Advancing Health Podcast

00:00:00:01 - 00:00:16:09
Tom Haederle
Welcome to Advancing Health. For many hospitals, philanthropic dollars are not just nice to have, they're a must have. Today we hear how this reality is supporting youth mental health and behavioral health efforts in central Iowa.

00:00:16:12 - 00:00:43:01
Rebecca Chickey
Hi everyone. I'm Rebecca Chickey, and I'm the vice president of behavioral health and trustee services at the American Hospital Association. And today, we are going to learn about a $1 million gift to advance mental health care in central Iowa that Eyerly Ball provided to UnityPoint health. Joining us today to share the impact of this gift, both now and into the future, is David Stark.

00:00:43:02 - 00:00:51:26
Rebecca Chickey
He is the chief of government affairs and a philanthropy officer for UnityPoint Health. David, thank you for joining us today.

00:00:51:28 - 00:00:53:02
David Stark
Good to be with you.

00:00:53:04 - 00:01:06:09
Rebecca Chickey
Let's get started. If you can first provide the listeners with a bit of a history behind Eyerly Ball. What has their role been in terms of shaping mental health in the Central Iowa communities?

00:01:06:11 - 00:01:31:15
David Stark
We are so blessed to have a history steeped in tradition. Over 55 years ago, two women, Jeannette Eyerly and Elizabeth Ball, saw a need for community health services here in the Des Moines area. And they started what was the county mental health center, now known as Eyerly Ball, a one stop shop that would take care of all the holistic needs, behavioral health wise for patients and families.

00:01:31:17 - 00:01:35:14
David Stark
And we're proud to carry on that tradition today some 55 years later.

00:01:35:16 - 00:01:45:11
Rebecca Chickey
So tell me a little bit about that. Why and how did UnityPoint Health get involved with this? Was there common mission vision? Tell the listeners a bit about that.

00:01:45:13 - 00:02:13:26
David Stark
There was tremendous alignment and synergy with our mission and vision eight years ago. Eyerly Ball became a wholly owned portion of UnityPoint Health Des Moines. Our mission of improving the health of the communities that we serve is not just about physical health. It is also about emotional, social and psychological health. Eyerly Ball's role of taking care of the entire patient fit seamlessly with what we did, and we've had tremendous synergies the past eight years.

00:02:13:28 - 00:02:40:26
Rebecca Chickey
That's wonderful. Particularly as I just saw a report this morning that the demand for mental health services continues to climb across all parts of the country and all ages. So the fact that you're able to step up and address and meet those community needs is phenomenal. But you couldn't have done it without that commitment of those two women, and their dedication years ago, but also without funding.

00:02:41:03 - 00:03:02:02
Rebecca Chickey
We all know that behavioral health services have been underfunded historically. And so I want to get your perspective on this phenomenal philanthropic gift, $1 million. Can you tell us a little bit of how that came about? And then shortly afterwards, we'll learn about how you are using those funds to improve access to care.

00:03:02:04 - 00:03:27:21
David Stark
It was quite remarkable. It is our largest and first endowed gift to Eyerly Ball in the 55 years. So this is a new thing for us which is wonderful. And really what sparked it was an investment in a new facility and an overall campaign we started of One Place for Care. That was a five year process in the making to get a new campus for Eyerly Ball and all of the services with it.

00:03:27:24 - 00:03:52:06
David Stark
Realizing that we had an approach to fund that from a building and infrastructure standpoint. But what inspired this donor was what we needed to do from a service standpoint and really to make sure that we were there, are there for the community each and every day. And so this endowment was sparked by that investment that was also philanthropically supported, and it really was a flywheel.

00:03:52:06 - 00:03:58:18
David Stark
That gift generated an additional gift. And those conversations really made a palpable difference.

00:03:58:20 - 00:04:25:17
Rebecca Chickey
Given your title, can you speak a little bit to the broader value of hospitals and health systems really embracing the path of including philanthropy as a focus area, as a way to help margins because no margin, no mission. So, speak a little bit about that because I've seen hospitals and health systems getting more and more involved in this area, and embracing it.

00:04:25:19 - 00:04:48:27
David Stark
We've made a concerted effort, starting with our board of directors, to talk about philanthropy, not as a nice to have, but as a must have. And we frame it this way. There are three sources of dollars for a not for profit community health center or a hospital. One is patient revenue, clearly. Two, we can go out and issue debt and bring in debt to raise money for capital projects.

00:04:48:28 - 00:05:13:25
David Stark
The third leg of that stool is philanthropy, and we need to use that and talk about that. And identify each and every day and each and every year. And it's become part of our lexicon here at UnityPoint Health of why that's so critically important, to fund those things that are not funded by Medicare or Medicaid or commercial insurance, that are critically important to providing community services right here in their local area.

00:05:13:27 - 00:05:37:02
Rebecca Chickey
The reason I wanted you to go a little deeper on that is for decades, I think, children's hospitals in particular, but it has been more the exception than the rule to see a philanthropic gift go to mental health services. So congratulations for having the broader reach. Also, particularly congratulations for having it dedicated to mental health services.

00:05:37:05 - 00:06:01:00
Rebecca Chickey
And with that, I'd love to turn to the impact of this. You mentioned One Place for Care and how that was the foundation for this. What are you doing with this endowment as it relates to expanding access to services? And I'm particularly interested if you can share how this is impacting access for children and adolescents. As we all know,

00:06:01:02 - 00:06:23:06
Rebecca Chickey
if you are going to have signs of psychiatric or substance use disorders, 50% of those symptoms show by the time you're 14 years old and by the time you're 24, 75% will show symptoms. And so early intervention and prevention is critical. So wondering how you're serving the youth through this endowment.

00:06:23:09 - 00:06:54:05
David Stark
Absolutely. We're so proud of the fact that at Eyerly Ball, we treat the entire continuum from childhood to adulthood and geriatric. And so it is truly caring for anybody that comes through our doors. I'd say the chief improvement we made in this, in this One Place for Care campaign, was to create a no wrong door policy. You can enter the system whether you're an adolescent, a teen, a child, and there's no just one spot.

00:06:54:05 - 00:07:16:10
David Stark
You have to come through an access center. You have to come through urgent care or whatnot. Any door we will get you connected with those services. So we put all the services under one roof. We used to be in three different locations, and so that makes it simple to say I'm going there. We added an urgent care center for behavioral health services, particularly for teens, to be able to come in and see that not in the emergency department.

00:07:16:13 - 00:07:41:19
David Stark
And then we've added things like a pharmacy and medication therapy management that we didn't have before that specifically help families deal with their mental health disorders and meet them where they are. Substance use is another component of the nine services we offer at Eyerly Ball and a tremendous amount of that are early detection for substance use, drinking and drug use with our teens and adolescents.

00:07:41:19 - 00:07:50:29
David Stark
So we're very proud of that fact that we've been able to expand this, that treats patients from over 22 different counties around our surrounding area.

00:07:51:01 - 00:08:12:29
Rebecca Chickey
That's phenomenal. I want to dig a little deeper. You said no one door, no wrong door. Which is particularly important. Does that mean that you coordinate through One Place for Care with your pediatricians that serve? How does that work? Is integrated care where they're looking at both their physical and their emotional health?

00:08:13:01 - 00:08:32:03
David Stark
That's correct. One of the best things that we have done is we have all of our service providers on the same electronic health record. So when you're seeing a pediatrician in an office that's, say, ten miles away from Eyerly Ball and you need that service, the Eyerly Ball provider can see that record and the pediatrician can see that record.

00:08:32:03 - 00:08:58:15
David Stark
So there's not this where did the record go? The patient forgot to bring it. I wasn't sure what happened there. All of that's been coordinated in a much bigger way. The second thing is that we have embedded social workers and mental health counselors in our primary care offices. So we try and do that easy handoff that so often when somebody is in for their wellness visit or in for another PE, they express some issues regarding mental health.

00:08:58:18 - 00:09:15:14
David Stark
Let's make it easy. And reduce the stigma to be able to have that soft handoff and meet with somebody right away to see what can we do to get you into the right level of care. Those are two examples. We put our money where our mouth is when we talk about integration and integrated care. That's what it means to us.

00:09:15:14 - 00:09:18:24
David Stark
And that no wrong door that you can get that access there.

00:09:18:27 - 00:09:41:09
Rebecca Chickey
I would assume as well, that you can report the same that I've heard from others. It also by embedding them in their pediatricians office in the primary care offices, that helps the mental well-being of the clinicians as well, because they may not have the background or the training in, as much in psychiatric and substance use disorders.

00:09:41:13 - 00:09:50:00
Rebecca Chickey
But right there, they have a resource that can help that patient in real time and do a warm handoff. Are you hearing that?

00:09:50:02 - 00:10:07:07
David Stark
I hear it almost every single day. And the ability to hand that patient off to an expert there, that doesn't fit within a 15 minute appointment, but they need a little more time, and they feel better about themselves. We're providing that care for the whole patient, and it really affects their overall health and well-being.

00:10:07:09 - 00:10:12:01
Rebecca Chickey
What question have I not asked you, David, that you're proud of in this work?

00:10:12:03 - 00:10:42:06
David Stark
The question that I think would be helpful for the listeners is what role did governance play in this effort? And I would say two really important things. One is we are blessed to have a board that supports our investment in mental health. That's critically important. And two: that understanding of the importance of philanthropy in pulling off our mission, 100% of the board members of Eyerly Ball gave to this campaign.

00:10:42:09 - 00:11:06:18
David Stark
So we had support from the very top, and that really sent a message to our community that this was important. Not only do I volunteer my time to serve in the governance role, I am providing my well earned and hard earned money to this service. I believe that much in it. So I think that's a critically important role in this is engaging your governance in terms of improving access to mental health.

00:11:06:20 - 00:11:32:26
Rebecca Chickey
Thank you for mentioning that. Last year, actually, we did four podcasts directed towards trustees about the value of philanthropy. They're in the community. They are, as you said, giving up their time already, but then giving up their hard earned dollars. It's leading by example and it allows others to see the value of what their contribution could mean.

00:11:32:29 - 00:11:42:05
Rebecca Chickey
What call to action would you share with the listeners, how to inspire them to have something like this in their own community?

00:11:42:08 - 00:12:05:03
David Stark
I would start with this. The call to action is to ask questions, not to necessarily have the right answer. What I mean by that is engaging community members in what they're passionate about. And the anonymous $1 million donor was a great example of that. And the 55 other individuals that supported the campaign. We started with questions. And where is your passion?

00:12:05:03 - 00:12:25:13
David Stark
Where is your purpose? That is something any of us can do. Board members can do, leaders can do. And it's amazing what you will hear and how that aligns with where you're trying to go from a missional standpoint. So engage your community with asking those kinds of questions. Number two is be willing to put your own dollars into the pot.

00:12:25:15 - 00:12:46:23
David Stark
So one of the biggest pieces of this project, this 15,000 square foot building. We made a commitment organizationally that we would invest our money into it as well. We're not just asking for 100%. So it's a shared responsibility. And really that public-private partnership is critically important. And the call to action is there's no right time to start.

00:12:46:28 - 00:12:55:05
David Stark
Today is just fine. Start today. Don't worry about that you haven't done it in a year or two years. Start today and there's no wrong time to start.

00:12:55:07 - 00:13:20:02
Rebecca Chickey
David thank you. Thank you for sharing your time, your expertise, clearly your passion for all that you do. Thank you for sharing the journey and giving some insights into the impact that two individuals 55 years ago can have because, that's where their passion was. And look at where it's led to today. Thank you so much.

00:13:20:04 - 00:13:22:04
David Stark
My pleasure.

00:13:22:06 - 00:13:30:18
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.

00:00:00:01 - 00:00:13:18
Tom Haederle
Welcome to Advancing Health. 7 in 10 U.S. adults say they receive medical bills they can't afford. In today's podcast, meet two experts who say the system just can't go on like this.

00:00:13:21 - 00:00:36:12
Molly Smith
Hello everyone! My name is Molly Smith. I am the group vice president for public policy here at the American Hospital Association, and I am really pleased to have with me two leaders from Undue Medical Debt, Allison Sesso and Eva Stahl, who are here to talk to us today a little bit about how Undue Medical Debt works, particularly how they work with hospitals.

00:00:36:14 - 00:00:56:28
Molly Smith
And just, you know, their ideas about what we can do around the challenges associated with medical debt, both prevention and solutions, once it occurs. So really excited to have them here with me today. So at this point, I would love to just actually turn it over to you both, Allison and Eva. And please just kind of start by introducing yourselves.

00:00:57:00 - 00:01:26:15
Allison Sesso
Great. So glad to be here. My name again is Allison Sesso. And I serve proudly as the CEO and president of Undue Medical Debt. And we really have one mission. We're a nonprofit that relieves medical debt, and our mission is to end medical debt. And we do that both by working directly with hospitals. We've been able to work with over 70 unique systems, representing about 300 plus hospitals across the country buying medical debt.

00:01:26:17 - 00:01:58:12
Allison Sesso
This is the bad debt portfolios that sit on their books that we understand a lot of hospitals have written off and think that they're not creating any harm for patients. But what we've learned is that by getting rid of that debt, we are actually relieving a burden from people. Not only does it live in their like mental health space in their heads, but it actually is, something financially that is hurting them as well because they're always thinking about what they can be doing, how else they could be kept figuring out how to pay that bill, and it creates a sense of overwhelm for them.

00:01:58:12 - 00:02:21:10
Allison Sesso
So our mission really is to get rid of those debts for our patients. We've gotten rid of $27 billion of medical debt for over 15 million patients at this point. And that work just keeps growing. We work like a for profit debt buyer, except that when we get our hands on those debts, we relieve them. We never ever collect a single penny from a patient.

00:02:21:10 - 00:02:41:08
Allison Sesso
We would never do that. We focus on people that are 400% of poverty below, or if a debt or 5% or more of their income. And the reason why I brought Eva here today is because we understand that fundamentally, what we're doing is not solving the problem of medical debt in its creation in the first place. And that is something we really like to do.

00:02:41:09 - 00:02:54:03
Molly Smith
We like to think about how we can be bolder and bigger in terms of making sure that our work absolutely is obsolete one day by solving this problem more fundamentally. And so I'll let Eva introduce herself.

00:02:54:05 - 00:03:16:21
Eva Stahl
Sure. And I actually was brought on to Undue Medical Debt about three years ago. And I think it is it was really anchored in Allison's background in social services, but really a longer term vision for not just being a Band-Aid for people in the moment, but really thinking about how we could influence policy upstream and mitigate the harms of medical debt.

00:03:16:24 - 00:03:53:14
Eva Stahl
So with that, we really focus on listening to our patients. So we hear from patients. So Allison mentioned that we've abolished debt for over 15 million individuals and we hear from them. So we actually have an anthropologist that works for us and helps to listen to their stories and record them and find themes. So those are messages that we can take back both to our hospital partners, but also to policymakers that are interested in learning about that experience and really the most harmful parts of medical debt, which include mental health harm and stress, but also delaying and deferring and forgoing care.

00:03:53:16 - 00:04:03:16
Eva Stahl
And being constantly worried about their financial well-being. So, and that's largely due to, you know, very high out-of-pocket costs and coverage that is not really serving as coverage for them.

00:04:03:23 - 00:04:14:05
Molly Smith
So maybe we could start at the beginning, if you will, which is, maybe helping us understand a little bit about the situation that many Americans are facing with medical debt.

00:04:14:07 - 00:04:27:14
Molly Smith
You just mentioned some pretty, kind of eye popping numbers that you've helped 15 million people relieve $27 billion worth of debt. But what does medical debt look like in the U.S. right now?

00:04:27:17 - 00:04:37:20
Allison Sesso
Yeah. So it is a substantial problem. I think it's something like 1 in 4 Americans have medical debt of some form, how it shows up for them, you know, is it on a credit card?

00:04:37:20 - 00:05:03:21
Allison Sesso
Is it money borrowed from a friend or family? Is it sitting with the hospitals, etc., being written off? It's all bundled together and there unfortunately aren't really great numbers as to specifics. But KFF has put some numbers out that it's at least $220 billion problem. We obviously know that we're going in the wrong direction on this issue as well, because coverage really is the best solution to protecting people from medical debt.

00:05:03:21 - 00:05:23:24
Allison Sesso
And we have made some policy decisions in Washington, to your point, that have really undermined, I think, the coverage situation for way too many people and we've seen, you know, that those numbers just starting to unravel right now. So really, I think the problem is it's large to begin with, and it's only about to get worse.

00:05:23:27 - 00:05:49:06
Allison Sesso
And it's a very, very common American problem, which is why I think that there's so much conversation around this affordability question. And I think the problem for a lot of the people that we help and we hear this from constituents all the time, is they want to pay their bills. But the gap between what they're expected to pay and what they actually have in resources is just way too wide and wider.

00:05:49:12 - 00:06:16:00
Allison Sesso
So while coverage is the best answer, good coverage that actually doesn't rely on them to pay out-of-pocket costs that they no way they can afford, is really an important, I think, element of this. And what we're seeing is a really big and surging under-insurance problem. And now I think increasingly we're going to see, more people with no insurance at all as well, because premiums are just way too high and out of reach for people.

00:06:16:02 - 00:06:39:13
Molly Smith
So this issue of coverage being the fundamental kind of, base protection against medical debt. And yet, you know, we're at a point in time where, you know, around 90% or so of Americans have health care coverage. So I'm wondering if you could just be a little more specific about where it is that we're really falling short in terms of that coverage?

00:06:39:13 - 00:06:48:03
Molly Smith
So, you know, the 10% who are uninsured, but then you just used this term, underinsured, and maybe you could just provide a little bit more color about what that looks like.

00:06:48:05 - 00:07:04:06
Eva Stahl
When we talk about under insurance, that's pretty much saying that somebody has insurance, but it's not really protecting them, right? So it feels useless, right. But really, I think from a granular perspective, it means that people are spending more than 10% of their income on health care expenses.

00:07:04:06 - 00:07:30:15
Eva Stahl
Right? So that tends to be the more formal definition. But increasingly, when people walk through the door of a hospital or emergency room, rather, and they have a $5,000 deductible, but their earnings in no way allow them to pay or meet that deductible, right? They're under-insured because their insurance is actually not serving them or protecting them. And so increasingly, as we see increased rates and take up around high deductible health plans, right,

00:07:30:15 - 00:07:58:12
Eva Stahl
and a move certainly in the proposed rule that came out this spring to increase access to catastrophic coverage with very high out-of-pocket costs, it means that people at low incomes, low and middle incomes that don't have that kind of cash on hand will be able to use their health insurance without accruing medical debt. So we think that that is just a move in the wrong direction, because hospitals then end up having to absorb those losses.

00:07:58:15 - 00:08:12:05
Molly Smith
You know, and I think that even some of the latest data from the federal government regarding enrollment in the marketplace plans for 2026 shows double digit increase in people who are enrolled in bronze plans, which

00:08:12:08 - 00:08:32:07
Molly Smith
in theory, are supposed to protect from catastrophic costs. But I think what we're hearing is that even those, you know, really high deductibles, coinsurance, you know, that comes along with some of those plans people just simply can't afford. So let's play this out. So an individual in your scenario comes to the hospital. They let's say they have one of these high deductible health plans.

00:08:32:07 - 00:08:57:06
Molly Smith
They're facing a $5,000 kind of, out of pocket, contribution towards their care. They can't they can't pay that bill. You know, kind of goes through the process. And now it's kind of qualifies as medical debt. You mentioned that you work with hospitals to help alleviate some of this medical debt where you can. Can you tell me a little bit more about what that process looks like to work with a hospital on this?

00:08:57:08 - 00:09:15:29
Allison Sesso
It's relatively similar to working with with an outsource collections entity, if you will, right. Usually it's after that you've done that already. So there's been attempts to collect, a recognition that there's not going to be an ability to collect, because again, the difference between what the person actually owes and what they have is pretty vast.

00:09:16:01 - 00:09:33:04
Allison Sesso
These are not people have been put on payment plans, but people who are really just not able to pay and aren't, aren't paying anything towards the bill. So that goes into the bad debt file that's been written off by the hospital, written down to zero. We go ahead and we take a look back. We go back seven years.

00:09:33:07 - 00:09:55:10
Allison Sesso
And we do an analysis sort of like presumptive eligibility, like this very similar approach. We identify based on income everyone that is 400% of poverty or below. It is by far the vast majority of the people in the file. If someone said is particularly large and it's 5% or more of their income and they're above that threshold, we will also flag them.

00:09:55:13 - 00:10:14:23
Allison Sesso
We will price the debt. The debt is priced similar to the market. So because these people are unable to pay, you know, in the for-profit debt buying market, the chances of you collecting is very low. So the pricing is very low. Working with us is not going to be a windfall for hospitals. They do get some revenue and that's great.

00:10:14:25 - 00:10:40:11
Allison Sesso
But it's pennies on the dollar. So we do pay pennies on the dollar for these debts. The younger the debt, the more we'll pay. But you know, in general, $1 of, of a donation to us, is $100 on average of medical debt. And, and this is my favorite, most important part is we notify all those patients that the debts have been relieved, and that they then feel confident and comfortable going back to the doctor to getting that, that care that they need.

00:10:40:11 - 00:10:58:19
Allison Sesso
Because we do know that that really is a big barrier to care, which really undermines sort of the purpose of the health care system and the hospitals in the first place. And I think that that's one of the main benefits that hospitals see in working with us is the fact that this removes that barrier to care that they want to see removed.

00:10:58:24 - 00:11:06:21
Molly Smith
There's so many things there that I want to circle back to. But before we go there, you talked about every dollar that you spend. Whose dollars are these?

00:11:06:24 - 00:11:30:15
Allison Sesso
Yeah. So it's a great combination. We have so many donors. There's churches that love working with us that we can focus the debt relief to their communities. It's one of the things that our, proprietary debt engine, as we call it, does, is it actually puts every dollar to a specific patient where they are so that we can restrict their donation, if you will, to the patients living in a specific community, etc..

00:11:30:18 - 00:11:51:20
Allison Sesso
We do get increasingly governments. It's probably to nobody's surprised that governments are increasingly knocking on our door and asking us to work with us. We have about almost 30 government contracts we've completed to date, or in the midst of. And Eva, maybe this is a great time to bring you in to talk a little bit about, these conversations that you are having with policymakers.

00:11:51:22 - 00:11:59:26
Molly Smith
What are some of the things that you are seeing, whether it's state or federal officials thinking about in terms of trying to mitigate medical debt?

00:11:59:29 - 00:12:10:00
Eva Stahl
Sure. So I would say that we really see it as a window of opportunity to talk more broadly around some of the more challenging issues that these patients just along their medical debt journey.

00:12:10:02 - 00:12:48:21
Eva Stahl
And most notably, I would say that you've seen a lot of activity in states, particularly over the last 2 to 3 years. So these are things like, suing people or applying leans or wage garnishment. And that often it comes to top of mind for legislatures. And there is a lot of bipartisan agreement, in that area of extraordinary collection actions, there are other, efforts to, put up guardrails around financial assistance policies, whether that's, applying some thresholds around who should get financial assistance, when they should get financial assistance and when they should be screened for financial assistance or move to debt collection.

00:12:48:24 - 00:13:15:01
Eva Stahl
And then I think we've seen not as much work in the area of health insurance coverage, which we'd like to see more. Unfortunately, a lot of steps are being taken to erode coverage, which will lead to more medical debt. So that of course is frustrating. And then I think, you know, you can't not talk about what is the, you know, most common talking point right now, which is around price transparency, which we're seeing a lot of efforts pop up in various states out of people.

00:13:15:01 - 00:13:26:24
Allison Sesso
I think, you know, states feeling like they want to take action on the cost of health care. And seeing that as a silver bullet, which we don't believe that it is, but it certainly is where there's some interest in movement.

00:13:26:27 - 00:13:37:16
Molly Smith
Yeah. And I think, you know, this point of financial assistance, clearly that is such an important function and benefit that hospitals when they can provide it to their patients, do.

00:13:37:16 - 00:14:02:15
Molly Smith
But I think that the one of the points that you're sort of alluding to is that it can't be the solution to medical debt, not least of which because there just simply isn't enough financial assistance in the country that could be made available to close some of these coverage gaps. You know, Eva, I don't know if you want to talk at all about some of the things you guys have thought about in terms of ways that we could improve coverage to try to prevent this upstream.

00:14:02:17 - 00:14:21:15
Eva Stahl
I mean, I would just say and reiterate, Molly, what you just said, which is financial assistance is not health coverage. And so we need to stop treating it like that because it's an important backstop. I think that, you know, momentum toward something that would really help people on the ground that are experiencing medical debt is to have access to affordable, comprehensive health coverage.

00:14:21:18 - 00:14:45:04
Eva Stahl
So I think for us that we're open to whatever structure that might look like. But where the people that we represent and what's important to us is that any approach or policy or cost containment activity or whatever the spectrum of portfolio of options is that it actually is having a meaningful impact on people's out-of-pocket costs without sacrificing access.

00:14:45:07 - 00:15:06:23
Molly Smith
Yeah. So complicated is definitely, unfortunately, a word that we can use to describe many aspects of the health care system. I do want to ask you really quickly a little bit about presumptive eligibility for financial assistance, because I think that is something that you've done a lot of thinking about. So, could you tell me a little bit about your work around presumptive eligibility and what you think hospital should be thinking about in that space?

00:15:06:26 - 00:15:44:12
Eva Stahl
Presumptive eligibility for financial assistance, not to be confused with presumptive eligibility for Medicaid, is really just screening people much earlier in the medical billing workflow. So closer toward the point of service, rather than sifting through people that might be moving toward debt collection. So by screening people early, then you have the opportunity to, estimate their income or use other sources to identify their income and then decide if they are eligible for your financial assistance program and swiftly move them into financial assistance, reducing administrative burden for yourself downstream.

00:15:44:14 - 00:16:17:04
Eva Stahl
Right. And also offering a contactless and paperless option for patients. So we also know from the deep work we've done around financial assistance, that many people never even fill out the financial assistance application. They feel overwhelmed by it, or they're under duress because they're in the middle of a health episode. So this tool really being introduced early on in the workflow, allows for patients to swiftly move into those categories and before the first bill is dropped. And then they can be notified that they have access to free care or discounted care.

00:16:17:06 - 00:16:18:26
Molly Smith
Regarding presumptive eligibility,

00:16:18:26 - 00:16:39:23
Molly Smith
also, I think for our hospital listeners out there who might be interested in exploring these programs, I do want to note that both the AHA and I'm aware Undue Medical have resources available, including things like case studies where you could learn more about what it takes to implement a presumptive eligibility program. Eva, Allison, thank you so much for your time today.

00:16:39:26 - 00:16:54:19
Molly Smith
I really appreciate all of the information you just provided. That really important, really important work, just been very eye opening. Also, to really get to work with your team and learn from you and these various discussions about what the solutions are here. So thank you.

00:16:54:21 - 00:17:03:02
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.

00:00:00:00 - 00:00:17:00
Tom Haederle
Welcome to Advancing Health. In this discussion, we learn more about the role of the chief medical and quality officer, an influential position in many hospitals and health systems that's been described as "a powerful cycle of leading people through change."

00:00:17:03 - 00:00:34:08
Chris DeRienzo, M.D.
I'm Dr. Chris DeRienzo, the chief physician executive for the American Hospital Association. And today, I am incredibly excited to be joined by Dr. Philip Chang. He serves as the chief medical and quality officer for Common Spirit Health. Phil, thank you so much for joining the series.

00:00:34:10 - 00:00:39:17
Phillip Chang, M.D.
Chris, delighted to be here. And good to catch up again.

00:00:39:19 - 00:00:52:22
Chris DeRienzo, M.D.
Likewise. Before we jump in, we've got a standard set of five questions. But, before we get into the questions, I always like to ask, tell us just a little bit first about yourself personally and about the health system that you serve. CommonSpirit Health.

00:00:52:24 - 00:01:30:19
Phillip Chang, M.D.
Absolutely. So, again, my name is Philip Chang. I'm the chief medical quality officer for CommonSpirit Health. And what I really love about CommonSpirit is the first and foremost it's mission driven. For me, if we were to geek out a little bit in the acute care side, for instance, we have small critical care access hospitals all the way to large academic hospitals with transplant and the whole works such as, you may know, Baylor St. Luke's, sort of the birthplace of in Houston, of advanced cardiac surgery and one of the premier liver transplant programs.

00:01:30:19 - 00:01:54:02
Phillip Chang, M.D.
But we also think that equally important to something as prestigious as Baylor St. Luke's, we have critical access hospitals where we anchor the community and the health they receive. So I'm very proud of that fact. My background, I'm a trauma surgeon by training. Sort of stumbled into quality safety. And the chief medical officer land.

00:01:54:04 - 00:02:18:01
Phillip Chang, M.D.
I think I think we'll talk about this a little more, but, I didn't grow up thinking "My gosh, I want to be a CMO." I sort of joined the medical staff and go, who's the CMO guy? But I gravitated towards that because I think many of us have, because the impact that we're able to make both is multifaceted and it's significant, right?

00:02:18:01 - 00:02:37:12
Phillip Chang, M.D.
And we think about patient impact, but we also think about medical staff impact. Now we call it physician well-being, which is also so important. But then the ability and the necessity to interface with the clinician administrators so that we can all work together - that that drew me to it.

00:02:37:15 - 00:02:56:21
Chris DeRienzo, M.D.
I was just going to get to that, actually, because you hit on something that is driving this, which effectively is so many of us wound up in leadership. It was less of an intentional journey. And, you know, we discovered in a paper that we wrote last fall that that effectively defines the leadership experience for college,

00:02:56:21 - 00:03:14:07
Chris DeRienzo, M.D.
you know, our vintage of chief physicians today. And it's the responsibility of folks like you and me and leaders and health systems across the country to try to make that difference. But in order to get there first, folks have to understand what job like yours actually look like. And yours is a pretty big one. So walk us through briefly a little bit,

00:03:14:14 - 00:03:20:28
Chris DeRienzo, M.D.
you know, your team at CommonSpirit. And what does a typical day look like for you as the chief medical and quality officer?

00:03:21:00 - 00:03:47:25
Phillip Chang, M.D.
We're looking at our team, and our team is obviously a number of very, very, strong experts in quality and safety, patient process improvement. But I also have a little liaison to interface with all of our chief medical officers. We have region, market, and then sites and how we work together. And the management structure is come in place.

00:03:47:25 - 00:04:14:17
Phillip Chang, M.D.
But I also have a, small but very mighty team of like minded clinicians, and they really push CommonSpirit to think through what the right clinical standards should be based on evidence based medicine. Obviously, we leverage all the experts within our organization. So that I like to think of as a continuous cycle. So we've got the data monitoring.

00:04:14:20 - 00:04:44:22
Phillip Chang, M.D.
We detect things that we believe we can improve on, bring it over to clinical standards, revise the standards, and then take it to the CMOs so they can help us execute. And that cycle continues. As you know, I'm fairly new at this role. It's now going on about ten months, nine, ten months. So I'm building some of these bridges and this collaborative sort of spirit. I like to think about not necessarily as the typical day. I'll tell you a funny story.

00:04:44:22 - 00:04:54:24
Phillip Chang, M.D.
So when I was operating a lot my kids knew if I'm there operating, you know, I'm at work. Now that's in the office, home office.

00:04:54:27 - 00:05:14:09
Chris DeRienzo, M.D.
Well sometimes you're there and sometimes you're in hospitals and sometimes you're in convention centers. I mean, I know your travel schedule looks, looks a lot like mine. But being ten months into the role, you know, I'm curious what you described as this very powerful cycle. And it becomes a flywheel of, of leading people through change.

00:05:14:12 - 00:05:20:06
Chris DeRienzo, M.D.
What is the biggest challenge that you're tasked with leading your teams through right now?

00:05:20:09 - 00:05:48:21
Phillip Chang, M.D.
Yeah, I think biggest challenge, and these are all fun challenges from my sort of vantage point. But we, we want to really think about how we redefine, how we measure what is high quality of care? But, you know, in addition to the traditional benchmarks that we all look after, right? There's, you know, CMS has health grades and the star ratings.

00:05:48:24 - 00:06:13:15
Phillip Chang, M.D.
I really think about what does it mean to CommonSpirit when we serve our community, what's right? And I'm not saying we're inventing new measures all the time and altogether. I'm saying that beyond the sort of overarching, okay, there are there are complications or there's, you know, patient safety indicators that we measure. What are other things that our patients might care about.

00:06:13:17 - 00:06:34:17
Phillip Chang, M.D.
And I know it is patient experience, but I also think it is a little bit of our promise to the patient to be able to deliver care at their level at their time, not our time. That paradigms got to shift, right? We used to be okay with the doctor will see you now. Now it's well, I'm ready for the doctor to come see me.

00:06:34:19 - 00:06:38:28
Phillip Chang, M.D.
And we really have to think that way because I think our patients deserve it and they expect it.

00:06:39:00 - 00:07:04:24
Chris DeRienzo, M.D.
One thing I've grown to appreciate deeply since I joined AHA about four years ago is that every health system serves a unique role in their communities. And the role that, you know, that you just described that a critical access hospital serves as an anchor in a very rural community, maybe only with a couple of patients inpatient every day  - is both the same and different from a role that, you know, a large center in Atlanta with a multi-tiered emergency department can serve.

00:07:04:26 - 00:07:43:20
Chris DeRienzo, M.D.
But defining that North Star and how you want your communities to experience it, that that's a big challenge. You describe a little bit of your pathway, to becoming a leader and becoming the CMQO at CommonSpirit. My path was similarly circuitous, as are many of our peers. And so I'm wondering if you can speak to either one person, or one experience that you didn't plan for, but that fundamentally helped you develop either the knowledge, the expertise or the experience based on that framework that we wrote about in the NEJM Catalyst that you needed to be successful doing what you do today.

00:07:43:23 - 00:08:12:07
Phillip Chang, M.D.
I was at the time an associate chief medical officer at University of Kentucky. I was, I was the perioperative medical director. The chief medical officer position opened up. It was primarily an internal search, or at least in the end all the candidates were internal. And we're going through a number of interview process, and I go, well, you know, I managed an operating room for five years, and if I could do that with that group of characters, I could do the hospital.

00:08:12:09 - 00:08:38:16
Phillip Chang, M.D.
And, I was asked a question during the during the process, and it was really about quality framed as why is the CMS, sort of quality measurement, why should we believe in it, you know, and, and tell us the nuances about it. And it took me aback and, fortunately I had the job despite me fumbling through that question, but I really doubled down.

00:08:38:19 - 00:09:14:05
Phillip Chang, M.D.
Okay. This is not something, at least at the time, that we have ever measured in the operating room. It was always a serious safety event, and it was all about volume through put, long time, turnover time, etc. so I really just put my head down and learned as much as I could and understand the nuances of it. And I think that's really helped me in my career, because a lot of what we're thinking about at CommonSpirit as well is how do we take a set of data's. You know, chief medical officer, chief quality officers, and I believe this is going around now.

00:09:14:12 - 00:09:42:13
Phillip Chang, M.D.
We're beginning to think of ourselves as sort of the CFO of quality measures, because we are presenting data in a coherent way to those who can directly impact and improve the unit that they are responsible for. And if you look at the CFOs charts, it's very clean, it's very standard because they have a shared common currency called US dollars.

00:09:42:16 - 00:10:05:04
Phillip Chang, M.D.
We are thinking through a lot of this in this, in this sort of fashion so that we're delivering usable information to our frontline, both ambulatory side, primary care service lines in the hospitals, obviously, and to say, okay, well, you are performing better than last year, but you're not performing fast enough compared to your peers inside CommonSpirit.

00:10:05:06 - 00:10:06:19
Phillip Chang, M.D.
So how can we help?

00:10:06:21 - 00:10:32:15
Chris DeRienzo, M.D.
You're all in. And you know, I love to geek out, Phil, and I love your analogy, in part because CFOs are accountable for the financial health of an institution, though they have very, very little direct ability to impact it. And to your point, chief medical officers and chief physicians have had the same kinds of accountability is often shared with other clinical leaders, but very, very rarely have all of the levers that they can directly pull to drive that change.

00:10:32:15 - 00:10:51:05
Chris DeRienzo, M.D.
Yeah. I'm curious, looking back at your career so far, is that the one thing that you wish that, that you had had learned earlier, or is there something else that that you wish you looking back at pre-associate CMO Phil, even, you know, trauma surgeon Phil. What one thing do you wish he knew that you know now?

00:10:51:08 - 00:11:14:21
Phillip Chang, M.D.
You know there's so many but I would say the one thing and to any sort of future CMOs is out there, take care of yourself. You know, for all of us, even though physicians are, you know, we take on a lot mentally and physically and, and, and I think it's not just for CMO, really, it's for any one of us who are giving ourselves, burning the candles for our patients.

00:11:14:27 - 00:11:20:15
Phillip Chang, M.D.
I think it's important to take a moment and spend some time with your family and take care of yourself.

00:11:20:18 - 00:11:39:29
Chris DeRienzo, M.D.
That is a spectacular note to end it on, Phil. And one that's again, I think when I speak to medical students and residents today, I tell them, you could not have picked a better time to be coming into medicine. First of all, we went through digital transformation over the last 25 years, and the electronic records that we're working in are much better than the digitized paper versions we started with.

00:11:40:05 - 00:11:56:11
Chris DeRienzo, M.D.
We're using AI enabled solutions at the points of physician and clinician experience, and we have a different appreciation for the negative axis of burnout and the positive axis of well-being. And crucially, folks like you are leading the way to do something about it.

00:11:56:13 - 00:12:04:24
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.

00:00:00:01 - 00:00:18:20
Tom Haederle
Welcome to Advancing Health. An aging population. Nursing shortages. Overcrowded emergency departments. These all add up to an intense demand on acute care hospitals, where inpatient days are projected to rise by 9% in the coming decade.

00:00:18:22 - 00:00:40:20
Tom Haederle
Hi everyone. I'm Tom Haederle, senior communication specialist with the American Hospital Association, and very pleased today to welcome Scott Edelman to our podcast. Scott is executive director of Burke Rehabilitation and he joins me today to talk about ways we can alleviate the growing stress on acute care hospitals.

00:00:40:23 - 00:00:43:24
Tom Haederle
Scott, thank you so much for joining me on Advancing Health today.

00:00:43:26 - 00:00:51:20
Scott Edelman
Oh, thank you so much. It’s just thrilled to be here. I listen to every podcast. And you know, they all serve a tremendous purpose.

00:00:51:22 - 00:01:09:05
Tom Haederle
Maybe we can frame this at the start by talking about acute care hospitals in general in terms of the demand for their resources right now and their ability to meet that demand. Where is the disconnect there? Are there more people that need their services than they really have the capability to deliver on?

00:01:09:08 - 00:01:33:03
Scott Edelman
So. let's just talk about the strategic role we play. The role we play is decompress acute care hospitals. We are a safety valve for acute care hospitals and improve the whole patient flow. One of the main contributors to the entire system right now is post-acute care. Where does someone go after a traumatic event? Burke, we have being 150 bed inpatient hospital,

00:01:33:06 - 00:02:02:03
Scott Edelman
we are seeing a shrinkage of IRF inpatient rehab facility beds in the tri-state area because of how busy the hospitals are, and they need to create capacity. So we become the safety valve. So it's a critical point that all acute hospitals that we have fantastic relationship with use us as a safety valve to remove and reduce the number of people in an emergency rooms that are in the hallway waiting for beds.

00:02:02:09 - 00:02:12:15
Scott Edelman
So to answer your question, I feel right now at 150 beds, we have enough beds. And when it becomes where we need more, we will petition the state for more.

00:02:12:18 - 00:02:21:25
Tom Haederle
So if a patient goes to an acute care hospital and is told we are really crowded, can't deal with you right now, they know to refer that patient to Burke?

00:02:21:27 - 00:02:47:12
Scott Edelman
So the rules to the game about being referred to an acute rehab hospital, you have to have a three day inpatient hospital stay. So a patient goes to White Plains Hospital for a traumatic event, a stroke. They're there 3 to 4 days, stabilized. Then they're referred to Burke, and then the journey continues. Another valve is a skilled nursing facility because they might be too sick for Burke or not sick enough.

00:02:47:18 - 00:02:51:21
Scott Edelman
But we're here to treat the patients in the right setting at the right time.

00:02:51:23 - 00:02:58:09
Tom Haederle
Doesn't Burke deal with some of the same capacity management and workforce challenges that many of the other hospitals do?

00:02:58:11 - 00:03:24:20
Scott Edelman
So right now, we don't have a capacity issue, right? So we're 150 bed hospital. Today's census is, I think, 142 so, you know, the myth that Burke is full or IRFs are full, I always tell the acute hospitals just refer the patient. Let us go through the clinicals. Let us go through the insurance approval. Right now because of the culture at Burke, we have one of the lowest turnover, employee turnover rates in the tri-state area.

00:03:24:22 - 00:03:42:04
Scott Edelman
We had made some changes to our compensation philosophy, to our retirement plan, to our medical plan, and we're seeing less than a 5% turnover. And as far as the Tri-State area that's seeing an RN crisis, we're almost fully staffed with RN's.

00:03:42:07 - 00:03:52:01
Tom Haederle
That is really impressive, because all we hear about today, of course, is workforce challenges. And it's so hard to recruit and train and keep people. But you're really, sounds like you're really doing it right.

00:03:52:04 - 00:04:14:08
Scott Edelman
Yeah. Tom, on the recruitment side, you know, we're always looking for the best and the brightest. You know, we want to hire a lot more physical and occupational therapists and speech because of our rapid and aggressive expansion plans. You know, we have 15 outpatient sites. I think the number is 50 that we need, but we're going to need a lot more qualified PTO, OT and speech therapists.

00:04:14:11 - 00:04:28:05
Scott Edelman
We have a great complement of physicians. We have one of the biggest teaching programs in the country. We have 20 residents and four fellows, and we train our physicians to go out and do amazing things.

00:04:28:07 - 00:04:47:13
Tom Haederle
Well, let's drill down into that a little bit. The hands on if I have the number right. I think I read that Burke Rehabilitation receives more than 200,000 patient visits each year in total across all of your facilities. I know you offer both hospital based rehabilitation and an extensive menu that you talked about at the beginning of our conversation.

00:04:47:21 - 00:04:58:14
Tom Haederle
An extensive menu of outpatient therapy programs. What is Burke doing differently in both of those settings to support and treat clinically complex cases more efficiently and more economically?

00:04:58:16 - 00:05:30:27
Scott Edelman
Great question. So on the inpatient side, in 2025, we treated 3,300 inpatients. On the outpatient, it was over 200,000. What we're doing differently is making sure that we add the right services and can support those services. And I'll give you an example. A year ago, we added inpatient dialysis to our programs here at Burke. Prior to that, if you need an inpatient rehab and you are on active dialysis, you wouldn't be able to [be] admitted.

00:05:30:29 - 00:05:51:28
Scott Edelman
Last year, we admitted over 100 patients that needed rehab and on dialysis. We've added TPN, total parental nutrition. We're looking ahead - disorders of consciousness. We want to make sure that if there's a neurological or traumatic event, the entire country knows that Burke is the right place to get better.

00:05:52:00 - 00:06:09:21
Tom Haederle
Well said. And it's just so impressive, the sheer breadth of the different services and therapies that you offer. Which kind of leads me to the next question. What kinds of care or medical procedures seem the most promising in terms of delivering care in new ways that that do put less stress on acute care hospitals?

00:06:09:24 - 00:06:40:18
Scott Edelman
Right. So what we're seeing is neurological diagnosis are on the uptick. We're seeing a lot more strokes, especially in young people. And a lot of hospitals aren't equipped to deal with stage one or trauma one. And what we're doing in our Montefiore Health System is making sure from any initial diagnosis that we have everything in the health system, from your first admission to your discharge to home for continuum of care and follow up.

00:06:40:20 - 00:07:02:19
Scott Edelman
We're seeing a lot less orthopedic admissions because they're going more to skilled nursing facilities or to home. And as a product of this, Tom, 90 of our 150 beds are focused on neurologic conditions, and we might have to expand that more of our 150 beds. We do a lot of transplant patients. We do a lot of cardiac.

00:07:02:19 - 00:07:26:17
Scott Edelman
We do pulmonary patients. Our patients' average length of stay is 14 to 15 days. Once they check in to our beautiful 61 acre campus, they really get settled in, understand what recovery is. Three hours plus hours of therapy per day. We also do ancillary therapy that's not really required of an acute rehab. We do neurological music therapy.

00:07:26:20 - 00:07:32:06
Scott Edelman
We do pet therapy. And this is all to help the patients get better.

00:07:32:09 - 00:07:47:07
Tom Haederle
It struck me that maybe one of the secrets to your success so far has been what patient needs are, where they're moving. As you pointed out, we're seeing growth in this area, some declines in that area. You're really just sort of tracking what's going on in health generally in this country, isn't it?

00:07:47:10 - 00:08:07:06
Scott Edelman
I think you hit the nail on the head, but it all starts with the patient. Everything we do is focused on how can we get the patient back to maximum functional recovery. When we look at a product or service, it doesn't necessarily have to have direct ROI, return on investment, but it has to speak to patient quality, patient safety.

00:08:07:10 - 00:08:28:04
Scott Edelman
How do we get patients back home, back to the life they love and how after discharge do we stay connected, right? So it's constant follow up in phone calls and being part of the Burke family. We actually, all patients that are admitted, we give a card on admission and says, “Welcome to the Burke family.” We want to keep everyone connected.

00:08:28:07 - 00:08:41:15
Scott Edelman
We’re nationally recognized, U.S. News and World Report. We're on Newsweek's list of best physical medicine rehab centers in the country. We're also - our employees voted us best places to work. That has to say volumes.

00:08:41:18 - 00:08:57:00
Tom Haederle
It really does. I guess I would conclude then, and you've touched on some of these things already, but what advice would you have for your peers out there? You know, in the in the health care field who look at Burke and say, “my gosh, you're just doing so many things right. We'd like to follow their example.” What would you share?

00:08:57:06 - 00:08:58:23
Tom Haederle
What are your thoughts about that?

00:08:58:25 - 00:09:23:14
Scott Edelman
So Tom, I would go twofold. On the clinical end, listen to the acute care hospitals challenges. Help with reducing length of stay. That is what acute hospitals want to hear. It's better for the patient. It's better for the hospital. It's better for everyone. In addition, don't be afraid to swing big and fall hard. Not everything is going to work, right?

00:09:23:18 - 00:09:44:09
Scott Edelman
When we did our strategic plan, we threw spaghetti at the wall and see what stuck. Right? And we had 53 initiatives. Not every one of them are going to be home runs, Grand Slams, but we're hoping some base hits there. And leadership is everything. I start and end my day on the patient units, talking to patients and families and employees.

00:09:44:12 - 00:10:00:09
Scott Edelman
Sometimes you could find me at the front desk welcoming visitors. You could find me at the admissions center welcoming new patients. It's really all about presence, visibility and being humble and caring about your organization and the people we serve.

00:10:00:11 - 00:10:13:18
Tom Haederle
That is just a great summation of everything that you guys are doing right. Thank you so much for what you do on behalf of your patients. Thank you for your time joining me on Advancing Health today. And best of luck in everything you're doing and good luck in the future.

00:10:13:20 - 00:10:16:12
Scott Edelman
Thank you. It's been my pleasure and thrill.

00:10:16:15 - 00:10:24:26
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.

00:00:00:09 - 00:00:21:15
Tom Haederle
Welcome to Advancing Health. March's Leadership Dialogue podcast explores how a collaboration between Rutgers Health and RWJ Barnabas Health is unleashing the power of AI - carefully and methodically - to improve patient safety and reduce clinician burnout.

00:00:21:18 - 00:00:44:23
Marc Boom, M.D.
I'm Marc Boom. I'm the president and CEO of Houston Methodist and the chair of the board of the American Hospital Association. So I want to continue this thread of our discussions this month. We're going to focus on innovation in patient safety. All hospitals and health systems we know put safe, high quality care first for their patients. And for decades now, we've been using innovation to improve outcomes.

00:00:44:23 - 00:01:06:27
Marc Boom, M.D.
And we know that we've seen really dramatic improvements. But we also know we can never be complacent. We need to continuously work to advance safety and quality, because we have a sacred responsibility to keep our patients safe at every single step, whether it's our physicians or nurses who are at the bedside or leadership shaping systemwide decisions. We always have the same goal, which is be safe, deliver safe care.

00:01:07:03 - 00:01:26:26
Marc Boom, M.D.
And innovation is a critically important tool in making that happen. And thankfully, we have a lot of new tools that help that happen. So, for example, small wearable devices that can monitor vital signs in real time and send updates directly to nurses, giving nurses more time at the patient's bedside, patients more time to recover and less sleep interruption.

00:01:26:29 - 00:01:53:17
Marc Boom, M.D.
Adopting innovative approaches is really, as I said, critically important, but it sometimes feels pretty challenging. And so I'm very excited to have a guest with me today who is expert and really doing exactly the kinds of things I was just talking about. So please join me in welcoming Amy Rockman. Amy is the director of the Artificial Intelligence Center of Excellence, which is a system wide collaborative initiative between RWJ Barnabas Health and Rutgers Health.

00:01:53:23 - 00:02:14:06
Marc Boom, M.D.
Amy, welcome. So, Amy, I want to begin by asking you to share a bit more about the partnership. I understand that your mission is to dedicate responsible development and integration of artificial intelligence to improve patient care and also a goal of reducing clinician burnout. So tell us a little bit about how it came to be and why it's notable for the work you're doing.

00:02:14:09 - 00:02:37:05
Amy Rockman
Thank you so much Dr. Boom. So we started this center and this group a few years back. So forward thinking leadership was really seeing the potential of these powerful AI tools. And so what we created is essentially an AI focused learning health system. So that's a system between our university and our health system in which research is informing practice and practice is

00:02:37:05 - 00:03:11:04
Amy Rockman
then again informing research. And so the idea between these two structures and bridging them together for the center is to bring those research experts, together with our everyday heroes, real clinicians in the health system, practicing medicine so that we can better inform the tools that we're introducing and how they can really drive change throughout our hospitals. So we brought together these two different sides of the health system and the university, and we did it with AI because it really requires this next level focus.

00:03:11:12 - 00:03:29:28
Amy Rockman
When you're bringing in and integrating these powerful artificial intelligence tools, there are so many things to think about from a safety perspective. There's safety and security, of course. Then there's validity and reliability of the tools. And that's with a lot of the technologies that you're bringing in. But AI introduces this whole new layer, since there's so much about it that we still don't understand.

00:03:30:00 - 00:03:53:14
Amy Rockman
So explainability for example, and transparency, interpretability of the tools. All of this we're still learning as AI is coming out. AI is looking at these huge sweeping statistical associations. And it's so incredibly powerful. It's able to do incredible speed, accuracy, so many changes that come with the tools, but we need to be able to understand them, validate them, evaluate them.

00:03:53:21 - 00:04:15:28
Amy Rockman
So there's actually a whole AI product lifecycle that we started to follow. And the Coalition for Health AI has really created this in detail, and it fit very closely with our work and how we think about how do we determine which area of our health system would most benefit from a tool right now? How do we then identify a tool?

00:04:16:00 - 00:04:40:13
Amy Rockman
Is it going to be homegrown internally, the university, or is it going to be vendor acquired and introduced? Then once we introduce it, there's a whole integration process of integrating it both technically into your infrastructure and into your clinical workflow. Then you need to monitor it, fully evaluate it, identify gaps, and the process restarts. So as we're following this AI lifecycle at each step there's a lot to think about.

00:04:40:14 - 00:04:57:10
Amy Rockman
And so it's not just so much that you need to think through. It's how interdisciplinary the work truly is. So how many people you really need on the team to be able to think through this in the most impactful way and in the safest way for our patients.

00:04:57:12 - 00:05:11:17
Marc Boom, M.D.
I hear that. It sounds like you're extremely intentional on how you're approaching this. I mean, you're not just sort of waiting for things to come to you. You're sitting there saying, what are the problems you want to solve? And how might we build something ourselves or go to look for a solution? Is that correct?

00:05:11:20 - 00:05:32:02
Amy Rockman
It's actually incredible how there's multiple different wavelengths coming together to make a lot of these decisions. And so a lot of it starts from our KPIs and drivers and risks and thinking through, you know, first we started introducing, for example, administrative tools as they were low, much lower risk. And there's still a lot of high reward even for patient safety, right?

00:05:32:02 - 00:05:50:03
Amy Rockman
If you're able to catch a lot of those documentation issues, you're able to address those. You have better documentation for your patient, you have a better patient history. So we introduce some of these low risk tools first and then started introducing the more high risk tools. We also we started introducing it by again looking at you know, those KPIs - 
00:05:50:03 - 00:06:11:19
Amy Rockman
those drivers, our verticals, our horizontals. But as we're doing that, we're building these interdisciplinary teams. And as we're doing that, we're starting to learn from the teams and really get a deeper understanding of how the AI tools we started to introduce are affecting the clinical environment. And so now we're getting a grassroots input as well. And so the decision making is really, really thoughtful.

00:06:11:25 - 00:06:17:00
Amy Rockman
It involves a great number of people and a great interdisciplinary effort.

00:06:17:03 - 00:06:34:04
Marc Boom, M.D.
So I knew a lot of people would like to follow your lead and do things on his own. Can you walk me through an example of something you've tackled, and how big is the core personnel versus interdisciplinary team versus getting to the grassroots? Would you walk me through kind of an example of something that's worked and how that has been put together.

00:06:34:06 - 00:06:53:06
Amy Rockman
We've introduced dozens of tools at this point, and some of them really have taken these incredible team efforts. So I'd love to give you an example of one. And so I think the AI enabled Clinical Deterioration Index is an off the shelf EPIC tool that we introduced into RJW Barnabas Health. And we introduced it starting with a small pilot.

00:06:53:08 - 00:07:20:15
Amy Rockman
And it required a large interdisciplinary team of providers, administrators and tech experts who are really working, coming together on a weekly basis at one point to really review, as you introduced this tool. And so let me share what the tool is. It is a early warning system for clinical deterioration, flagging a patient for potential deterioration 24 hours before the deterioration is expected.

00:07:20:17 - 00:07:41:00
Amy Rockman
And so we all know that earlier intervention in many of these cases is essential. And so it's really a game changer to be able to have that much warning and be able to make a change and actually impacts the care. And you can impact the care in different ways. In our health system, we chose to impact the care by moving that person to the ICU in advance.

00:07:41:00 - 00:07:58:06
Amy Rockman
Other health systems have made different choices. But you have a choice people can make, and that's what matters. You can really respond sooner. And so in order to do this, though, and to make it work, a lot of thought needed to go into it. Because even though these products, many of these products, they're off the shelf, they should be easily implemented.

00:07:58:08 - 00:08:17:14
Amy Rockman
They might be easily implemented into your technical infrastructure if you have EPICF, for example. But that does not necessarily mean they're easily implemented into your work streams and your workflow. And so when we first implemented it, there was so much to think about as far as who is getting the flag? It's a rapid response team. How are we adjusting this team?

00:08:17:14 - 00:08:38:03
Amy Rockman
How is that getting to the providers? And then we're looking at constantly the sensitivity and specificity because we're getting false warnings. You know, we want to ensure we're not missing warnings. And so how do you adjust the algorithm when the algorithm is a complete black box? Most of the algorithms that we get, even when they're data analytics focus, we don't know everything about it because it's proprietary.

00:08:38:05 - 00:09:00:28
Amy Rockman
But in AI it's truly a black box in many of these situations. We don't know all how it's getting to the answers that it is. And so we need to create our own interpretability layer or explainability layer, if you will, to really try to understand. And so when we did that, we started to stratify and we started to see that there are different proportions in our population and in the population to which this was initially trained.

00:09:01:00 - 00:09:20:21
Amy Rockman
And so we can make some adjustments. We made some adjustments for hospice, for example, when we removed some of the stratum and we found that we could adjust it and really get it to an ideal sensitivity and specificity. Where now the 24 hour flags were so meaningful that we saw an over 18% reduction in in-hospital mortality.

00:09:20:23 - 00:09:35:29
Marc Boom, M.D.
Wow. That's very impressive. So that really meets that noble goal of what you're talking about with this. So when I've read up on your center and I think you already give us an example, but give us a little more around an inside of a living laboratory. What do you mean by that exactly?

00:09:36:01 - 00:09:56:04
Amy Rockman
Yeah. So we're, you know, exploring the world, and we're doing this work right in that real world health care setting. And so if you think about how we're moving research from bench to bedside, most of the work really is focused on that bedside space of integrating directly into the health care system. But as I mentioned, the AI life cycle earlier, right,

00:09:56:04 - 00:10:17:12
Amy Rockman
comes back to the bench. It comes back to homegrown at certain points. But it's a living lab because we're doing a lot of this evaluating and studying and all of this work together, interdisciplinary work in that real world space. And so what ended up happening is that we brought these interdisciplinary teams together to integrate into the workflow.

00:10:17:16 - 00:10:39:10
Amy Rockman
We also brought the interdisciplinary teams together to evaluate afterward as part of that lifecycle. And as we started bringing these different expertise and areas together, naturally, a research hub formed. And so you started to have everyone that I just mentioned who's in the health system trying to integrate and look toward those dashboards and those analytics and really make adjustments in the clinical workflow.

00:10:39:12 - 00:10:58:22
Amy Rockman
And now we're also introducing engineers and computer scientists and statisticians who are going to look even a little bit deeper from a research perspective. Now that we've fine tuned to a certain degree, let's look even deeper and really study and validate and ensure that we really know what we saw isn't due to confounders. What we saw is real, right?

00:10:58:23 - 00:11:15:28
Amy Rockman
That 18% drop is a real value that we're seeing, and that we took off line into a lab and studied it further. Once we have findings from that, which currently for the 20th Ethical Deterioration Index, we have a publication here under review with NEJM AI where we looked into all of those indicators.

00:11:16:00 - 00:11:32:26
Marc Boom, M.D.
You're impacting patient care and patient safety, and at the same time studying it and having the discipline to really make sure that it is indeed your interventions that are doing that and then sharing it with the rest of the world. So we can all move the needle forward. I mean, it's really wonderful the way the way you all do that.

00:11:32:26 - 00:11:37:18
Marc Boom, M.D.
So give me a couple other examples of some things you're working on these days.

00:11:37:21 - 00:11:57:07
Amy Rockman
Yeah, there's so many different tools and technologies out there and there's so many different areas where we're really trying to expand and understand this technology further. So we also introduced some different platforms that are ambient AI, which is really popular right now because it makes such a difference in our ability to practice medicine with our patients.

00:11:57:07 - 00:12:01:12
Marc Boom, M.D.
Yeah. You can count me as a fan. I use it in my primary care clinic, I love it.

00:12:01:15 - 00:12:19:28
Amy Rockman
That's great. Exactly. If you can have a tool that can record your conversations so that you can interact with the patient directly, then it's a game changer. And now they're even, you know, they're advancing so rapidly, able to take those notes and actually input it into the system for you. Now your documentation is potentially even better than before.

00:12:20:01 - 00:12:37:29
Amy Rockman
But with all these tools as we're introducing them, you really do need to think through those strengths and limitations. That's where that living lab model really comes into play. Because as we're introducing this, you can't take human in the loop out of that one, right? So at the moment you have your, you know, your analytics, your bridge, all of your different vendor products

00:12:37:29 - 00:12:58:06
Amy Rockman
that can do this ambient technology. When you get your notes back in your practice, you need to review it, right? It's like you got a trainee, right? Who's working on it. And they're great and they're amazing. But if you don't review those notes fully, something will get missed potentially. And that impacts the patient safety ultimately. So making sure human in the loop is there, especially as we move toward more advanced AI types.

00:12:58:06 - 00:13:17:23
Amy Rockman
And so there's a couple different ways that we're doing that. One is that as we start to build these homegrown technologies, we're moving toward agenda AI. And so now the AI is not only generating content, the AI is taking autonomous action potentially. And so human in the loop has become more important than ever. And ensuring that where that's needed, the human the loop is still there.

00:13:18:00 - 00:13:41:00
Amy Rockman
And there isn't a problem of overreliance, right? And that we're trying to reduce bias in the algorithm by reviewing thoroughly from a traditional practice perspective as well. Then there's also, again, as mentioned earlier, the explainability and transparency of the products themselves. And so we are trying to understand better because some of these tools are so powerful that we're introducing them due to the changes that we're seeing.

00:13:41:00 - 00:14:00:06
Amy Rockman
So we see, you know, that 18% drop in mortality and it's worth introducing that tool, right? But we also want to know how the AI is getting to the answers that it is. And so we're starting to think through in our AI learning lab, how do we actually make these tools more explainable. And starting to work with the vendors on how explainable is this tool and can we get there?

00:14:00:09 - 00:14:10:03
Amy Rockman
Do we only have post-hoc methods or we're looking at heatmaps? Do we have ante-hoc methods where the AI can actually show me its work, the same way that you would ask a person, a trainee or resident to show theirs.

00:14:10:06 - 00:14:20:18
Marc Boom, M.D.
I often hear that part of what AI is doing these days, nobody really totally understands in terms of some of that black box. So that that I imagine could be a little bit of a challenge, what you described there.

00:14:20:21 - 00:14:21:01
Amy Rockman
That's right.

00:14:21:09 - 00:14:26:07
Marc Boom, M.D.
If you could tackle something, what's the big something you'd like to tackle coming up?

00:14:26:10 - 00:14:47:24
Amy Rockman
There are so many different opportunities here. And this area is moving so fast. Everything is moving so quickly at lightning speed, and there's so little that we know at the moment. Right? We don't know, for example, there's not a lot of information about how this impacts your ROI when you first go to choose a tool. There's not a ton of information about how it might affect your patient population as you go to pick this tool.

00:14:47:28 - 00:15:05:03
Amy Rockman
All of these, you know, you need to some degree take a leap of faith and you need to invest in these tools. But these tools are the way of the future. And as we've seen, they're so incredibly powerful. And so I think one thing that we're working on is how do we maximize the strengths of these powerful tools while minimizing the limitations?

00:15:05:08 - 00:15:25:15
Amy Rockman
Right? And in many ways, it's both dual about how it's designed and how it's used, right? So we're introducing, for example, AI chat bots or for using automated response technologies. Speaking to a chat bot would seem like it's more empathetic, for example. Right. Because it never tires, or speaking to a chat bot that seem less empathetic because it feels like a robot, right?

00:15:25:15 - 00:15:41:02
Amy Rockman
Right. How the tool is designed and how that tool is used make such a difference? Same with the elements, right? So Open Evidence was released not so long ago, and it's a super powerful large language model to be using the clinical setting. But it really depends what prompts are entered into that.

00:15:41:08 - 00:15:42:07
Marc Boom, M.D.
Yeah. Input matters.

00:15:42:07 - 00:15:59:08
Amy Rockman
Yeah, exactly. Prompt engineering is an entire study of itself now. And what kind of you're going to use - is it going to be one shot or zero shot? You know, is it going to be structured? So training the next generation of providers to understand how to use these tools properly is a huge area for us. And how do we think through that.

00:15:59:08 - 00:16:26:03
Amy Rockman
How do we essentially ensure to the best of our ability that the tools are being used in a way that does minimize bias, that does minimize over reliance? MIT just came out with your Brain on ChatGPT study showing what a big cognitive debt you're seeing if there is overreliance on the tool. And so we're trying to avoid that by now educating the next generation on how to use this. By educating decisions that are in the hospital at this moment and are starting to get these tools.

00:16:26:03 - 00:16:44:18
Amy Rockman
And I will say that we've managed through this center, through this structure to drum up a lot of excitement about these tools. So we're seeing a lot of the providers are coming to us eager to get more and more and more of the tools. And so that's great. That's a great place to be. People are very interested in working on these interdisciplinary teams together, which is really important.

00:16:44:21 - 00:17:00:19
Amy Rockman
But so the key now is to ensure that every time we adopt one of these tools, we've thought through the process, we've thought through that AI life cycle. We've thought through how the providers are going to interact with it. How are you going to use it? We've thought through how is it designed. We have a sense of what the bias is for this tool.

00:17:00:22 - 00:17:22:24
Amy Rockman
Do we have a sense of what the explainability level is for this tool? And so we know to the best of our ability what we're acquiring and integrating into our health system. And we have an expectation of this powerful tool. What will be the change, the transformation we'll see? And then the super fun part for me with my epidemiology background is we're monitoring it and we're ensuring that that really happens.

00:17:22:26 - 00:17:38:12
Marc Boom, M.D.
Again, I'll say I love how structured and thoughtful you are and how you're liking it all of that, and now education as well. I mean, I know you have many residents. This is bringing up the next generation of physician residents, as well as obviously nurse trainees and others, which is great. Well, let me ask you one closing word.

00:17:38:12 - 00:17:55:21
Marc Boom, M.D.
If you had some closing thoughts to the colleagues who are watching this, you know, you all have a very impressive center. Not everybody is going to be quite as far along, but we're all on this very fast moving train. What would you say to those individuals about how to embrace change, how to invest in innovative technologies? What would be some key messages?

00:17:55:24 - 00:18:26:21
Amy Rockman
Absolutely. So communication is key and being honest, showing the excitement and potential of these transformative applications. But being practical about it, it's not always going to be easy. You're not going to see that transformation potential right away. I think some of the ambient technology is a great example of that. It also required a lot of tweaking before people felt like the output was to the same level as their own notes, and that they would take it without drafting, taking more time than if you just had written them on your own.

00:18:26:23 - 00:18:48:19
Amy Rockman
Right. So being really practical about that, but being supportive and excited. This is the first generation of these tools, right? We really put the investment into this. You'll see, as they continue to grow just more and more powerful to support our workforce. And that's a key piece of communication too, and the messaging is that AI is here to support and enhance our workforce, not to replace it.

00:18:48:21 - 00:19:04:03
Amy Rockman
And it has been enhancing it. You can tell it as you talk to a lot of the providers who are using it, they're excited. It's meaningful. There's change happening that makes them feel like they can have the joy of work back again. It makes them feel like they can really take care of their patients in a way that felt like it was gone for a while.

00:19:04:09 - 00:19:09:07
Amy Rockman
And these tools are there to make that difference in medicine.

00:19:09:09 - 00:19:31:12
Marc Boom, M.D.
I love that. You know, at Houston Methodist, we have kind of two overarching principles around new innovation in the work we do. And one is obsessive focus on the needs of our patients, the communities we serve. And then a close second is improve the lives of the people caring for those patients and connect them to the things human beings can do, you know, take away some of the drudgery and other things that prevent it.

00:19:31:13 - 00:19:51:12
Marc Boom, M.D.
Sounds like we're on a very similar page. So anyway, thank you, Amy, for your time today. What you're doing is really, really very impressive, very inspiring. And I know you all are already making a difference in people's lives. I can't even imagine as this promulgates across the field profession, you know, we all share that goal of keeping patients safe, keeping people at the center ready to do so.

00:19:51:12 - 00:20:01:09
Marc Boom, M.D.
Thank you again. Thank you, everybody, for finding time to listen. And I will be back in another month for another Leadership Dialog conversation. Thanks so much.

00:20:01:12 - 00:20:09:23
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.