Advancing Health Podcast

00;00;00;19 - 00;00;22;29
Tom Haederle
Imagine getting an email or a phone call from a total stranger with this message: "I have your medical information and I know that you had surgery on this date." Pretty scary stuff. We've seen a sharp uptick this year in the brutal tactics of cybercriminals, who are now directly contacting and threatening patients during ransomware attacks, pushing the boundaries as never before.

00;00;23;01 - 00;00;48;26
Tom Haederle
As always, the bad guys demand payment and if a victim resists, they may threaten to publish sensitive photos online, take advantage of stolen patient records, or even send phony incident reports to the local police to trigger a harrowing visit from a SWAT team. Yes, that's happened too.

00;00;50;06 - 00;01;20;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA communications, John Riggi, AHA’s national advisor for cybersecurity and risk talks over with two experts how this latest despicable tactic in the arsenal of cybercriminals should be managed starting with updating incident response plans. As John notes, if there were ever any question that the intent of these gangs was to harm patients, it is now clear that is their fundamental intent.

00;01;20;22 - 00;01;45;21
John Riggi
Hello everyone, and thanks for joining today. I'm John Riggi your national advisor for cybersecurity and risk at the American Hospital Association. Today we'll discuss a new cybersecurity trend. Cybersecurity criminals are contacting and threatening patients during ransomware attacks. And there is a need to update incident response plans to adjust for the uptick in this despicable criminal behavior.

00;01;45;24 - 00;02;31;11
John Riggi
Unfortunately, last year was the worst year on record for data theft attacks and ransomware attacks. Foreign-based bad guys, primarily Russian ransomware gangs, are continuing to evolve their despicable tactics to increase the likelihood of payment by victims, including calling victims directly based on information in their stolen health care records, demanding payments from them directly, and/or conducting swatting attacks, dispatching local police to fake armed incidents at those homes of patients, which is very, very dangerous for the patients and responding law enforcement, and also threatening to publish very sensitive photos of patients online.

00;02;31;13 - 00;02;56;11
John Riggi
So, as you can see, they are pushing the boundaries directly, threatening patients. If there was ever any question that the intent of these gangs was to harm patients, it is clear now that is their fundamental intent. Today I'm joined with Jake Milstein, chief marketing officer at Critical Insight, and Johnathen Inskeep who was the former CIO at Caribou Medical Center.

00;02;56;13 - 00;02;59;12
John Riggi
Jake and Johnathen, thanks for joining the podcast.

00;02;59;15 - 00;03;00;14
Jake Milstein
Thanks for having us, John.

00;03;00;14 - 00;03;01;21
Johnathen Inskeep
Yeah, thank you.

00;03;01;23 - 00;03;12;00
John Riggi
Jake and Johnathen. Let's jump right in. Can you help our listeners understand what cybercriminals are doing during ransomware attacks and how they affect patients?

00;03;12;00 - 00;03;38;09
Jake Milstein
I think you, you know, you hit on some of the attacks that just occurred, but I want to go back actually a couple of years here, and recognize that this has been a criminal tactic in sort of a spotty way. You know, you go back 3 or 4 years and there was an attack on a school district in Texas, and that attack on the school district in Texas, the school district, I don't know, they either didn't pay quickly or decided not to pay.

00;03;38;11 - 00;04;02;20
Jake Milstein
And the criminals started calling parents and emailing parents and saying, oh, I know your son's name. I know your daughter's name. And of course, the parents started calling the school district. We saw it in health care a couple of years ago, but it was kind of spotty. The big change here is at the end of 2023, we saw it several times.

00;04;02;20 - 00;04;27;10
Jake Milstein
We didn't just see it one time. We saw it at a health care organization in Oklahoma, and then we saw it at Fred Hutch Cancer Care Center, which you talked about, which is in Seattle. And in the Fred Hutch case, the criminals went so far as to threaten these swatting attacks. The swatting attacks are when the criminals would, you know, they threatened to call 911 and say, you know, this person has kidnaped me and I'm in the basement.

00;04;27;10 - 00;04;48;27
Jake Milstein
Send the SWAT team, right? So the SWAT team would come. And you know, how might it affect patients? I mean, wow, can you imagine getting an email as a patient? You know nothing about cybercrime. And all of a sudden, you know, somebody emails you and says, I have your medical information and I know that you had surgery on this date.

00;04;48;29 - 00;04;52;05
Jake Milstein
You know, I mean, that's pretty scary stuff, right, Jonathen?

00;04;52;07 - 00;05;11;17
Johnathen Inskeep
Oh, absolutely. I just try to put myself in the shoes of, like the patient. If you're receiving those phone calls, you start to wonder. It's like, is this really happening to me? And then you start like, how did you get my information? And, you know, they point back to the hospital and you immediately lose trust and value in the health care service provider that you were going to.

00;05;11;18 - 00;05;21;13
Johnathen Inskeep
It's just devastating. And then a lot of people, it's like, I don't really have any problems, but I don't want any problems that I've had shared with anybody. So it really just leaves you vulnerable.

00;05;21;15 - 00;05;42;15
John Riggi
Just think about it from the patient perspective. As you said, you're getting these calls. And of course, the first thing that patients are going to do is call the hospital. Now the CEO is getting calls. . . . word that these patients are being directly extorted. Imagine again the pressure on the hospitals. Nobody wants to pay ransom. And again, of course, we at the AHA strongly discourage the payment of ransom.

00;05;42;15 - 00;06;06;07
John Riggi
It will only encourage these groups to continue to conduct these attacks and fund them for perhaps other, more serious crimes as well. But you know what I was confused about, I should say, wondering about in this latest, highly publicized case when they were contacting patients directly for demanding a ransom payment from them, they were only asking $50 each.

00;06;06;10 - 00;06;08;13
John Riggi
I don't get that. That's a lot of work.

00;06;08;14 - 00;06;28;01
Jake Milstein
You know, it's super interesting. It's super interesting. And, you know, I've seen a debate and actually been part of a debate on this. So folks know what this is. And I might have the exact figures wrong here, but basically what the criminals said was pay us $3 and we'll let you know if we have your records. You can see your record for $3.

00;06;28;01 - 00;06;50;23
Jake Milstein
And if you want us not to expose your record publicly, then it's $50. And so some people have said that really this is just a pressure tactic that I personally think that that is more advanced than a pressure tactic. And I actually think that the bad guy - this is just a new revenue stream for that. It is the what is the triple extortion?

00;06;50;23 - 00;07;09;13
Jake Milstein
The quadruple extortion. I think you know, this is the you know, we're going to tier your payments. I actually think it's a revenue stream because, you know, you know, criminals are you know, they're good at math. We know this. You know, let's say you have what, 100,000 patients and everyone pays you $50,000. I mean, you know, it's real money.

0;07;09;15 - 00;07;33;00
John Riggi
Right? And, you know, as I'm thinking this through, ransomware as a service has proliferated dramatically the past couple of years. And people are assuming, wow, if they're demanding millions from the hospital victim, why would they go after patients for $50? Well, maybe this is a separate department within the ransomware as a service. Said, you guys can have the patient aspect of this.

00;07;33;03 - 00;07;54;12
John Riggi
There's others we know that are making money off stolen credentials. So we have the initial access brokers. This is truly a very efficient underground economy all around ransomware where there are multiple components making money off different aspects of the attack. So this is my theory only there's probably some groups said, hey, whatever you can collect from the patients you keep.

00;07;54;15 - 00;07;58;11
John Riggi
And that helps apply pressure to the victim organization as well.

00;07;58;16 - 00;08;32;17
Jake Milstein
Yeah. I mean, rewinding back to that Texas attack on the school district. There was no demand for money from the parents. That was strictly a hey, call the school district and, you know, get them to give us $5 million or whatever the ransom was. This new thing is different. Now, I will also say there's another case in, I believe, the Los Angeles area - plastic surgeon, bad guys got the pictures and both extorted the plastic surgery clinic and demanded $500 per patient from the patients.

00;08;32;19 - 00;08;47;01
Jake Milstein
Now, I will say that is an actual moneymaking scheme. And, John, if you're right, you know, what we're looking at here is these criminal enterprises, and they are enterprises are now developing a B2B wing and a B2C wing. Like this is ridiculous. But that's what we're starting to see here.

00;08;47;03 - 00;09;07;26
Johnathen Inskeep
Yeah. The other thing I would say, too, is when you have a victim called like that, what are they preying upon? The reaction of the victim, right? So as the victim...oh my gosh, they have my information. I'm going to pay the $3. Well, that's a great way for that victim to be victimized again, because you put in through their paywall your information to be able to pay that.

00;09;07;26 - 00;09;22;05
Johnathen Inskeep
Now they have your financial information to take advantage of your debit card, right? So a great way to snag the person once again, unfortunately, it's just a great way to prey upon a person, which is just unthinkable.

00;09;22;08 - 00;09;25;01
Jake Milstein
Are you saying the criminals don't accept cash, Johnathen?

00;09;25;04 - 00;09;29;10
Johnathen Inskeep
I've never got one to accept cash. I would try to get him to do monopoly money once, but he told me no.

00;09;29;12 - 00;09;30;05
Jake Milstein

00;09;30;08 - 00;09;58;00
John Riggi
Wire transfers? No, that's no good. Digital currency? I recently made a provocative comment on social media, in a sense. And I said that digital currency is the root of all cybercrime. And ultimately, if it wasn't for crypto digital currency, it would be much more difficult for bad guys to conceal, transfer, anonymize the proceeds of crime and certainly would take a massive reduction.

00;09;58;00 - 00;10;04;12
Jake Milstein
Yeah. I mean, I think that that is definitely true. I'm not sure I agree that it's the root of it.

00;10;04;12 - 00;10;05;07
John Riggi
They're meant to be thought-provoking.

00;10;05;07 - 00;10;25;20
Jake Milstein
I understand. You know what, I don't know if it's the root of it, but I do think that it brings up an interesting question for folks like it is. I understand deeply that the AHA tells people not to pay a ransom. I don't think people should pay a ransom. Some organizations make the business decision to pay the ransom.

00;10;25;23 - 00;10;47;14
Jake Milstein
And one of the things that folks need to do in building an incident response plan is to come up with, are we going to pay the ransom? Under what duress would we pay the ransom? Would we never pay the ransom? And I will say, if you come to the possibility that you might pay the ransom, think about how you're going to do that before you're in this situation.

00;10;47;17 - 00;11;02;23
Jake Milstein
If you're going to have to buy Bitcoin, how are you going to do that? If you're going to use a firm, how are you going to do that? Again, do not think anybody should pay the ransom. But this is all part of it. I will tell folks, I was in a fascinating tabletop with this guy, John Riggi, who's joining me on this podcast.

00;11;02;25 - 00;11;18;12
Jake Milstein
There was, hospital exec and the hospital exec said, I'm never going to pay the ransom. I'm never going to pay the ransom. John, I don't know if you remember this. And John got to, you know, all your systems are shut down. No, I'm not going to pay the ransom. You're on divert. I'm not going to pay the ransom. 00;11;18;16 - 00;11;26;08
Jake Milstein
And then John said, the criminals have started calling your patients. And this hospital exec said, okay, I'm paying the ransom.

00;11;26;10 - 00;11;46;04
John Riggi
Exactly right. There is a boundary. They know what the pressure limits are to extort these payments. These are equivalent of violent crime extortions. So you know my background, 30 years in the FBI - dealt with a lot of bad guys, including Russian organized crime bad guys, and terrorists as well. They know what the pressure points are, apply pressure to get whatever their objective is.

00;11;46;04 - 00;12;08;10
John Riggi
They claim these are financially motivated crimes, the bad guys, but really financially motivated, under threat of harm to patients, under threat of harm to patients again is why we always say these are threat to life crimes. There is a whole network now. Again, I said a whole industry around how do we creatively find ways to extort money out of the victims?

00;12;08;10 - 00;12;37;03
John Riggi
We extort the patients. We also have data leak sites that if the organization, the victim organization has not reported the attack publicly, the ransomware guys publicize it on their public web leak sites, notifying the government. So they have all types of issues there. Again, trying to maximize pressure on the victim to pay. Again, we discourage payment. We know that ultimately, even the FBI says this is a business decision.

00;12;37;06 - 00;13;01;11
John Riggi
And if patient safety is at risk, that is a consideration of whether to pay or not. Now, the best way is you talked about being prepared. Cyber insurance companies now actually generally come with their cyber policy methodology is to pay the ransom in digital currency. They actually have ransomware negotiators. There's a whole industry on the good side that's developed around ransomware.

00;13;01;14 - 00;13;22;12
John Riggi
So all these things have to be thought out. But ultimately we say, look, just don't get yourself into that position if at all possible. Offline secure backups that are immutable, that you can use to restore, know where your data is. But ultimately, if your data is encrypted, the bad guys can't use it. Even if they get to it, they can't use it.

00;13;22;14 - 00;13;48;28
John Riggi
Quite frankly, I think that there is not enough attention being focused on data mapping and encrypting the data. All these layers of technologies, millions and millions we spend are around protecting data, ultimately to protect patients. So let's start at the bullseye. Let's encrypt the data at rest and in transit. Even the government says if the bad guys get to your data and it's not readable, you don't even have to report it.

00;13;49;00 - 00;14;10;15
John Riggi
So again, let's start with some of the fundamentals and the basics. So speaking of vulnerabilities right? Which lead to these attacks for both of you. So are there common vulnerabilities in hospital systems that you see that cybercriminals, especially ransomware groups, are most frequently exploiting? Maybe Johnathen, you could take that.

00;14;10;18 - 00;14;31;04
Johnathen Inskeep
I think they take advantage of obviously the patient care aspect, right? But what they're finding is a lot of these real hospitals and stuff like that, maybe lack a little bit of direction and don't have the securities in place to be able to handle those type of attacks. And then what happens is that can either come in through a third party.

00;14;31;06 - 00;14;46;09
Johnathen Inskeep
There's a lot of risks that's there. There's a lot on the plate for the hospital, and it just puts them as a prime target, right? They've got all the medical record information there on the patient. They know they can hit a bunch of people all at once. And so it's actually kind of a scary scenario. You're just you were talking about targets.

00;14;46;09 - 00;15;00;25
Johnathen Inskeep
Hospitals are the prime target. And so to try and find a way to curb that, I agree with the encryption process. I also think that you should be following a security framework to help narrow that gap, to be able to identify risk. Yeah. Ultimately you're always going to be a target for the bad guys to hit.

00;15;00;28 - 00;15;23;21
Jake Milstein
And I think there's a basic unfairness here. There's a basic unfairness in that you can do everything that you should do to build up your defenses, and yet the bad guys only need to be able to get in one way. And when you look at that and you look at how they're getting in, it used to be the number one way bad guys got into hospitals was through email.

00;15;23;23 - 00;15;58;01
Jake Milstein
That's no longer the case. So when you look at the HHS data, you know, the number one way that they're getting in is through vulnerabilities and through third parties. What's a vulnerability? So a vulnerability is every time Chrome tells you to update or your iPhone tells you to update or whatever, because there's a vulnerability. If you look at all of the devices, if you look at all of the software a hospital is using, all of them, there are vulnerabilities that need to be patched, and those patches need to be treated as urgent incidents so that bad guys can't get in.

00;15;58;03 - 00;16;21;13
Johnathen Inskeep
And I would add to that, the other thing that's really makes it difficult is you to patch your home computer pretty easy-peasy, right? For some of these hospital systems, for them to be able to implement a patch, whether it's an EHR patch or even just a simple Microsoft patch, it takes a lot of coordination to make sure that that patch doesn't have a profound effect on other operating systems, right?

00;16;21;13 - 00;16;39;13
Johnathen Inskeep
So there's a lot of times that those patching processes take proper planning, like how do we have time to be able to have downtime for the network to be able to restart and implement the patch, do a little bit of testing. And so when they drop, unfortunately, we can't just immediately go run and patch it and come up all good, right?

00;16;39;20 - 00;16;44;11
Johnathen Inskeep
There's a little pre-planning that has to take place which leaves you exposed.

00;16;44;13 - 00;17;16;09
Jake Milstein
And you know we mentioned third party. So I want to break third party vulnerabilities into two buckets. Bucket number one is third party is holding patient data or employee data. And bad guys get it by getting into a third party system. And that's the data theft. The other is the third party has a door into the hospital network, and then the bad guy uses that door to get into the hospital network, and then is able to launch a ransomware attack on the hospital network.

00;17;16;09 - 00;17;22;02
Jake Milstein
Those are two different kinds of third party vulnerabilities, and both are getting bigger and bigger.

00;17;22;03 - 00;17;52;21
John Riggi
Yeah, I agree, and is actually even a couple more. So not only do they hold the data or they are the electronic pathway in because how does that all that data move through electronic transmission, but also that the third party themselves maybe become victim of a ransomware attack, which then disrupts hospital operations? You have some mission critical or as I often say, life critical third party that immediate patient care depends on - is then struck with ransomware.

00;17;52;21 - 00;18;14;21
John Riggi
And the bad guys are strategic and intentional. They know if we hit this particular third party, it will disrupt care in 100 health systems, placing massive pressure on that third party to pay tens of millions of dollars in ransom, tens of millions of dollars in ransom. So and then there's the other third party risk of their technology risk, third party technology that has vulnerabilities in it.

00;18;14;21 - 00;18;21;19
John Riggi
Right? We don't write our own operating system code very often I would assume. We don't build our own medical devices. We rely on third parties.

00;18;21;21 - 00;18;41;05
Johnathen Inskeep
Yeah, absolutely. I can't remember the last time I broke down the code to build something, right? So we have all these dependencies. And I think one of the biggest things centered around that is proper risk identification, right? If you take a third party on for operational purposes, how much do you know about either of that product? Where was that product made, manufactured?

00;18;41;05 - 00;19;01;02
Johnathen Inskeep
What's the risk of it coming into your environment and third parties you work with? Like what's the obligation? How strong is your business associate agreement with that third party vendor? Did you identify things that are related to risk in your environment that you're talking about in your business social agreement? Because I tell you, if you don't have it listed, they're not going to be held accountable for it.

00;19;01;05 - 00;19;23;02
John Riggi
Quite frankly. You know, we don't want to alarm folks too much here, but really it's third party risk management and fourth party. So, who are the subcontractors for those third parties? That should be part of the evaluation. Where are they based? Are they based in the United States or overseas? China's ofering a lot of good deals these days to get into our health care sector.

00;19;23;09 - 00;19;26;26
John Riggi
Unbelievably good deals, related to the Chinese government.

00;19;26;26 - 00;19;28;24
Jake Milstein
We saying that deals are too good?

00;19;28;27 - 00;19;53;23
John Riggi
They're too good to be true, right? As we always say. So take a close look at that. What type of technology are they using? Is that technology vulnerable? Third and fourth party risks? Some of it you can control, some of it you can't. But that's where we have to be ready with that incident response plan that not only takes into account if you are the direct victim, but what about if our mission critical third parties are attacked?

00;19;53;28 - 00;20;05;14
John Riggi
How does that disrupt our operations, disrupt and delay patient care, risking patient safety. And the IT department has no control. Right, Johnathen, your third party gets hit. What do you what can you do about that?

00;20;05;21 - 00;20;23;26
Johnathen Inskeep
No control because you have to function. I think one of the most interesting things was this like our EMR vendor that we had - American company, right? However, when we went to do updates at night with the HR vendor, they were people from India that we worked with. And what was interesting to us is we had a geo blocked on India.

00;20;23;29 - 00;20;41;28
Johnathen Inskeep
So they had to call me and say, hey, we can't connect to your system. Can you make an allowance on your firewall? And that wasn't a risk that we thought we would run into because we're working with the American company that's here in America, and they outsourced their technical deployment out to India. And it was just this astonishing.

0;20;41;28 - 00;20;47;26
Johnathen Inskeep
Like we didn't factor that in when we committed to the HR program. And it's things that hindsight we should have looked at.

00;20;47;27 - 00;20;53;03
John Riggi
Right. And of course, the time you discover that is in the midst of a crisis.

00;20;53;05 - 00;20;54;05
Johnathen Inskeep
Absolutely.

00;20;54;07 - 00;21;26;15
John Riggi
You know, I do a lot of media. Talk to a lot of reporters. I explained to them in these terms, hey, these are foreign bad guys being sheltered by hostile nation-states, attacking us, putting us at risk. They're very sympathetic. They understand and generally do want us want to help by promoting good, accurate information. So just as when we face the threat of terrorism, the media was very helpful to distribute alerts to really show what the impact of these threats are and help folks prevent attacks.

00;21;26;17 - 00;21;54;17
John Riggi
Thank you both, Johnathen and Jake, for sharing your thoughts and insights and joining this podcast with us today. For AHA members, for our listeners, if you would like to learn more about AHA's cybersecurity programs, please visit aha.org/cybersecurity. This is been John Riggi, your national advisor for Cybersecurity and Risk.

00;21;54;20 - 00;21;57;23
John Riggi
Stay safe.

00;21;57;25 - 00;22;06;07
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;20 - 00;00;35;04
Tom Haederle
Federal rules restrict an airline pilot to a flight maximum of eight hours if he or she is piloting the aircraft solo. This is because the human brain operates at peak performance for only so long. Minds and bodies tire and require rest. One term for handling highly technical and information heavy tasks is cognitive load, a measure for the mental effort required for processing whatever you're dealing with at the time.

00;00;35;06 - 00;01;06;03
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Clinicians bring all of their skill, expertise and mental firepower to bear on great patient care. But there are many aspects of care today that can derail or compete for their attention. In this Safety Speaker Series podcast, we explore ways to ease the cognitive load that many physicians and other caregivers face to allow them to focus on the most important job of treating patients.

00;01;06;05 - 00;01;19;16
Tom Haederle
As today's guest, a retired professor of psychiatry at the University of Rochester Medical Center puts it. Brainpower is a finite resource. We have to budget the expertise like we would money and allocate it in the right places.

00;01;19;19 - 00;01;42;25
Elisa Arespacochaga
Thanks, Tom. I’m Elisa Arespacochaga, vice president of clinical affairs and workforce, and today I'm really excited to be joined by Dr. Michael Privitera, a professor emeritus at the University of Rochester Medical Center who is a leading researcher on the intersection of health care quality and safety with well-being. And a good friend. Today's podcast is part of AHA's Patient Safety Initiatives Safety Speaks series.

00;01;42;27 - 00;01;48;08
Elisa Arespacochaga
So, Mike, to get us started, tell me just a little bit about you and how you came to this work.

00;01;48;11 - 00;02;10;11
Michael Privitera, M.D.
Sure. Absolutely. Elisa, good to see you. Basically, from the point of view, I've seen many changes in health care and how we tend to get overwhelmed with the information explosion that we have and a lot of expectations, but without the adequate resources really to deal with them and the overload, basically. So trying to look for a science that would help us with give us language.

00;02;10;17 - 00;02;18;10
Michael Privitera, M.D.
That's kind of how I came across human factors and ergonomics. And one of the things you talk about today is cognitive load.

00;02;18;12 - 00;02;36;19
Elisa Arespacochaga
Well, let's get into it. Let's start with that. Can you explain to me, because I didn't understand it before I heard you explain it. What do you mean by cognitive load and why is it particularly relevant for clinicians? You're a retired physician now. But why is this so important, particularly for our clinical colleagues?

00;02;36;21 - 00;02;58;14
Michael Privitera, M.D.
Sure. Cognitive load is basically it's kind of a measurement of mental effort that's required in processing whatever it is you're dealing with at the time. So it could be very simple to very complex. If you're in medicine and nursing it tends to get very complex sometimes. So that would have a higher cognitive load than something that's very simple to deal with.

00;02;58;17 - 00;03;19;06
Michael Privitera, M.D.
And this all gets processed through a part of our brain called the working memory. And we only have kind of a short time to deal with it. So our working memory only gives us about 15 to 30s to actually process something. So we easily can get over the limit to overload. And we've found workarounds around this, but that's why it becomes so important

00;03;19;06 - 00;03;35;10
Michael Privitera, M.D.
so we don't make a mistake. If your profession has really high cognitive load per se, it's your higher risk for burnout. In a particular task, if the cognitive load is measured to be too high, the research shows that you're more likely for medical error. So it's very important.

00;03;35;12 - 00;03;43;16
Elisa Arespacochaga
So can you tell me a little bit about sort of the cognitive load. Can you dive in a little bit about how it works and what it really measures?

00;03;43;18 - 00;04;07;23
Michael Privitera, M.D.
Sure. It's where I think human factors and understanding cognitive load can really help us out of the current predicament we're in with ever increasing expectations and basically technology really exploding and making it harder for us humans to adapt. Right? The good news about cognitive load is there's the essential part, which is the intrinsic cognitive load. And it's basically the inherent difficulty.

00;04;07;26 - 00;04;34;18
Michael Privitera, M.D.
And how we present something really makes a difference about how much of that brainpower we're using. So this research originally started in education. Doctor John Weller in Australia was understanding the three parts of cognitive load and talked about intrinsic. Germane is how much brain power is being used to make the mental model in your mind of what it is you're dealing with, so you can store it into your long term memory.

00;04;34;21 - 00;04;56;26
Michael Privitera, M.D.
Or if you come across a pattern, you just heard a patient's history, well, that sounds like congestive heart failure. And you're kind of downloading from the long term memory back into working memory. And then you say, oh my gosh, that's a diagnosis here. So then, extraneous cognitive load is where we have lots of opportunity. That's basically the waste that we could get rid of.

00;04;57;02 - 00;05;18;22
Michael Privitera, M.D.
What is it that we could remove by better design and sometimes a lot of conflicting pieces of information or too much information, or we're trying to synthesize all these expectations. There's extraneous cognitive load, and it kind of pulls our brainpower away from the task at hand that we either have to learn or do. So that's where our opportunity is.

00;05;18;22 - 00;05;27;23
Michael Privitera, M.D.
We can really work by understanding how to get rid of this extraneous cognitive load and actually be able to see this invisible thing that's getting in our way.

00;05;27;26 - 00;05;36;22
Elisa Arespacochaga
You've mentioned human factors and ergonomics a couple times. Can you just dig in a little bit more on that as well? I want to make sure folks understand. What does that even mean?

00;05;36;25 - 00;06;09;11
Michael Privitera, M.D.
Human factors and ergonomics is a science really. It's embraced in many other professions, but not enough in health care. That's kind of our problem. So in other words, astronauts, pilots, even if you're into simultaneous translating at the United Nations, they consider how much you're having to deal with cognitively. And they have mandatory breaks. But in health care, it's kind of like we're not seeing the human limitation even though you're boarded in one, two or three things, if you stay up all night or you have excessive cognitive load, you might make the error in that board

00;06;09;11 - 00;06;19;27
Michael Privitera, M.D.
certification times 2 or 3 doesn't really protect you enough. It helps a little bit, but you're still in the human club is the point here. We're not addressing the human club part of all this.

00;06;20;03 - 00;06;32;08
Elisa Arespacochaga
Absolutely, absolutely. Every time I've tried to translate between English and Spanish, I'm very tired at the end and I cannot do simultaneous translating so.

00;06;32;11 - 00;07;00;04
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, the chief physician executive and a champion of the 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;07;00;06 - 00;07;32;03
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 1500 other hospitals already involved, visit aha.org/patient safety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA Patient Safety Initiative.

00;07;32;06 - 00;07;40;06
Chris DeRienzo, M.D.
Remember, together we can make health care safer for everyone.

00;07;40;08 - 00;08;03;09
Elisa Arespacochaga
Let's talk a little bit about some of the primary factors that really contribute to that high cognitive load in health care. Obviously, you talked a little bit about some of the challenges there. As a clinician, you're trying to bring disparate information together, but can you talk a little bit about how we sort of get in our own way I guess, in terms of driving up that cognitive load in health care environments?

00;08;03;12 - 00;08;34;28
Michael Privitera, M.D.
Really excellent point. And I hope that just kind of helps people to start to really see that this actually is a problem. It may be invisible to us, but it's a real problem that affects us safety, well-being, quality and our ability to sustain our career, actually. It comes from a lot of sources in in basically high volume too. -uch of it is well-meaning, but it can be excessive and non-strategic, and sometimes it comes in the form of what we think might be patient safety initiatives or regulations.

00;08;35;00 - 00;08;56;25
Michael Privitera, M.D.
And they might, the way they're designed backfire in purpose. A good example that comes to mind a lot in electronic medical record that we deal with is the best practice alert or pop up. You realize it's guaranteed to derail what you're thinking about at the time, but yet it's woven in as a guardrail or protective factor, or to remind you not to forget about something.

00;08;56;28 - 00;09;20;20
Michael Privitera, M.D.
But if you don't know where that clinician is in their thinking process, their cognitive flow, they might be at the point that after they've seen their patient, they're in differential diagnosis. Well, they have these symptoms. What might it be? If you derail somebody right there they have anywhere from about a 20 to 40% chance that they might not get back to the material thinking about, plus the loss.

00;09;20;23 - 00;09;43;17
Michael Privitera, M.D.
So in other words, what we're doing well-intended, but it can take up extra brainpower to get back on track. And you may actually lose info on healthcare. We have multiple regulators. We have multiple sources of authority or the payers. You have to do this, that and the other to get paid. So we have multiple sources and trying to reconcile those different things.

00;09;43;17 - 00;10;09;19
Michael Privitera, M.D.
Sometimes if they're directly passed down, coming through the C-suite directly to the clinicians that have to do something, that's a lot of brain power you're trying to reconcile. And it takes away from patient care implication. I guess the whole message here is this is a finite resource, and the more we know about it, we have to budget the expertise of their brain power like we would money and allocate it in the right places strategically.

00;10;09;19 - 00;10;16;17
Michael Privitera, M.D.
So that's the hope of this science. The more we know about it, we can understand how we have to strategically allocate.

00;10;16;19 - 00;10;38;10
Elisa Arespacochaga
I'm fascinated by this, and so much I think about how much I get when someone interrupts me when I'm in the middle of writing something, or at the end, the amount of time it takes you to get back to where you were. I don't think I had actually ever thought about that. But yeah, if you're constantly being assaulted by pop-ups, whether they're best practice alerts or emails, it can disrupt your thinking.

00;10;38;12 - 00;10;55;27
Elisa Arespacochaga
So let's talk about some strategies that are helpful. We sort of, you know, define where the challenge is. What are those effective ways of managing cognitive load with the health care workforce, so that we can appropriately budget that very finite resource of their ability to think through a problem?

00;10;55;29 - 00;11;14;25
Michael Privitera, M.D.
That's a really great question. And a lot of this is in process in the work. So it's probably going to keep evolving over time. But we have one mantra to think about. Don't make them think more than they necessarily have to. If you can keep that in mind. Extra stuff if you can get to the point, concise, whatever.

00;11;14;25 - 00;11;50;08
Michael Privitera, M.D.
But standardization helps if you allow a certain wiggle room for, you know, the exceptions that are needed, what we call aligned autonomy. It's still following the strategic plan of the institution, but a little bit of room for specific things. Come on learning some of the points, like consolidating information together. The concept is called split attention. So split attention is the greater the amount of time between two pieces of information or in space. Either one that makes it harder to see those two pieces of information is related, and being able to put it into your long term memory that they're related.

00;11;50;08 - 00;12;14;29
Michael Privitera, M.D.
So put things together that are related: process coupling is another example of that. If there's two types of processes, try to get them closer together. That saves cognitive load. Some of the things we do naturally like dashboards help us cross comparative charts so we can work within that. 15 to 30s of working memory redundancy. We talk about in engineering is having two systems.

00;12;15;07 - 00;12;39;16
Michael Privitera, M.D.
That's like in the airlines industry, a backup set of breaks for the plane if the one set doesn't work, gets redundancy. But in information redundancy can backfire. So trying to keep it to one source of information where possible. Satisficing is a term that's from economics. It's basically satisfactory and sufficient to do the job. But in everyday things, think of satisficing.

00;12;39;21 - 00;12;44;26
Michael Privitera, M.D.
Is it good enough to do the job? It's a decision making strategy.

00;12;44;26 - 00;13;04;18
Elisa Arespacochaga
I understand. Yeah, it's one that I struggle with understanding a way to, you know, do is it good enough to do what needs to be done, and where are the places where that extra energy can help, where it's really needed? What you're saying is really being very strategic and thinking about ways to really tighten down on where that finite resource is being used.

00;13;04;22 - 00;13;05;10
Michael Privitera, M.D.
Yeah.

00;13;05;13 - 00;13;20;00
Elisa Arespacochaga
Seems like it, you know, can last forever, but clearly it can't. I know one of our earliest interactions was one of your great papers on executive function and how quickly that deteriorates when you are tired or you're having a bad day or you don't feel you have control.

00;13;20;03 - 00;13;45;24
Michael Privitera, M.D.
Oh, yeah, it does. It does. If you think about how some things are designed, like if a CEO, for example, might have somebody that's your first contact to get in towards his or her office. And so it protects their brain function for thinking of high level decisions. So if we can do that for the everyday person, what are the things that we can get off their plate so they can think for the most critical thing, especially if they're thinking about health care?

00;13;45;27 - 00;14;09;00
Elisa Arepacochaga
Yeah

00;14;09;07 - 00;14;27;09
Elisa Arespacochaga
Yeah absolutely. So let's talk about an example where some of these interventions that you just laid out actually lead to improvement. I know you've done this work, in your role at University of Rochester. How is this making measurable improvement in clinician well-being and patient safety?

00;14;27;11 - 00;14;52;05
Michael Privitera, M.D.
Well, in terms of some of the examples, you know, it's like the well-meaning aspects of, mandatory education, for example, it was all meant for improving patient safety and quality. But since they're coming from different authorities, they added up in ways and trying to reconcile the different needs, understanding the quantity, no resource provided for doing them. For example, you had to do them and finding time for them somehow.

00;14;52;09 - 00;15;13;08
Michael Privitera, M.D.
All those things, when we took this on as our wellness committee, first thing we did is just list them all, put them all together and all the sources they came from. And then we shared that together with Quality and Safety Office and Education office. And immediately the first week when they looked at everything, 20% were taken right off.

00;15;13;11 - 00;15;39;20
Michael Privitera, M.D.
So 20% went away to the gratefulness of most of the clinicians, realizing that so many things accumulated over time, they weren't kind of monitor it enough. And that happens because they come from different offices. That's one just in the major measurement of well-being. What we use a well-being index in 2018 and three years later, we reduced burnout by about 14% by 2021.

00;15;39;23 - 00;15;59;29
Michael Privitera, M.D.
I love the term that you've told me about Elisa. This was back in the days when it wasn't cool to work on burnout, and I was in that stage and boy, was it uphill. The culture is strong. Yeah, and also the feeling that there's no limit to the brain power and the fact that they're tired and they're up all night shouldn't affect your quality and safety.

00;15;59;29 - 00;16;25;21
Michael Privitera, M.D.
Where I don't know where we got that image from, but it part of it is our medical culture, especially as things have expanded. We really are having a hard time doing that safely nowadays. And if you think about the 14% reduction, we already know the research and how that converts to patient safety and the economic benefits. The study and surgeons high burnout was associated with a 200% increase risk of medical error.

00;16;25;21 - 00;16;31;11
Michael Privitera, M.D.
So the benefits of the reduction are clear just by looking to correlations with the research.

00;16;31;13 - 00;16;45;08
Elisa Arespacochaga
Absolutely. So, you know, when you brought this and you did this work, what role did leadership and what role can they play in addressing some of these challenges. So the leaders who are listening, what can they do to really engage in this?

00;16;45;10 - 00;17;19;00
Michael Privitera, M.D.
Okay. Great questions. And part of what I've been doing for the last 14 years or so is trying to extract from human factors engineering, putting it into words that might make more sense to a layperson because we're not engineers in health care. That's been the process. So basically, realizing so many things from disparate authorities come through the C-suite, the CEO, chief financial officer, chief operations, etc. and realizing that is the opportunity for how we implement. How do we implement mandatories, how do we implement requirements?

00;17;19;03 - 00;17;44;11
Michael Privitera, M.D.
It usually gets dispersed to many different offices. The whole idea from the human factors point of view is trying to get an idea of what are all the expectations going out? And that's we're connecting well-being with quality work, you start to see that these are all interacting. If you understand what's happening to our brain, there's no doubt all this overloaded is affecting patient safety and quality.

00;17;44;11 - 00;18;10;26
Michael Privitera, M.D.
Plus, it's the unspoken reason why people keep leaving. So basically, trying to get an idea of acknowledging that this cognitive load is a real thing. And the more we start to understand it, try to understand it in leadership positions, some of the basics of what this means in terms of cognitive load. A great work that has been really instrumental in me understanding what to do in health care organizations is by William Passmore.

00;18;10;28 - 00;18;38;18
Michael Privitera, M.D.
Two really great things is designing effective organization, socio-technical systems perspective. That's a book he wrote in 1988. He kind of did predict our current situation by not dealing with the balance of people and technology. Right now, we're in the process of kind of buying tech, buying tech, buying tech, and we're finding that the people adjusting to all those learning curves or how they interact kind of get in the way of process.

00;18;38;20 - 00;18;56;22
Michael Privitera, M.D.
You know, people know how to take care of the patient. They can't make it happen through the tech or other things like that. So realizing these are real things, the more we know about it. Taking on halo bias is another. Halo bias is something because it might have a term patient safety or quality associated with it, we don't push back on the science.

00;18;56;24 - 00;19;21;02
Michael Privitera, M.D.
It already gets in the door because it's got that term. My point is, when you see if they're coming and there's so many of them, maybe it's not quality or safety anymore. Maybe it's actually doing the reverse and it's causing a problem because it's all totaled together. Understand how and where the impact is being felt. So that's feedback systems - try to get feedback systems from front lines back to leadership, frontline leadership.

00;19;21;04 - 00;19;45;03
Michael Privitera, M.D.
The way we're structured now, there's a communication flow: national state, industry leadership and requirements go through the C-suite down to clinicians. It's mostly a one-way communication. We don't have a feedback system to send a really critical. So the more we can do about getting more regular surveys, the psychosocial safety that's needed for being able to speak up if there's an issue is critical.

00;19;45;03 - 00;20;01;00
Michael Privitera, M.D.
So that culture is really important. So actually health care leaders have a big key in improvement. And they can really do a lot more than they know right now. So the more that we understand about human factors, I really believe it's a way out of our struggles.

00;20;01;03 - 00;20;22;03
Elisa Arespacochaga
Oh, absolutely. I couldn't agree more with some of the things you said. I think the building those feedback loops give you so much opportunity to understand because you don't know until you walk in someone's shoes to some extent, or get their feedback what it is to be them and to do their job. And we keep adding...in healthcare, we tend to be a little bad at taking things away.

00;20;22;06 - 00;20;40;12
Elisa Arespacochaga
Yeah. And de-implementing. I know that's one of Krasinski's favorite words and I love to use it, but how do we de-implement some of the things that we've put in place? Oh, Mike, you have been really just such a shining light on this issue. I know you're - at least for me - you were the person who explained it to me and helped me understand it.

00;20;40;12 - 00;21;03;08
Elisa Arespacochaga
And I just want to thank you so much for sharing your expertise, your experiences, all of the work that you've done over the last 14 years, trying to figure out how to make us a kinder, gentler, and safer place to work and continuing to do it even though you're, you know, enjoying a well-deserved vacation. But thank you again for joining me and sharing just a little bit about the work that you've done.

00;21;03;10 - 00;21;25;27
Elisa Arespacochaga
If your organization has not signed up with the AHA Patient Safety Initiative, I absolutely encourage you to join us. You can gain a wealth of information and resources and collaborative opportunities and get to talk to people as awesome as Mike. So please sign up on the AHA Patient Safety Initiative web page. Thank you for listening and I hope you have a wonderful day.

00;21;25;27 - 00;21;26;21
Elisa Arespacochaga
Thanks again Mike.

00;21;26;21 - 00;21;30;08
Michael Privitera, M.D.
Thank you Elisa for your continuing support.

00;21;30;11 - 00;21;38;20
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;17 - 00;00;29;27
Tom Haederle
Access to quality mental and physical health services can be a challenge for many people, even those with good health insurance and plenty of care providers nearby. However, for individuals of color, various ethnicities, and people dealing with severe or chronic mental illness, finding the treatment they need is even a steeper hill to climb.

00;00;30;00 - 00;01;00;27
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Studies have shown that among individuals diagnosed with a severe or chronic mental illness, black people are less likely to seek out treatment than whites, often facing barriers such as cost, transportation and even provider bias. In this podcast hosted by the AH's Rebecca Chickey, senior director of Behavioral Health; Tracey Lavallias, executive director of behavioral health with Penn Medicine,

00;01;00;27 - 00;01;23;19
Tom Haederle
Lancaster General Health, talks about the steps Penn Medicine has taken to increase access to care among underserved patient populations. They include cultural competency training, help with language barriers and most importantly, integration of mental and physical health services that are more likely to flag a problem and direct a patient to the care they need. Let's join Rebecca and Tracey.

00;01;23;22 - 00;01;56;11
Rebecca Chickey
Thank you Tom. Indeed, it is an honor and a privilege to be here today with Tracey. Tracey and I are going to be talking about the value of integration. And when I say integration, I mean integrating physical and behavioral health, in particular the value of integration as it relates to improving access to care for historically underserved patient populations: individuals of color, various ethnicities, as well as individuals with severe and persistent or chronic mental illnesses.

00;01;56;14 - 00;02;27;29
Rebecca Chickey
Often you may think of disorders or conditions such as schizophrenia or bipolar disorder when you think of someone with a severe or chronic mental illness. All of those patient populations that I've just mentioned often struggle even more than others to improve access to care. And Tracey has experience and expertise in having seen the value of integration and how it can reduce stigma and increase access to care.

00;02;28;01 - 00;02;53;12
Rebecca Chickey
So enough about me. I'm going to turn now to Tracey and say, Tracey, can you share with the listeners a couple of things. One: What are the realities of the challenges of accessing mental health services and treatment for addiction for individuals of color as well as, what are some of the reasons for those challenges?

00;02;53;15 - 00;03;28;08
Tracey Lavallias
Well, first of all, Rebecca, thank you for having me. I appreciate the opportunity to discuss this very important topic. We have been on this journey at Penn Medicine for a long period of time. And one of the things that you mentioned was the disparity amongst individuals of color versus individuals who are white. So I'll give you a little bit of information that we found. That even when diagnosed individuals are diagnosed with a mental health disorder, Hispanics and blacks are traditionally less likely to seek mental health treatment than whites.

00;03;28;11 - 00;03;53;02
Tracey Lavallias
This has been highlighted in many studies and it certainly has manifested in our particular environment here. There are a variety of barriers to receiving mental health care for individuals of color, some reports. We did a recent study here in our community about the stigma associated with mental health. Recently there was a campaign called Five Signs that helped to reduce that.

00;03;53;02 - 00;04;16;24
Tracey Lavallias
But we're still not at the level of where individuals can speak about mental health in the same way that we speak about physical health. And that has been exacerbated in the, communities of color. Also, biases of providers. Interestingly enough, we spent a great deal of time just having a campaign to reduce the biases of our provider community.

00;04;16;27 - 00;04;39;26
Tracey Lavallias
we focused on our emergency department here. We've also focused on our treatment providers. We've instituted things such as cultural competency to try to reduce those barriers. In many cases some of our communities of colors have poor health literacy. We do have a large immigrant population. And so, as you know, mental health means different things to different individuals.

00;04;39;29 - 00;05;05;17
Tracey Lavallias
And the interpretation of mental health is perceived differently in certain cultures. So that's an issue. Sometimes its poor insight into navigation. And our mental health system, particularly in state of Pennsylvania, is not easy to navigate. So in some cases, being able to navigate the health system and the insight into navigating a health system calls for some concern for those populations.

00;05;05;20 - 00;05;32;22
Tracey Lavallias
There's geographic inaccessibility. And what I mean by that is poor transportation. In many cases, these individuals don't have an opportunity to access it because of not having transportation and the right means. And then there's other things like linguistic, or as I stated earlier, just cultural barriers. And so in many cases, the language is not being spoken in a way that can be communicated in order for these individuals to receive care.

00;05;32;23 - 00;05;47;04
Tracey Lavallias
So, you know, those are the realities that we deal with on a regular basis. And some of the things that we work to try to reduce, to make sure that those individuals have the same level of access that our white patients do.

00;05;47;07 - 00;06;21;16
Rebecca Chickey
Well, it's particularly timely that we're having this discussion now, Tracy. For the listeners, we are releasing this podcast in the month of July, and July is Minority Mental Health Awareness Month. And the challenges that Tracy just described, I will share, just briefly, a personal journey. I am white, and I had a family member who was suffering from major depression and had what I would call the the "golden egg" of health plans and many connections.

00;06;21;16 - 00;06;54;11
Rebecca Chickey
I've been in this field for over 30 years, and so I know the chiefs of psychiatry at stellar organizations across the country. And even so, trying to get treatment for my family member, it took over two months to get in to see a psychiatrist. And even then, they did not take my health insurance. As an individual who is connected, reasonably educated in trying to navigate the mental health system as well as having, you know, stellar health insurance

00;06;54;13 - 00;07;23;04
Rebecca Chickey
thanks to the American Hospital Association, it was still a struggle. We want to talk about the value of integration. But first I want to ask you about another patient population. As I mentioned earlier, those with severe and persistent mental illness, chronic mental illness. I don't know if the listeners know this, but, individuals with chronic mental illness usually die somewhere between 15 and 25 years earlier than individuals without schizophrenia or bipolar.

00;07;23;06 - 00;07;45;29
Rebecca Chickey
And you may jump to the conclusion that that might be due to higher suicide rates. Indeed it is not. They die most often from their physical illnesses, which they are not taking care of because of lack of access to both physical health and mental health services. So can you speak a little bit to that? Because that's also a health disparity.

00;07;46;01 - 00;07;52;17
Rebecca Chickey
And, I wonder how you have been addressing that and what you know about their challenges and the realities.

00;07;52;20 - 00;08;18;03
Tracey Lavallias
Yeah. Rebecca, you bring up a really important point, and I appreciate the conversation around this. And in fact, we, try to stress this issue locally and any opportunity we get to kind of speak about this. But these are preventable diseases. In many cases, the individuals with serious mental illness, interact with and die from earlier than the same population

00;08;18;05 - 00;08;59;03
Tracey Lavallias
that does not have a serious mental illness. Things such as, you know, cardiovascular disease, diabetes and, you know, complying with insulin. These are different types of things that are preventable. The largest percentage of care in our particular - in any network - is through primary care. And we have found that individuals with serious mental illness do not seek this level of care out, as much as they should. In particularly those, as you spoke about earlier, those that are in minority communities, they have not access the primary care services as much as we would like.

00;08;59;03 - 00;09;30;17
Tracey Lavallias
In many cases, those individuals seek care in traditional mental health or inpatient environments. In many cases, we found them in our emergency department. So the fact of the matter is that individuals with significant severe mental illness do not access their primary care as often. And then you add on top of that those individuals that are communities of color access - those primary care resources and less.

00;09;30;19 - 00;09;44;19
Tracey Lavallias
And subsequently it leads to those factors that cause premature death. Cigarette smoking, things of that nature or diet and those types of issues that can be addressed if they went to a primary care physician.

00;09;44;21 - 00;10;01;01
Rebecca Chickey
So now that we painted a unfortunately fairly bleak picture for the listeners here, let's give them a bit of light, a bit of hope. How can and does integration help to reduce these disparities? Give me some examples.

00;10;01;04 - 00;10;35;25
Tracey Lavallias
What we found here, in fact, what my doctoral dissertation was done on our primary care offices here ... we did a study on  - this is going back, maybe seven years ago now. And we utilized four primary care sites here. And we went to look about three different factors, actually, we were really focusing on. First factor was, was there a reduction in the issues that we just spoke about, some of those issues that were preventable.

00;10;35;28 - 00;11;03;09
Tracey Lavallias
Did they actually comply with the primary care physicians, recommendations for those individuals that were receiving integrated care within a primary care practice? And the other components that we spoke about, we wanted to see if there was a reduction in the emergency room utilization of those individuals that received primary care and mental health services within the primary care practice.

00;11;03;11 - 00;11;29;06
Tracey Lavallias
And the last factor that we focused on was, whether or not those individuals sought care in our emergency department. Remember I spoke about traditionally those individuals sort of surfaced in our emergency department due to the lack of primary care resources. The study found that we have 50% reduction in those individuals receiving care, under primary care integration.

00;11;29;06 - 00;11;55;25
Tracey Lavallias
So they're less likely to come to the word see department. There was a significant reduction of stigma in the primary care office, based on the fact that these individuals did not seek services or receive services under the umbrella or title of a mental health facility. There was more compliance with the recommendations of their medication management or the recommendation of their primary care physician.

00;11;55;27 - 00;12;22;13
Tracey Lavallias
And this was primarily based on the fact that they may have been depressed. There may have been other factors that, were focused on their mental health issues that caused them not to take their physical health medication. So the fact that we were integrating care within a primary care office and allowing these services to be seen as seamless, really improve the quality of care for those individuals.

00;12;22;15 - 00;12;45;15
Tracey Lavallias
And as a by-factor of that, there was a significant increase in provider satisfaction. So not only did the patients get better and services delivered in a more quantitative fashion, but the provider satisfaction just increased. So I think that's the positive side of integrating mental health into your primary care offices.

00;12;45;17 - 00;13;15;21
Rebecca Chickey
So I'm going to emphasize again, some of the key points you just said. One, with all the workforce challenges that are out there right now, if you can improve provider satisfaction, that is a positive impact. Equally, perhaps even more importantly, what you said is that you improved patient outcomes. That's what we got into healthcare for in the first place, right, is to improve individual's quality of health and ability to live their best lives.

00;13;15;23 - 00;13;31;23
Rebecca Chickey
You reduced stigma through integration and then, I'm going to connect the dots here. So please keep me honest if this is not the case. But you said you reduced visits to the emergency department by around 50%, and so that's correct?

00;13;31;24 - 00;13;33;00
Tracey Lavallias
That's correct. Yeah.

00;13;33;03 - 00;13;57;07
Rebecca Chickey
And every emergency department visit, it's not the least costly level of care, I will say. And so you have you're reducing the total cost of care for that individual as a whole. And you're also improving access to other emergency services because the emergency room is not treating someone who could have been treated in a lower level of care.

00;13;57;09 - 00;14;10;25
Rebecca Chickey
Well, is there a story that you might want to share for the listeners? Of course, not identifying a name, but is there a story that you might want to share to, illustrate this on a on a personal level?

00;14;10;28 - 00;14;42;02
Tracey Lavallias
We had an individual and I spent a lot of time with this individual, and he was a parent of a individual that was a chronic behavioral health patient. And what I mean by chronic symptomology had become so severe that she would cycle through our emergency department on a regular basis. This situation all escalated up to our CEO and CEO sent the information to me.

00;14;42;02 - 00;15;10;28
Tracey Lavallias
So I had several conversations with the parent of this individual who was really reaching out for help and really didn't have the ability or capacity because he had been dealing with this particular issue for such a long period of time. It manifested in complaints. But really, when you drill down and you had a more conversation, it was about access and the fact that this individual had not accessed our services within our PCP.

00;15;11;00 - 00;15;35;23
Tracey Lavallias
One thing led to another, and I'm shortening the story because of the time frame. But imagine this situation went on for about six months. We began to build a bridge with the parent who in fact begin to build a bridge with the daughter. We connected this daughter with our integrated care within our primary care offices, they're currently in all our primary care offices now.

00;15;35;23 - 00;16;06;13
Tracey Lavallias
So we integrated them based upon the location that was closest. She immediately connected with the therapist there. There was less of a stigma associated with the services that she received. And, she just got better, significantly better, throughout the course of time. Her parent was a conduit because she was limited linguistically and really reached out to us to talk to us about the care that they received in this environment.

00;16;06;15 - 00;16;37;17
Tracey Lavallias
The therapist, the integration of the primary care doctor, addressing the physical health needs. She became much more compliant with her physical health medication which was a conduit to her being in the emergency department as well. So I point that story out just to say that that is probably one that came to my attention, but that's the norm for what we've what we have seen in our primary care offices when we integrate our mental health clinicians there.

00;16;37;19 - 00;16;50;22
Tracey Lavallias
And has been certainly a positive outcome for the system because these individuals are receiving timely care and just getting better, Rebecca. And so I'm really, really proud of the work that they've done there.

00;16;50;25 - 00;17;09;23
Rebecca Chickey
I think what you just described was truly patient centered care. So thank you for doing that and for sharing that story. As we close out the podcast today, is there a call to action that you'd like to perhaps challenge or encourage the listeners to consider doing?

00;17;09;26 - 00;17;29;07
Tracey Lavallias
A couple things? One thing that I would say is that you had, alluded to this earlier. There are significant challenges from a workforce perspective to be able to keep up with the amount of patients that need health care. So in the medical field, you can see it nationally that there's just not enough providers, not enough individuals going into the field.

00;17;29;09 - 00;17;53;14
Tracey Lavallias
So I encourage those who have an empathy for this population to go into this field, contribute in any way that you can to this population so that these individuals will have the same quality of life that we've grown accustomed to. The second thing that I would say is we talked about the disparity between the physical health and the mental health, and really trying to close that gap as relates to stigma.

00;17;53;17 - 00;18;32;18
Tracey Lavallias
We talked a little bit about it earlier. I would like to prioritize things such as mental health first aid. You know, we get first aid in many of our jobs that we go into, particularly in the health care field, and it's a way to sort of prevent the physical issues if you're so encountered and trying to stabilize the patient. The same things are taught as it relates to mental health first aid, the ability for individuals, loved ones, family members, friends to engage with individuals because in most cases, they're the ones that see them first to be able to do some of their first aid, mental health, first aid, things that can stabilize the

00;18;32;18 - 00;18;46;21
Tracey Lavallias
patient prior to them engaging with the system. It would broaden our ability to have access, and it creates the opportunity to reduce stigma. So in those cases, I think that would be my two calls to actions.

00;18;46;24 - 00;19;12;24
Rebecca Chickey
Thank you so much. I think I'm about to quote Maya Angelou, but as you were saying that, this quote came to mind: "Once you know better, do better."
And that would be my call to action. So as we close this out, there are a number of resources, around the value of integration, the value of integrating physical and behavioral health that can be found at

00;19;12;26 - 00;19;28;14
Rebecca Chickey
www.aha.org/behavioral health. This podcast will be available there and of course on AHA's Advancing Health podcast. Tracy, thank you so much for the work that you do and your willingness to share your insights and expertise with us today.

00;19;28;16 - 00;19;35;14
Tracey Lavallias
Thank you so much, Rebecca. I appreciate you the opportunity to discuss this important topic. And I'll see you soon.

00;19;35;17 - 00;19;43;21
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;18 - 00;00;23;07
Tom Haederle
Every rural care provider in the United States can attest that finding, hiring and retaining clinicians across just about any specialty is getting harder and harder. In south central Washington state. Kittitas Valley Health Care, KVH, the only provider offering comprehensive OB-GYN services for many miles around, was suddenly faced with a huge problem. Within the space of about a year

00;00;23;08 - 00;00;37;27
Tom Haederle
its three full time OB-GYN specialists all decided to leave.

00;00;38;00 - 00;01;05;12
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Prior to 2022, KVH was delivering between 300 and 350 babies each year. Its six bed labor and delivery unit was the most in-demand service the hospital offered. In this podcast, we learn from the hospital's CEO how KVH kept its balance and its promise to area residents to preserve critical obstetric services

00;01;05;19 - 00;01;09;27
Tom Haederle
in the wake of the departure of several highly experienced clinicians.

00;01;09;29 - 00;01;22;18
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Julie Petersen, CEO, Kittitas Valley Health Care and Public Hospital District. Good afternoon. Julie.

00;01;22;20 - 00;01;23;20
Julie Petersen
Hello.

00;01;23;23 - 00;01;56;18
John Supplitt
For our listeners, Kittitas County Public Hospital District number one, also known as Kittitas Valley Health Care, provides care to Kittitas County and surrounding areas in central Washington state. KVH includes a 25-bed critical access hospital and provides care through clinics and specialty services in upper and lower Kittitas County. Julie, we're here to discuss how KVH has responded to a crisis to ensure continued access to obstetrical care in Kittitas County, Washington.

00;01;56;20 - 00;02;00;10
John Supplitt
How essential is obstetrics to your community?

00;02;00;12 - 00;02;22;10
Julie Petersen
We know from our latest Community Health Needs Assessment that admissions for women of childbearing age is our number one admission to our hospital. So this will include delivery as well as complications from deliveries and prepartum and postpartum issues. So it's not just an essential, it's a core service for our community.

00;02;22;12 - 00;02;39;03
John Supplitt
And I think I want to pull a thread on that because it's remarkable when I looked at your community health assessment and improvement plan, to see these conditions as being the highest source of admissions to the hospital for women of all childbearing ages, including teenagers.

00;02;39;03 - 00;03;03;04
Julie Petersen
Correct. And we staff a dedicated labor and delivery unit, a six-bed labor and delivery unit. We are a 25-bed critical access hospital. So our general medicine CCU population includes a number of different DRGs and conditions. But again, the number one major diagnostic classification that we have is those moms prepartum postpartum and the deliveries themselves.

00;03;03;04 - 00;03;25;28
Julie Petersen
And we deliver about 300 to 350 babies a year in Kittitas County. We have about 80% of the of the market of deliveries. And we're very, very careful in how we screen our moms. We know our limitations with our labor and delivery program. But again, that's 300 to 350 babies a year that rely on us to deliver them in Kittitas County.

00;03;25;29 - 00;03;27;24
Julie Petersen
We are the only hospital in the county.

00;03;28;00 - 00;03;44;15
John Supplitt
And that's a remarkable number. And I think we need to really get a sense of where you are relative to the other providers in your area with respect to location. You're in south central Washington to the south of you. The nearest city is Yakima.

00;03;44;17 - 00;04;05;00
Julie Petersen
That's correct. So any direction you want to go to deliver outside of Kittitas County, you're going to have to travel over a mountain range. You travel to Wenatchee, which is a mountain pass. That's about 40 miles. You can travel to Yakima, 35-40 miles over a mountain range or into the Seattle metropolitan area of the Cascades.

00;04;05;02 - 00;04;12;17
John Supplitt
And so recently, you've experienced significant disruption, disruption in your OB-GYN services. Tell us what happened.

00;04;12;20 - 00;04;43;23
Julie Petersen
Prior to 2022, we have worked with a pool of community providers, including those sole practitioners who retired in 2022. We also had an FQHC in our community that participated in our call and delivery program. And due to changes in the residency program and then just a tight OB market, that program has slimmed down in our community. But we have employed three OB-GYNs, and our community has been kind of the core of our model.

00;04;43;26 - 00;04;59;00
Julie Petersen
But in 2022, all three of those providers gave us notice that they would be leaving. Two of them continue to live in our community, but they travel to metropolitan areas to participate in labor programs in the large hospitals.

00;04;59;02 - 00;05;13;20
John Supplitt
Well, and again, I have to pull a thread on this because your model through 2022 was an employed service through your own OB-GYNs, which is remarkable to think that you were able to recruit them into the first place and that they were committed to the community for so long a period of time.

00;05;13;28 - 00;05;40;10
Julie Petersen
Right. And that that level of commitment, that market of being able to employ an OB-GYN who is responsible for their patients, 24/7 who disrupts their clinic life to go to the hospital to deliver a baby on the middle of a Wednesday afternoon. That market is harder and harder to draw to, and that is absolutely what we were trying to maintain in KVH, again with the participation of some great partners

00;05;40;10 - 00;05;47;29
Julie Petersen
in the FQHC and some private practitioners. But within the span of about 14 months, that entire model just came up hard on us.

00;05;48;03 - 00;05;55;19
John Supplitt
So you get punched in the gut as you see this attrition in your employed model of care. How did you respond to this crisis?

00;05;55;21 - 00;06;22;12
Julie Petersen
Well, the governing board, we are an elected board of five commissioners in Kittitas Valley. And they came out of the gate assuring the community and assuring our staff that we were going to remain in the OB business. So my charge was to make it happen. We'd already been recruiting to replace the traditional OB-GYN providers that we'd had in the past and we were not having very much success.

00;06;22;14 - 00;06;45;14
Julie Petersen
We did come across a family practice OB who has surgically trained, who's a key component of our program going forward. But after about 12 to 14 months of looking to backfill our OB-GYNs, we had no choice but to look outside for an outsource service, and we found a partner in OB hospitalist group or OBHG.

00;06;45;16 - 00;07;11;29
Julie Petersen
So again, I think the first thing we did was make the commitment from the governing board on down that we were going to continue to deliver babies in Kittitas County, and that's key, because one place where we're particularly strong is in our nursing program. We have an amazing group of labor and delivery, specialty trained nurses who have stuck through us, with us through this entire sort of meltdown in OB.

00;07;11;29 - 00;07;17;11
Julie Petersen
And the last thing we wanted to do was make ourselves vulnerable to losing those nurses.

00;07;17;13 - 00;07;26;23
John Supplitt
Well, and I'm going to share a couple of observations. First and foremost, this is a public district hospital and that the board is committed to delivering babies to this community.

00;07;26;27 - 00;07;28;09
Julie Petersen
That's absolutely correct.

00;07;28;09 - 00;07;31;11
John Supplitt
And that's at the core of your mission.

00;07;31;11 - 00;08;01;28
Julie Petersen
Right. That was never a question. And I think the way we see this is, again, our folks have been rigorous and determining who should deliver at KVH. We don't do high risk deliveries. And when you take 300 to 350 moms who can deliver in a safe hospital environment and put them on the road over mountain passes or 35-40 miles stretches, you take low risk, comfortable births, and you turn them into high risk births. That was not acceptable at my board.

00;08;02;00 - 00;08;25;25
John Supplitt
And then the other observation is, as we see hospitals drop obstetric services from their service components, I again reflect on the fact that as a public district hospital, your commitment to the community is at the core of what it is that you do. And in this particular, you're willing to take on this loss- leader in order to make sure that there's access to safe care to the women that live there.

00;08;25;27 - 00;08;49;29
Julie Petersen
And we see this service line also. At the core of this service line is labor and delivery and obstetrics. And that certainly is the biggest challenge in terms of continuing the service line. But it is bigger than that. We are a county of about 45,000 people, and we're a little bit unique in that we are growing as a sort of a long distance neighbor to the Seattle metropolitan area.

00;08;49;29 - 00;09;12;05
Julie Petersen
We are growing and we're holding our own in terms of age. So we're not aging the way some rural communities are. So long term, we need not only to be able to deliver our own babies, but we need to be able to take care of women generally in our community, the reproductive health needs of women, gynecological needs of women in our community are core to this as well.

00;09;12;07 - 00;09;25;28
Julie Petersen
And if you can't attract OB-GYNs, if you can't attract the nurses who care for women in the clinics in the hospital, you're going to lose your ability to take care of women generally, and reproductive health specifically.

00;09;26;01 - 00;09;43;00
John Supplitt
Julie, let's talk about the selection of OB hospital group as your agency to service this labor model. There had to be some research that went into that. There had to be some board buy-in and acceptance of this. Tell us a little bit about that process and how it went.

00;09;43;02 - 00;10;08;02
Julie Petersen
During the pandemic and initiating our research, one of the things that we learned is in a very short period of time, many, many hospitals had transitioned to a labor site model. And while it's largely an urban/suburban phenomenon, we saw some of it moving into the rural communities as well. So we looked for somebody who had experience in rural communities. And rural is different than urban,

00;10;08;02 - 00;10;33;24
Julie Petersen
they needed to be able to or willing. They needed to attract candidates who would work in a clinic setting, who would do general GYN surgery, and to that time as a laborist as well. So we needed to partner with someone who would be flexible, who would include our own dedicated staff, our family practice OB that I mentioned, our certified nurse midwife.

00;10;33;26 - 00;10;58;09
Julie Petersen
We had folks who we knew were really dedicated to our community, and we needed a partner who would build around them. So we worked with GBHG. They basically said, sat down with us and said, let's build some schedules. Let's see how we can make this work. And we settled on a three week a month rotation. When you were on call to deliver babies, that's all you do.

00;10;58;11 - 00;11;21;23
Julie Petersen
So again, delivering maybe a baby a day, that's not overly burdensome. It is a 24 hour commitment. But for seven days that's what you do. The next week you get off, you return to clinic work and just clinic work for the following two weeks. And that seems to have been an attractive model, not just for our own delivering physicians, but for OBGH as well

00;11;21;23 - 00;11;25;00
Julie Petersen
and they're having some success in recruiting to that position.

00;11;25;05 - 00;11;39;07
John Supplitt
Which is excellent news and I'm sure a relief to you. So this is how you're going to put this model into practice. How has the community received the message, or do they even understand the message that you're changing the model? Is it relevant to them?

00;11;39;09 - 00;12;03;08
Julie Petersen
You know, you lead with the fact that except in a rural community, people don't expect the OB they see in their clinic to deliver their baby in very many facilities anymore. So this is not new to people. It's new to Kittitas and to our population, but they were very much aware of it. And if they delivered somewhere else, that's probably the model that they had seen.

00;12;03;11 - 00;12;20;07
Julie Petersen
The thing we had to say over and over again is that we are committed to this. It's not going to be easy. We're not going to be able to do it overnight. But we have never been on divert for deliveries. So whatever it took to pull that together and keep that service intact, our board has been willing to make that commitment and do that.

00;12;20;07 - 00;12;26;03
Julie Petersen
And frankly, I think the community has come to believe us. They've seen how we've struggled, but they know we're in it.

00;12;26;06 - 00;12;38;17
John Supplitt
Nevertheless, Julie, it's a radical change in the way in which you've delivered OB in the past. I'm curious to know, given the importance of the nursing component, how has your nursing service responded to the change?

00;12;38;20 - 00;13;02;27
Julie Petersen
Labor and delivery nurses are the number one reason that we're seeing rural communities go out of the OB business. So while we have struggled with an OB-GYN component with first assist, of course have to have anesthesia available. You have to have someone there to take care of the baby as well. You have to have pediatricians or acute newborn providers and a cesarean section to take care of the babies.

00;13;02;27 - 00;13;27;02
Julie Petersen
So it takes a team. But our nurses are the bedrock of that. And we talk about labor and delivery. Eleven hours of labor and delivery is all about the nurse. The doc walks in and is there for a short period of time. Our nurses are dedicated. They have a lot of longevity, and they are just used to doing whatever it takes to get the job done, and that's what they've done for the last 15 months.

00;13;27;05 - 00;13;51;26
John Supplitt
So all these things considered, given the changes that you're planning - two questions. The first is what's the timeline for implementation? You really started this process back in 2022-2023. You've moved forward for the research. You made the decision to go to be with OB hospitalist Group in October of 2023. What's the timeline now for looking forward in terms of making this permanent?

00;13;51;28 - 00;14;23;06
Julie Petersen
We believe we will be fully staffed between our own providers and OBGH in July of this year. So it has been a long haul. We've been on the pediatric side of it. We've been building our acute newborn so that that's a very reliable group now. And anesthesia as well. So we feel like once we have weathered the storm of a lot of locums and short term locums, and we get our OBHG hospitalist on board, our own folks on board, we're going to be ready to go.

00;14;23;06 - 00;14;53;12
Julie Petersen
So July, August of this year. And again, a component of this and one of the ways that we make this affordable - and labor and delivery has always been a loss leader - but one of the ways we make this affordable is through this OB-GYN model is we do have built in GYN surgical time. So we're able now or we will be able to take care of more of the general gynecological needs of the women in our community than we've ever been able to take care of before.

00;14;53;15 - 00;15;05;17
John Supplitt
Well, and I think that that's the question, and that'll be the last question I ask. And that's the one that everybody wants to hear, is, how are you going to pay for this? How are you going to meet the expenses to make sure that this service remains viable moving forward?

00;15;05;20 - 00;15;34;24
Julie Petersen
So every schedule we've put together also includes that GYN surgery day. So our OB-GYN will be doing more surgery than are the ones that have been working 24 hours a day to deliver babies were willing to do. So GYN services will continue to increase. This, frankly, is a service that we have always look to our 340B savings to help support and like everyone else who delivers babies, we lose money on it

00;15;34;24 - 00;15;46;20
Julie Petersen
so we made a direct connection to those 340 B savings. So we keep a close eye on that as well. It is not going to be easy financially. We will struggle because of this. But again, we're committed.

00;15;46;22 - 00;16;05;27
John Supplitt
Well. And you raised some very important points is that none of these programs exist without the other. And 340B is essential to rural community hospitals across the country. It is the margin for many critical access hospitals and what you're suggesting, it's going to be pretty much the margin for you to be able to continue this OB service.

00;16;06;00 - 00;16;33;26
John Supplitt
I think I really, on behalf of all of our listeners, want to thank you and your board for the commitment to making sure that OB is available to the residents of your community. That they're not put at risk for unsafe deliveries, unhealthy situations, becoming unsafe because they have to cross a mountain pass. I think it's a huge commitment on behalf of your community and your leadership in making this happen to really implementing this practice and making it come so quickly

00;16;34;00 - 00;16;37;01
John Supplitt
given the crisis that you were confronted with just a few months ago.

00;16;37;07 - 00;16;38;25
Julie Petersen
Well, thank you. It's a privilege.

00;16;38;28 - 00;17;09;02
John Supplitt
I want to thank my guests. Julie Peterson, CEO of Kittitas Valley Health in Ellensburg, Washington, for sharing her important story and providing essential health services and reimagining OB to ensure continued care for the residents of Kittitas County. Your commitment is inspiring, and we'll be watching closely as you grow and evolve under this new model of care. I wish you every success in your effort and hope to learn more about how we can learn from your experience.

00;17;09;04 - 00;17;19;01
John Supplitt
I'm John Supplitt, senior director of Rural Health Services. Thank you for listening. This has been an Advancing Health podcast from the American Hospital Association.

00;17;19;04 - 00;17;27;15
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;17 - 00;00;38;18
Tom Haederle
Some 57 million rural Americans depend on their hospital as an important source of care, as well as a critical component of their area's economic and social fabric. But many rural care providers have faced and continue to face a rocky road ahead. Attracting and retaining workers. Financial stresses. Dealing with complicated and sometimes conflicting regulations. These are among the factors that can jeopardize the ability of rural hospitals to provide patient access to care.

00;00;38;20 - 00;01;13;07
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. AHA has made improving access to rural health a top priority. Our 2024 Advocacy Agenda for lawmakers and policy recommendations to government agencies lays out the groundwork for needed change to improve the system for patients. In this podcast, two AHA experts drill down into some of the specific steps needed to help essential rural health care providers stay solvent, healthy, and able to serve the patients and communities who depend on them.

00;01;13;09 - 00;01;20;19
Tom Haederle
The discussion took place at the 2024 AHA Rural Health Care Leadership Conference in Orlando, Florida.

00;01;20;22 - 00;01;49;08
Lisa Kidder
Good day. I'm Lisa Kidder, senior vice president, AHA advocacy and political affairs. I am joined today by my two colleagues, Travis Robey, vice president of political affairs, and Shannon Wu, senior associate director, AHA payment policy, two of the experts on rural health care. Welcome, Shannon. Welcome, Travis. We all know rural hospitals continue to experience ongoing challenges that jeopardize the ability to provide local access to care and essential services to their patients and community.

00;01;49;11 - 00;02;19;17
Lisa Kidder
Examples include workforce shortages, financial instability, overwhelming regulatory burden, just to name a few. AHA continues to work with Congress and the administration to enact policies or sometimes to stop policies to support these rural hospitals. Recently, we announced our AHA Rural Advocacy Agenda for 2024. I am going to talk to Travis and Shannon about the advocacy agenda and share with you some of the details as we drill down a little bit.

00;02;19;20 - 00;02;39;04
Lisa Kidder
Travis, let's start with you. As AHA continues to work with Congress and the administration to support these rural hospitals. We're also looking to support a public policy environment that will protect access to care, innovation and invest resources in new rural communities. Could you talk about those five areas, please?

00;02;39;07 - 00;03;02;11
Travis Robey
Absolutely. Our first priority in our updated rural advocacy agenda is commercial insurer accountability. It continues to be an issue that we hear as a top tier issue of concern for our members. Second is supporting flexible payment options. Third is ensuring fair and adequate reimbursement. Fourth is bolstering the workforce. And fifth is protecting the 340B program.

00;03;02;14 - 00;03;19;15
Lisa Kidder
Great. Thanks. I will dig into some of those issues here in just a minute. Shannon, as Travis mentioned, the number one he first mentioned and maybe even number one on our priority list this year is commercial insurer accountability. Can you talk a little bit about what's been happening with the administration and some of the actions they've taken to address this issue?

00;03;19;17 - 00;03;42;06
Shannon Wu
Sure. We've already seen some moves in the right direction from the administration, from last year and the beginning of this year. So first, we are carefully monitoring compliance and the recent Medicare Advantage rules that were finalized last year, which went into effect last month in January. Many of these rules hold plans accountable for covering services and for their marketing tactics, among other requirements.

00;03;42;09 - 00;04;05;10
Shannon Wu
So we're keeping a close eye on how this Medicare Advantage plans are complying with those rules for the upcoming year. Second, the administration also finalized just last month in January again, prior authorization rules that the AHA advocated heavily on. These will go into effect in the next few years and are really aimed at streamlining and reducing burden associated with prior authorization and at promoting greater transparency.

00;04;05;12 - 00;04;14;21
Shannon Wu
Of course, our work here is not done, and we continue to advocate for ways to reduce administrative burden and help our rural hospitals navigate through the changing Medicare Advantage landscape.

00;04;14;24 - 00;04;30;21
Lisa Kidder
Thanks, Shannon. It sounds like lots of good work is being done. Travis, let's talk about another issue that has getting a lot of attention in Washington, D.C. right now from both sides, both those who are for it and against it. Can you tell us about site neutral and what is happening right now in Congress on the issue?

00;04;30;24 - 00;05;02;18
Travis Robey
Absolutely. Hospitals and health systems play a critical role in preserving access to care for patients and communities throughout rural America. They've increasingly stepped up to fill the voids in care by reinvesting through access points like hospital outpatient departments. These sites of care are essential services in so many rural and low income communities across the country. Our emphasis right now is trying to push back on congressional efforts to impose site neutral payments, particularly for drug administration.

00;05;02;19 - 00;05;26;21
Travis Robey
But their longer term vision is far more expansive than that. And the impact on rural communities is particularly acute. We've recently put out data that shows that disproportionately rural patients access care at hospital outpatient departments. And we want to ensure that that access continues going forward by opposing the site neutral cuts.

00;05;26;23 - 00;05;33;17
Lisa Kidder
And, Travis, I hate to put people on the spot, but I'll put you on the spot. What do you think the chances are that Congress takes action this year on the issue?

00;05;33;19 - 00;05;59;18
Travis Robey
Well, right now we've got, in the short term, the March 1st and March 8th government funding deadlines that put us at risk on these issues. The hope is that we can stave off any pending cuts in that government funding package that's going to move in the next month, but then we'll still have the lame duck session of Congress in November and December, where this will be a top tier issue.

00;05;59;21 - 00;06;20;13
Travis Robey
So we need to make sure that our rural members and all of hospital leaders across the country are engaging with their legislators to make sure that the message gets delivered, that the current payment model is essential to maintain access to care, particularly given the financially vulnerable position of so many rural and safety net hospitals.

00;06;20;16 - 00;06;36;19
Lisa Kidder
Great. So that sounds like a call to action as well as an update. The next issue I know is one that really hospitals and hospitals really across the country are dealing with that definitely peaked during Covid. But can you talk about workforce challenges? So Travis, I'll send it to you. But then, Shannon, you may have thoughts as well of some of the issues you've worked on.

00;06;36;19 - 00;06;39;10
Lisa Kidder
So, Travis, why don't you go first and then you can turn it over?

00;06;39;12 - 00;07;06;10
Travis Robey
Yeah. This is a key area where there is the potential for possible bipartisan support over the coming months. The National Health Service Corps is up for reauthorization. We're also advocating for an expansion of graduate medical education residency slots. Over the last several years, we've seen investments in more GME slots after nearly a couple of decades where there had been a freeze on those slots.

00;07;06;12 - 00;07;33;21
Travis Robey
But there are also rural specific proposals, like the extending the Conrad state 30 program, which allows J-1 visa waivers for physicians who train in the U.S. to be able to stay here if they practice in an underserved or rural community. So there are a variety of key workforce provisions that are specifically focused on rural, but I want to highlight one additional area: the SAVE Act. That's focused on workplace violence,

00;07;33;23 - 00;07;58;17
Travis Robey
such a key issue for employees and administrators at hospitals to take this issue head on. We just had a very successful - almost 100 congressional staffers attend a briefing on this issue that really, I think, drove home to congressional staff the importance of this issue, and we're looking to make progress on that over the coming months as well. And that's a bipartisan piece of legislation in the House and the Senate.

00;07;58;24 - 00;08;35;20
Shannon Wu
Great. Well, on the regulatory front, we've been really focused on the proposed nurse staffing minimum rules that were released by the Centers for Medicare & Medicaid Services last year. We strongly oppose these rules. So while we agree that staffing is an integral part of providing safe, high quality care, we believe that the proposed rules from last year really are an overly simplistic approach to a complex issue and that, if implemented, would have serious negative consequences not just for nursing homes but across the continuum, especially with ongoing workforce challenges that are preventing hospitals and rural hospitals especially, from discharging their patients in a timely manner to subacute or post-acute places.

00;08;35;23 - 00;08;43;26
Shannon Wu
So we are currently awaiting the final rule and in the meantime, have supported legislation that would prohibit the agency from finalizing those proposed requirements.

00;08;43;28 - 00;08;56;06
Lisa Kidder
Great, thanks. Going to turn to Travis again for an issue that has perennially gotten a lot of attention. And this is the 340B drug pricing program. Travis, I know that there's some interest in it right now on Capitol Hill. Can you bring us up to speed?

00;08;56;09 - 00;09;22;15
Travis Robey
Yes. The House of Representatives has had some hearings on this issue, trying to make changes that we think are problematic for the program. There's also been some legislation, a draft legislation put forward by some of the members of the Senate who have been champions of the 340B program. We're currently evaluating that to provide comments as they continue to refine that legislation moving forward.

00;09;22;18 - 00;09;43;28
Travis Robey
But I think the key message is that we want to make sure that all 340B hospitals are reaching out to their legislators to continue to explain the importance of the 340B program, how it ensures that you can stretch scarce federal resources further, and particularly for our rural members, how important it is to maintain access to care in your communities.

00;09;44;00 - 00;09;56;18
Lisa Kidder
Great,thanks. And just in the last couple of minutes, let me open it up to you. I know this is a question we sometimes ask our CEOs, but you know what's keeping you up at night? What's the unfinished business of rural health care that you'd like to see tackled? Shannon?

00;09;56;21 - 00;10;19;18
Shannon Wu
Well, I'll just continue on the 340B theme. And I want to mention here, obviously the AHA continues to oppose any efforts to undermine the 340B program, but in particular contract pharmacies. And we know how important that is for rural communities. So we know that there are still legal actions pending in the federal courts. And much of that action has moved to the states, which the AHA is very supportive and poised to help states in protecting access to contract pharmacy.

00;10;19;18 - 00;10;24;06
Shannon Wu
So that is something that we continue to monitor and continue to be engaged on for this year.

00;10;24;09 - 00;10;25;18
Lisa Kidder
Thanks, Travis. Anything from you?

00;10;25;25 - 00;10;46;01
Travis Robey
It really is site neutral for me. That's the issue that I think is front and center in Congress right now. There are certainly important provisions, like extending the Medicaid DSH cut moratorium that is essential for protecting the financial stability of the field. But I think right now, the number one threat to the hospital field are site neutral payment cuts.

00;10;46;03 - 00;11;02;07
Travis Robey
And that's what keeps me up at night, concerned that at a time of continued financial challenges for the field, that Congress might unwisely try to pass that legislation. So again, one last call to action on that. Please continue to reach out to your legislators on that issue.

00;11;02;10 - 00;11;14;20
Lisa Kidder
Great. Thank you so much to both of you. Lots of hard work being done. And again, thanks, Travis and Shannon for all your help. I am Lisa Kidder, and thanks for listening. This has been an AHA Advancing Health podcast.

00;11;14;22 - 00;11;23;02
Tom Haederle
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