - 00:03:52:15
Michelle Millerick
So, in other words, they're not really saying, you know, it's not about whether the claim was coded or billed correctly, it's about whether does the health plan believe that the patient actually had that diagnosis, and they're kind of coming back, after the fact, and trying to decide whether they think that the patient actually had that diagnosis based on the documentation.

00:03:52:15 - 00:03:53:14
Michelle Millerick
Is that right?

00:03:53:16 - 00:03:55:08
Richelle Marting
That's exactly right. Yes.

00:03:55:10 - 00:04:02:01
Michelle Millerick
Can you maybe give me an example of a patient case where that happened or sort of walk us through an example of what that might look like for a patient?

00:04:02:03 - 00:04:25:24
Richelle Marting
Sepsis is probably the most common example that I think a lot of hospitals can relate to, where we have a patient come in who's sick, who has some type of infection, maybe that's pneumonia or cellulitis, whatever that that infection is, and we have a physician who determines they believe the patient is septic. So, they would document their diagnosis of sepsis in the record.

00:04:25:24 - 00:05:05:10
Richelle Marting
And you typically see the progression of antibiotics and treatment focus both at the underlying infection and the patient's systemic manifestations of that infection. No question in the record that at least one physician, if not multiple physicians and multiple specialties, diagnosed and document the condition of sepsis. What we see then on the back end, our coders would, of course, code and report that condition according to coding guidelines, because it is documented by physicians in the medical record.

00:05:05:11 - 00:05:37:17
Richelle Marting
That diagnosis code gets transferred on to the claim form, and because it is a CC or an NCC, it increases the severity or the complexity of the DRG that is assigned on the claim. After submitting that claim, the health plan might ask for copies of the medical records to clinically validate whether they believe the patient actually was septic in the view of the plan, regardless of what the patient's local or personal attending and specialty physicians believe.

00:05:37:19 - 00:06:17:15
Richelle Marting
So, the plan might look at things like SOFA scores, they might look at the mean arterial pressure, the PF ratio, was the patient on oxygen, creatinine levels. And based on however the plan or their reviewers define sepsis and what criteria they expect to see, if they don't find all of those in the record, they might issue a letter to indicate we believe that the documented diagnosis of sepsis is not clinically valid and indicate what DRG they will pay the hospital if different from the DRG that was reported.

00:06:17:18 - 00:06:34:27
Michelle Millerick
So really, in most of these cases, the patient is getting the care and the treatment associated with that diagnosis. But this is something that happens after the fact to just really reduce the payment. So, Chris, maybe you can talk a little bit more. Feel free to add anything that you might want to Richelle's explanation of what these audits are,
but what are you seeing at Advent?

00:06:35:00 - 00:06:59:15
Chris Thompson
It is a huge issue for AdventHealth with many different payers and many different types of payers. But we met with a large payer in the state of Florida, and it boils down to this: the medical director there agreed that our treatment of a patient was absolutely spot on the way it needed to be, using the criteria of ICD-10 for sepsis.

00:06:59:17 - 00:07:26:18
Chris Thompson
And they agreed that they wouldn't want us to wait later for that sepsis case, because the criteria that they're using for payment much of the time is sepsis 3 and not sepsis 2, which he virtually said, oh, no, I would want you to treat that patient that way, but we're not going to pay for that. We're seeing with clinical validation audits, we're seeing it in all types of insurance: Medicare, Medicaid, commercial.

00:07:26:21 - 00:07:50:22
Chris Thompson
It's very prevalent in the Medicare space, obviously, but it is in all types for us. It's all payers are conducting clinical validation audits. It is a practice that continues to get bigger as time goes on. We have tried to put some things in place to combat the ability to do those clinical validation audits with not complete success, but a limited measure of success.

00:07:50:24 - 00:07:57:11
Michelle Millerick
Do you see these kinds of issues, you said all payers, but with traditional Medicare as well, or is it predominantly in Medicare Advantage?

00:07:57:13 - 00:08:06:18
Chris Thompson
I am of the opinion that Medicare does not do those based on my industry knowledge. It is only with Medicare Advantage that we see this practice, not Medicare.

00:08:06:20 - 00:08:09:15
Michelle Millerick
That's a helpful distinction. It may be something we want to come back to in a few minutes.

00:08:09:20 - 00:08:25:21
Chris Thompson
I think that is interesting as we think about sort of parity between traditional Medicare and Medicare Advantage, of the types or sorts of audits and payment issues we're seeing in MA that maybe don't sort of exist in the same way in traditional Medicare. I guess that also kind of raises another question. And maybe, Richelle, you want to weigh in on this about, you know, are these audits allowed?

00:08:25:21 - 00:08:32:05
Michelle Millerick
You know, that that if it's not something that happens in traditional Medicare, you know, is this allowed in Medicare Advantage or why?

00:08:32:07 - 00:08:54:25
Richelle Marting
Yeah, there's been a lot of, sort of, intellectual and academic discussion around that on both sides in trying to grapple with even defining and characterizing what it is and how it is different than DRG validation. Is it a medical necessity decision, or is it something else? So, I hate to give the lawyer answer, it depends, but maybe it depends.

00:08:55:02 - 00:09:41:21
Richelle Marting
And I think not having that very clear, well-defined concept is challenging. We do have some definitions, originating from the RAC scope of work. So when you mentioned does traditional Medicare clinical validation, that's one of the sources where CMS in its contract with RAC auditors years ago indicated, no, that RAC auditors cannot do clinical validation, and that's why it was defined to distinguish it from what is permitted DRG validation, where you're looking more at the coding guidelines. Whether it's allowed, for an MA plan, or commercial plan or a Medicaid plan, for example, and a provider, I think really is going to come down to the parties discussing that and putting some language in their

00:09:41:21 - 00:09:56:22
Richelle Marting
agreements to address what these are, parameters on when and how they're performed. At least at this time, where we don't have explicit guidance from CMS on how that can or cannot be handled with respect to different government programs.

00:09:56:24 - 00:10:23:08
Michelle Millerick
You know, I think one of the things, you know, just reflecting on what both of you just said, that's really troubling to me is, if you sort of think about this from the patient perspective, if you're a patient, you have an illness or an injury or a sickness that you go to a doctor for, your doctor diagnoses you with the condition, you know, and says you have this, treats you for this, but then somebody later reads your record who never even saw you as a patient, might not even be a physician necessarily, you know, and comes back later and says, even though you were treated for this condition, you don't actually have that.

00:10:23:09 - 00:10:27:17
Michelle Millerick
Like that just seems kind of crazy. So, I guess, you know, how do we make sense of that?

00:10:27:18 - 00:10:43:19
Chris Thompson
I think the plans let the attending physician do their job. I think the attending physician is the director of all of it. The problem that we have is that the health plan comes behind that physician and basically says, I'm just not going to pay you for that.

00:10:43:22 - 00:11:04:00
Chris Thompson
I want them to provide the care. You didn't do anything wrong. You didn't perform excessive tests. You didn't delay the care. You did all that was supposed to be done. But the health plan comes behind and basically says, we're not going to pay you for that. That that's the crux of it as I see it. I would welcome Richelle’s input on that too.

00:11:04:03 - 00:11:27:14
Richelle Marting
I think there's a couple of challenges there. And I mentioned the RAC statement of work, but there is a, there's a coding clinic article that I think providers and plans use in different ways and addressing that both providers and plans that have their own definitions of diagnoses. And so, we take that in different ways where our medical staff may have a definition of sepsis that we adopt, and we use.

00:11:27:14 - 00:11:50:29
Richelle Marting
And this is how we want to implement, identify early signs of sepsis, intervene and prevent that from being exacerbated, and a plan may say the same. So often it may come down to whose definition gets to trump. And that's assuming, of course, that a clinical validation audit is permitted to begin with. I think of several different rules that come to mind.

00:11:51:06 - 00:12:20:12
Richelle Marting
In Medicare Advantage, for example, there are regulations on poststabilization services and that when provider and plan disagree as to whether the patient is stable for discharge or transfer, there's deference to the attending physician in that example. To me, that signals that when we have two medical professionals who disagree, it might be appropriate to give deference to the provider that's actually there in the room, with eyes and hands, with the patient.

00:12:20:14 - 00:12:42:14
Michelle Millerick
Yeah, absolutely. The person who touched and met with and evaluated the patient, that makes a lot of sense. So, I want to shift gears a little bit to just the impact on hospitals and health systems, and, you know, it's clear that these kinds of audits are having an impact, or certainly we wouldn't be talking about it today. And I can say from the AHA perspective that we're increasingly hearing from hospitals and health systems across the country about concerns with these kinds of practices.

00:12:42:20 - 00:13:02:07
Michelle Millerick
And so, there's, you know, a real concern that these kinds of audits are inappropriate, but more so, too, that they're actively harming the financial viability of some hospitals, especially those that are rural and small and maybe don't have the resources to fight every one of these things on the scale that it's happening. So, you know, one of you is, you know, a midsize independent acute care hospital and another, a large system.

00:13:02:07 - 00:13:07:10
Michelle Millerick
And I wonder if you can both just sort of comment on kind of the impact that this has had on your organizations.

00:13:07:13 - 00:13:26:21
Chris Thompson
So, you know, when clinical validation audits first started, there was a trend for us where payers were not paying anything unless you removed the diagnosis code from your claim and resubmitted it. We still have two payers taking that stance with us in various markets.

00:13:26:21 - 00:13:54:04
Chris Thompson
So, the impact of that is huge because you've provided the care, yet no payment is received. More payers have moved to, we'll pay you the DRG we think we owe you, and you can use your dispute resolution process to deal with the rest. For AdventHealth, over the last four years, I would say this issue has been worth probably about $150 million total, and it just continues to grow.

00:13:54:07 - 00:14:17:06
Chris Thompson
Obviously, some payers are larger than others. You know, it does pay to be persistent with the payers. And that is, at the beginning, we were actually able to work with a payer who's fairly large in the Medicare Advantage space, and they agreed that clinical validation audits were not part of the Medicare program, were prohibited by Medicare, and they don't actually do them for our hospitals.

00:14:17:08 - 00:14:32:23
Chris Thompson
So, that was a win on our part. That was one payer out of many. But yeah, the trend is large for us. It continues to grow. I will be honest to say, our recourse has been pretty much the dispute resolution process within our agreements.

00:14:32:25 - 00:14:36:07
Michelle Millerick
Chris, can I also just ask you before Richelle comments, how far does that go back?

00:14:36:07 - 00:14:45:13
Michelle Millerick
Like when did you start to see these things? Because we think about that, that scale of impact that you're saying even just in terms of the dollar amount, has this been going on for a long time or is this relatively new?

00:14:45:16 - 00:14:50:14
Chris Thompson
I think it started and was kind of something before we actually tracked it the way we should.

00:14:50:14 - 00:14:57:03
Chris Thompson
But I know for us it goes back to probably 2018. That's about as far back as I have seen claims and issues for clinical validation audits.

00:15:00:26 - 00:15:05:14
Michelle Millerick
That's interesting. So, this is a relatively new phenomenon in the last five years, five or six years.

00:15:05:15 – 00:15:07:14
Chris Thompson
Yes, absolutely.
00:15:07:15 – 00:15:10:03
Michelle Millerick
Richelle, how about you guys? What's the impact been for you?

00:15:10:23 - 00:15:44:11
Richelle Marting
Yeah. Well, I'd echo that same timeframe. We were not seeing many. For North Kansas City Hospital specifically, I can say a handful, maybe a month, that we would see a true clinical validation audit that was not a coding issue. So, it certainly evolved, starting in about ‘18, ‘19, 2020, we started to see more and more to the point where there was this very clear shift from DRG validation to predominantly the vast majority were clinical validation.

00:15:44:13 - 00:16:05:04
Richelle Marting
We saw about 80% of those in the Medicare Advantage plan space. There were some commercial, and then I would even more recently, maybe in the last two to three years, where we started to see a small number of the Medicaid and COs doing the same thing. So, I expect that that's also an upward trend that we can expect in the coming years as well, and unless guidance or things change in the meantime.

00:16:05:04 - 00:16:37:25
Richelle Marting
Certainly has had a significant financial impact. Not only has the prevalence among different types of plans increased, but the volume is increased. Where we might have a handful four or five years ago, we are now easily appealing anywhere from 80 to 100 for one hospital organization per month. The average dollar amount in this dispute can be anywhere from, on average, I'd say $5 to $8,000,

00:16:37:25 - 00:17:04:14
Richelle Marting
the difference between two DRGs. So, you add that up, it adds up very quickly. And that's not just the dollar amount in dispute. These are extremely time consuming to process, to appeal. You've got somebody who needs to know coding and clinical digging into the record and can sometimes spend hours preparing a single appeal to do a really good, thorough job and address all of the plan’s concerns.

00:17:04:16 - 00:17:16:24
Richelle Marting
It is just a very burdensome, time-consuming process with a lot of administrative costs, delays in payment, yet pretty good outcomes at the end of the day, getting these overturned.

00:17:16:26 - 00:17:34:09
Michelle Millerick
That's a really good point as we think about just unnecessary cost and burden on the system and the resources required to fight against these things, especially if, as you said, the outcome at the end is that most of these things get overturned after many months or years of, you know, arbitration or trying to resolve them. I wonder if either of you could comment on this.

00:17:34:14 - 00:17:40:02
Michelle Millerick
Is there an impact to patients? You know, a lot of this is payment related, but is there a patient facing side to this?

00:17:40:05 - 00:18:03:17
Richelle Marting
Arguably, yes and no. It’s no, in the sense that you talked about a patient, who had their physician make a diagnosis and it's in the record and then a plan, a provider, hopefully a clinician, but who's never seen the patient, makes this change. Yet the patient doesn't really see those changes. There's really not a difference. We don't see often a change in the medical record.

00:18:03:19 - 00:18:29:08
Richelle Marting
What you might see, though, is a delay in getting the patient statement out to the patient while we are trying to adjudicate that inpatient claim and go through the appeal process, because this can often take, as you said, many months, and in fact, sometimes we've had, it's been years just to work our way through the internal appeal process, without even considering formal dispute resolution.

00:18:29:11 - 00:18:55:10
Richelle Marting
We had a patient example not too long ago, where the admission was in 2020, and we just reached a final decision this year. So patient impact, if there was a patient financial responsibility, getting their statement, you know, potentially four years after a date of service absolutely has an impact. Even if the dollar amount’s not different than what it would have been at the beginning,

00:18:55:13 - 00:18:58:12
Richelle Marting
that to me has a very real impact on patients.

00:18:58:15 - 00:19:00:28
Michelle Millerick
Chris, it looked like you wanted to jump in there.

00:19:01:01 - 00:19:27:12
Chris Thompson
I'm flabbergasted at, you know, four years. After four years, a patient thinks there must not be a bill. I mean, truthfully, and I always, because much of this revolves around Medicare Advantage, I know I have had to work with my mom in situations like this. She has a health plan, and this is an issue that she, just what Richelle said, the delay in getting the information and the bill to her.

00:19:27:19 - 00:19:34:27
Chris Thompson
I have seen that firsthand through her interactions with her health plan and hospital for various states.

00:19:35:00 - 00:19:46:15
Michelle Millerick
So, I want to shift this to sort of move into the final stretch of our conversation just around, you know, what should we do about this? Are there solutions? Are there things that that we should be thinking about to curb some of these potentially problematic practices?

00:19:46:20 - 00:19:53:26
Michelle Millerick
So, I'll ask you maybe both to respond to that. Maybe, Chris, if you want to start, you know, where do you think we go from here? What, how should we tackle this?

00:19:53:29 - 00:20:02:03
Chris Thompson
I don't know if I'm as forward thinking as Richelle is. I know how as a company, we have tried to tackle it, and that is, we're large,

00:20:02:03 - 00:20:23:22
Chris Thompson
we're typically contracted with every payer and every market, but we've tried to tackle it through different contract language that we negotiate into our contracts. I will tell you that we have payers that blatantly ignore what's in our contracts, which again, the dispute resolution process is, it's pretty much where we're channeled to go when you're contracted with and payer.

00:20:23:24 - 00:20:51:05
Chris Thompson
I would like to see, and I think others would like to see, CMS weigh in on this particular topic. When they prohibit it in their own program, but they allow it under the Medicare Advantage program, and it will become through the complaint portals that are changing for providers, I think it will become very apparent and much more in the face of CMS staff that these things are occurring.

00:20:51:05 - 00:20:58:14
Chris Thompson
It's a definite impact, maybe, that’s one of the avenues we can use moving forward.

00:20:58:14 - 00:21:26:16
Richelle Marting
One of the pieces we haven't really discussed yet that makes these challenging, in addition to plans, having specific criteria, is there's also a lack of transparency and that they won't provide them to the hospital where we can educate our medical staff. Chris is probably alluding to that in contract language, that to the extent there are these criteria or definitions from the health plan that are going to impact whether and how we get paid for sepsis or other conditions, we'd like to see that.

00:21:26:17 - 00:22:03:29
Richelle Marting
We'd like to know that; we'd like to have our medical staff weigh in, ask questions, express concerns before we're held to standards, and for the most part, with very, very, very limited exception, we have absolutely no insight into what those criteria are until after the fact. But I think that ties back to some of the work that CMS has been doing that could help in the space of clinical validation audits surrounding coverage criteria and defining and characterizing these audits, and whether a specific definition of diagnosis is a coverage criteria. CMS alludes to that in the final rule,

00:22:04:05 - 00:22:26:03
Richelle Marting
and there are pieces where they say, to the extent of plan, create specific definitions of diagnoses. They have to follow these rules, but really didn't elaborate that to be so explicit that we can really have a very clear conversation with health plans. Although I will echo Chris's sentiment that there are other places where we have very clear language

00:22:26:03 - 00:22:46:04
Richelle Marting
in the final rule, that we've also had plans directly say they're not going to follow it. So, whether that actually yields any results, but I think it's the start to have better clarity and guidance from CMS, not only for Medicare Advantage, but to the extent that may or may not also affect Medicaid programs and Medicaid NCOs.

00:22:46:06 - 00:23:10:12
Michelle Millerick
Those are a great set of points, and I think you certainly both have given us a lot to think about and want to thank, both of you, Richelle and Chris, for sharing your time, expertise and insight with us and really more broadly for all of the work that that both of you and your organizations do on behalf of the patients and communities that you serve., From the AHA perspective, holding commercial insurers accountable to their patients and network providers, continues to be really a top priority for us.

00:23:10:15 - 00:23:17:25
Michelle Millerick
So, we will continue to try to shed light on these kinds of issues and look forward to working with both of you going forward to continue trying to tackle these challenges.

00:23:17:28 - 00:23:19:15
Richelle Marting
Thanks for having us.

00:23:19:17 - 00:23:27:27
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.