Special Episode: Solving the Rural Healthcare Puzzle – A Second Opinion Podcast

Special Episode: Solving the Rural Healthcare Puzzle

Our panel and discussion are organized by the Nashville Health Care Council, the premier healthcare membership association with nearly 300 members here in Nashville, and the Bipartisan Policy Center, Washington DC based think tank that actively fosters bipartisanship by combining the best ideas from both parties to promote health security and opportunity for all Americans. I’m joined on today’s panel by Dr. Sarah Chouinard, rural health expert and chief medical officer of community care of West Virginia, a system of 17 federally qualified health centers operating across nine counties in rural West Virginia.

Alan Levine, president and CEO of Ballad Health, an innovative integrated health care delivery system that serves 1.2 million people in 29 rural counties of Northeast Tennessee, Southwest Virginia, Northwestern North Carolina and Southeastern Kentucky, and Stuart McWhorter, Commissioner of the Tennessee Department of Finance and Administration and the co-chairman of governor Bill Lee’s Health Care Modernization Task Force. Our wide ranging discussion touches on workforce issues, the challenge is rural and non-urban health system space with current payment models, and what on-the-ground conditions continue to see with the ongoing opioid epidemic. Our panel puts forth solutions as well as defines the problems.

Bill Frist:                       This is jointly sponsored by the Bipartisan Policy Center and the Nashville Health Care Council. It really is what the council does best, that brings together, in this case, 300 people, and oh by the way, we sold out about two weeks ago. We tried to blow that wall out to go to 600 people, but they wouldn’t let us. On an issue that when you start intuitively you’d say people aren’t going to be that interested, it really comes back to the fact that 93% of Tennessee is rural. Something that most of you probably did not realize because most of us are from urban or suburban areas, but 93% is rural. Health is influenced greatly. We know this from work with the Robert Wood Johnson Foundation and we know it from our own experience is greatly influenced by a place, a time, but place is a really critical factor in determining health and health outcomes in so many ways.

Bill Frist:                       60 million people living in rural areas are at greater risk of dying from the chronic diseases that we all know about. Lower respiratory disease, heart disease, cancer and stroke. The communities also face an alarming rate of hospital closures, which was just mentioned of worker shortages that we’ll touch upon, geographic challenges of getting timely care that in this great country today, a wealthy country today, every individual and every family deserves. While there’ve been a lot of renewed efforts to revive rural American, we’ll come back to some of that because much of health and well-being determines on the social determinants and nonmedical determinants. We got to address those and we’re doing our best to revive these communities.

Bill Frist:                       The residents, rural communities continued to face huge, huge disparities that in this century and in this great country really should not occur. Efforts at the federal level have taken a siloed approach, and siloed for access, and we’ve tried at the big legislation lab, but the siloed approach is simply not working, and that really does bring us today. We have a short period of time and we’ll go very quickly, but I do want to come back to solutions as we come through. Let’s look at where we are today. The introductions. I’m going to go really quick because you know, Dr. Sarah Chouinard, Chief Medical Officer of Community Care of West Virginia, a federally qualified health center, everybody in here should know what our federally qualified health centers are doing and we’ll talk about that.

Bill Frist:                       Previously recognized as a rural practitioner of the year, she is really here to represent the intimacy, the local, what goes on in communities in a direct way. Alan Levine, president, CEO of Ballad Health, an integrated health care delivery that serves 1.2 million people in 29 rural communities in Northeast Tennessee and also Southwest Virginia, Northwestern North Carolina and Southeastern Kentucky, a regional approach to rural health care, which really captures the innovation the best in the country in terms of new ways of looking at things. Of course, you all know Stuart McWhorter, Commissioner of the Tennessee Department of Finance and Administration, co-chairman of the governor’s Health Care Modernization Task Force.

Bill Frist:                       Just as a scene setter, let’s just continue down the line. Sarah, you’re on the ground each and every day. You’re taking care of patients, you’ve taken care of hundreds and thousands of patients. At the epicenter of the opioid epidemic, and we can come back to that, open us up and take us to the world of rural health.

Dr. Sarah Choui…:        Sure. Thank you for having me. When you look at, I think rural America, I don’t think West Virginia is necessarily any different. What you see is that patients are a lot sicker and they’re a lot older than they are in urban areas. As a result, we have chronic illnesses that are less controlled, more severe. This has been true since I started medical school, but what’s happened is, layered on top of that now is this opioid epidemic. I think it’s fair to call it that it really reaches every corner of everything that we’re doing in the office. We have 6,900 kids who are in foster care, double what it was a decade ago.

Dr. Sarah Choui…:        State officials estimate that about 80% of those kids are impacted by the opioid epidemic. What we’re finding is that these beautiful communities, beautiful farms, great people are really left addressing an issue that is new to them. One of the issues that we face in rural medicine is how do we get people, you mentioned workforce, how do we get the people there who can solve this problem? How do we get technology there that can help address this while still not forgetting that we’re among the sickest patients in all of America.

Bill Frist:                       So workforce technology, we’ll come back again. The scene setting, Alan.

Alan Levine:                 Thank you Senator. First of all, I’m just going to just sort of set the stage for what I think the general problem is for rural hospitals specifically. Not to suggest that rural hospitals are the only issue-related to rural health. Obviously they’re the epicenter of most of our rural communities, both in terms of workforce and access, but I think it’s really a three pronged problem. Number one, the movement towards our alternative payment models, which needs to happen. I guess the question is, why does a bank robber rob a bank? They do it because that’s where the money is. Well, most of federal policy that’s been driven to try to reduce the cost of healthcare, which is good, is really targeted towards where most of the money’s being spent, which is your urban and suburban areas.

Alan Levine:                 The solution for rural areas, by definition, has to look different. Issue number one is the movement towards value-based care which drives down utilization, and it’s still linked to a fee for service system is problem one. Problem two is the decline in population in rural communities, the decline in birth rates. So we’re seeing an out migration of young adults and we’re seeing a real challenge with population. When you combine population decline with the movement towards alternative payment models that decrease the volumes, you now have a business model that’s in decline. When you decrease the use rates in a hospital and there’s no population growth to offset that, those decreasing use rates, that hospital’s not going to survive unless there’s a bridge built to a different model.

Alan Levine:                 The third challenge, when you add on top of the combined decreasing use rates and decreasing population, you then to it the social determinant issues. There’s two types of social determinants. You have the obvious problem of people that are poor can’t afford their medications, don’t have transportation, don’t have home or food security. Those are legitimate problems. But the root cause, which is an emerging science, is the number of children that are born with adverse childhood experiences, and the first three years of their lives, the rest of their life is basically decided in that first three years. I’m going to talk later about some things that Ballad Health is going to try to do to address that very specifically, something Governor Lee said when he ran for office, which was the most honest thing I’ve ever seen somebody run for office say, and he attributed it to you, Senator, is don’t run for office and promise a bunch of bright shiny objects in health care. They don’t work. They cost money.

Alan Levine:                 Focus on the long game. This is something, whatever we’re going to do to solve these problems, they’re going to require patients commitment to the effort and time. That’s, frankly, I think if you’re going to solve these problems, you have to deal with both social determinant issues at the same time. Bail the boat out and plug the leak at the same time.

Bill Frist:                       Good, Alan. Again, we’ll come back and, as all of you know, the cards are either at your table or they’ll be delivered. Write down your questions that you have and we’ll save 15 minutes at the end, We’ll go through those fairly quickly. The social determinants to nonmedical determinants, clearly as I mentioned, and you mentioned, we’ll come back to. We like to talk innovation and we’ll talk the solutions, and we’ll come to things like telemedicine, telehealth, I said, and we’ll talk in health and well-being. Policy is absolutely critical. And Alan, you just introduced that.

Bill Frist:                       Stuart, a lot of people in the room here know you as a business man, a lot of people know you as an entrepreneur in many ways, and today you’re wearing the hat of state government. Talk to us a little bit about your history and also what you’re doing.

Stuart McWhorte…:     Thank you, Senator, and thanks again for having me. It’s great to be with the team here. A good segue from Alan’s comments. My background is, actually I was in the hospital administration and got into venture capital, did it for almost 25 years with my dad. Governor Lee asked me to join him when he won and asked me to serve in this role of F&A commissioner

Stuart McWhorte…:     What we really want to do, and there’s sort of two or three things I think the state can do in this. One is, we have the ability to convene, the power of convening assets. In order to do that, we have to take some time to assess what those assets are in the communities around the state, all 95 counties. There are some common themes that are contributing to some of the challenges that we all are aware of, but there are some very unique challenges, and what we need to do, what our job is, from the state’s perspective, is to convene the market, convene the departments, the agencies that serve the state, but also you all. So, we need to be able to do that, and in order to do that, we need to know what exists. Then I think the other really most important part of it is, allow the free market the ability to solve those problems.

Stuart McWhorte…:     The state shouldn’t be in the business of being a health care provider. In certain ways, we obviously are, but particularly right here in Nashville, Tennessee, the free market exists. So, we need to be able to utilize that in a way to help solve these problems no matter what those are. There’s lots of opportunity to do that. We’re looking at it. I think, again, to Alan’s point, what I’ve told the governor is if you do this right, coming in, you weren’t the health care governor, but you may end up being the health care governor in the next two governors or three governors from now. You may not get the credit serving hopefully seven more years, but the next governor or two might get that credit for the seeds that you are planting today.

Bill Frist:                       Sarah, take us just a little bit deeper. You’re on the front line, you’re in the community. I mentioned in a little bit, we’ll come back to the opioids, but it is the epicenter there. It is rural, it is West Virginia limited resources, and you’re taking care of patients through your clinics. There’s 17 clinics that she’s responsible for over nine counties?

Dr. Sarah Choui…:        Yes.

Bill Frist:                       Over nine counties. Tell me a story.

Dr. Sarah Choui…:        Well, there are so many stories, but what happened earlier this week really paints a really poignant picture. We have a health center that is truly in the middle of nowhere, not a stoplight, not a gas station, can’t get a sandwich. It’s just trees and a little wooden building. There we have an amazing doctor. She has one physician’s assistant and three other people who work in the building. That’s it. This is what you’re looking at. A gentleman walked in the front of the building and said, “There’s a woman outside who’s having stomach pain and you guys need to come help her.” And they said, “Sure. Great. That’s fine.” He said, “She’ll probably need a wheelchair.” “Great. Well we’ll come get her.” So out they roll, they get the wheelchair, they take this woman, put her in the wheelchair and the guy takes off, gets in the car and he’s nowhere to be seen.

Dr. Sarah Choui…:        Well, she comes into the clinic, and it’s because she is in active labor. She has had no prenatal care. Dr. Jones has not delivered a baby in 17 years. Adding to that, we finally got EMS to come in, and when EMS walk through the front door, they said, “Oh, we know her. We know her. Two weeks ago, we coded her in her house and last week we gave her NARCAN. She’s an active opioid user.” So, the baby ended up being delivered in the hospital. The baby will have neonatal abstinence syndrome and mom left and went home and that baby will end up in the foster care system. This is this week’s reality in just one of 17 clinics and 16 other stories like that happened this week too.

Bill Frist:                       It’s the challenge that’s out there and it’s really easy to walk away, especially if you’re living in a city and you’re doing well and your company’s doing well and you’re growing, but remember, 93% of Tennessee is rural and this is the reality that is there. That was West Virginia, but I think Tennessee is more rural than West Virginia, surprisingly, and no one will hold me to that, but it is everywhere. That’s what we need to address and come to solutions as we come through, but that’s the reality that’s on the ground every day. We don’t say it. The advantage of being here today listening to this podcast is that that’s the reality. How do we get out of our silos to address it?

Bill Frist:                       One way to do that is straight policy. We’ll come to that. Another is engineering, and we’ve been siloed in the past and we haven’t relied on an engineering approach of taking a regional approach, looking at the resources, reorganizing those resources, and that is painful because nobody wants to change when it comes to healthcare. Ballad has taken that on. Most people here know a little bit about Ballad, but Alan, I think it’s worth, sort of, what did you set out to do? What did it take to get there? We don’t have a lot of time, and then, where are you today?

Alan Levine:                 There’s a story that Gene Kranz once told, the guy that was the commander of Apollo 13, Senator. He said there was a story of a young kid that wanted to go do battle for his king. He begged the king, and the king said, “No, you’re too young. You’re not ready for it.” The kid said, “No, I’m going to go do it.” So, the king gave him a horse, a shining armor and a sword and sent him on his way. Stuart, you probably are going to feel this way when I tell you that your punchline, but the kid’s gone for like three weeks. He comes back, he’s beaten up, the horse is limping, the sword’s broken in half. The shining armor is all beaten up. And the kid says, “King, I have defeated our enemies to the East.

Alan Levine:                 The king looked at him and said, “Son, we don’t have any enemies to the East.” The kid looked at the King and said, “Well, sir, we do now.” In many ways, that’s how I feel out there because here we were, Ballad, you had these two big health systems in a rural region. Nashville has what? Two trauma centers. We had three trauma center serving a rural region, two level one trauma centers. We had two level three NICUs, one with a census of eight to 10, the other at a children’s hospital. This was irrational. So, I’m going to talk about where public policy meets the marketplace. In Greenville, Tennessee, we had two hospitals that each were lower than 20% capacity, had lost $50 million in the five years leading up to the merger. Both were financially insolvent.

Alan Levine:                 Ballad took over both of those hospitals, consolidated the two, and we’re converting one now to a residential facility for women who are pregnant and suffer from addiction or homelessness. Now, there’s no business model for this until the governor came along, and Stuart came along and the commissioner came along and said, we’re going to extend Medicaid benefits for women postpartum.” So instead of losing their eligibility at 60 days, they can keep it for one year. Number two, that all of a sudden created a sustainable business model for us to keep these services where we have women that can get prenatal care treatment, drug treatment, literacy, workforce training, parental training, and hopefully keep that baby out of the child welfare system.

Alan Levine:                 This is a better use of assets that meets what the actual demand was, but there was no business model for it, so therefore, it’s hard to skate where the puck’s going if there’s no resources there, but ballad was chalk-full of this. We had two hospitals in Kingsport, one of them, a major tertiary hospital that lost $80 million in the years leading up to the merger, lost $15 million two years ago trying to sustain all this duplicative service. Now, it’s hard. It is really hard to go into a community that has been told for years and years and years, “If they have it, we should have it.” And then to say that’s not the right model.

Alan Levine:                 The reality is, while rural hospitals are closing all over the country, in our region, not only have none closed in the last three years, we’re actually reopening one that was previously closed and we built America’s newest rural hospital in Unicoi County, Unicoi, Holston Valley and the two hospitals in Greenville were cited by the Tennesseean as four hospitals in Tennessee that were at imminent risk of financial collapse. None of that happened because we built a system with synergies to eliminate that duplicative cost. I’ll close with this one piece of information that we haven’t really announced yet, but Governor Lee has said that the best way to close the problem of health care costs, which I agree with, is to reduce poverty. That’s true.

Alan Levine:                 All of the data shows if you reduce poverty, you close the health care disparity gaps. You close the racial gaps, you close the income gaps and you reduce the cost of healthcare long-term. Well, if you look at our region, we have only a 52% workforce participation rate. 50,000 people are out of the workforce because they’re addicted, they’re alcoholic, they didn’t finish high school, they lost their job in the coal industry. The reality is that if we want to solve this problem, we need to make sure every 18 year old in this state graduates college or career ready. To do that, what does the evidence say? You got to be ready to read at the third grade level by the end of the third grade. To do that, you got to make sure kids get to kindergarten, kindergarten ready.

Alan Levine:                 Now, you’re entering Ballad Health’s realm. We deliver every baby in the region. We now have the opportunity to reach out to every pregnant woman that we find, do an assessment, determine if those children are at risk for adverse childhood experiences, and then link up with what we’ve created, which is the largest accountable care community in the country, and link those moms up to services before that baby is born and then to partner with East Tennessee State University at the Center for Rural Health and Research that the governor and the commissioner has created to study these outcomes. Over 18 years, we will be collecting more data than we will know what to do with to help the nation learn how to address these adverse childhood experiences early so they result in kids graduating college and career ready,

Bill Frist:                       Alan, of the 29 counties, how much of the care are you delivering there?

Alan Levine:                 On an inpatient basis, we’re delivering pretty much all about 75% market share we have. And outpatient, it’s a very highly competitive market.

Bill Frist:                       You’ve taken a lot of heat for closing down certain things and opening up others. We don’t have a lot of time, so I don’t want to address that now, but this is, if you’re doing an engineering approach to make things seamless and you’re having to take away existing structures, and it may be a NICU, it may be a trauma center, it’s scary to people. We’ll come back and talk a little bit about that because outcomes I think had been great today statistically, but it is really hard to do. Let’s come back to that as well. Stuart, this intersection of policy and health and innovation is critical when we come back several times, and I guess the most recent thing that all of us have heard about in that room is the budget and what the governor has said. Start with that and then talk a little bit about the policy initiatives that you see coming forward.

Stuart McWhorte…:     Sure. We focused quite a bit of attention in this current proposed budget that we released a couple of weeks ago now around health care. Knowing, as you all know, the legislature passed a bill in this last session for us to go apply for a block grant. So we’re obviously in the middle of that and awaiting some responses, but we all know that we’ve got to keep going down the track. So, we are addressing some things in this budget around health care. Alan mentioned some things we’re doing with TennCare and Gabe and his team are here. They’ve done a fantastic job, not only getting a block grant application out very quickly, which by the way is a very creative … it’s really not a block grant. We call it that, but it’s really not. I think it’s a very creative option.

Stuart McWhorte…:     But also, they came forward with some really creative solutions around the postpartum extension around dental care for pregnant women and a host of other things that are true game changers for TennCare. We also addressed in this budget the safety net around both primary care, specialty care, dental care and mental health. For the first time, we will have a children’s mental health safety net to address children under the 138% of the federal poverty level. But probably the biggest announcement and one that we’re still working on is the governor took some one time money, $250 million in proposing to set up a trust fund, and we’re calling it the K-12 Mental Health Trust Fund.

Stuart McWhorte…:     The purpose of that is to one, just from a pure financial standpoint, we’re taking it out sort of off balance sheet. The treasurer will manage the money just like the Tennessee Promise they’re doing with education, manage the dollars, how those dollars grow, and what we can yield and get the interest off of, we will then turn around and invest that in our mental health programming in districts in our schools. Specifically, we want to have resources in every school in the state to deal with some of the behavioral issues that some of these kids and students are challenged with. Because I think again, it’s along the lines of what Alan has described, which is we want to focus on the family structure. We need to get even to the earliest of infancy to start addressing some of the challenges that these families and these children are facing. Because if it’s not addressed early on, it just compounds itself.

Stuart McWhorte…:     So, we’re trying to get to these things that are really, I wouldn’t say easy because they’re not, they’re challenging, but there are areas that have not had the focus and attention until now. So, this governor, again, long view, these are things, investments we have to make looking in the next 10, 20, 30 years. But what’s great about this trust fund is that we’ll start with 250 million. We know because we’ve talked to them. There’s foundations that will walk alongside with us and invest alongside with the state. There’s other groups that will participate. This, hopefully will be … it could be a billion dollar fund at some point, hopefully soon, and that can last forever. That’s what’s great about this. This is a long-term, serious commitment that won’t encumber the state fund in terms of recurring dollars and be a drain, or when times are tough, we’re pulling back and having to pay for things that are essential. That’s why I’m excited about it.

Bill Frist:                       We’re beginning to see a little glimmer of hope and optimism, and I want to move into that field because there are huge opportunities of solutions from this sort of what I call a systemic engineering approach, from a policy approach, we have a governor, the first words out of his mouth were rural health, were rural issues and then rural health, and education, others, but rural health, and we have an F&A commissioner who’s basically said, “We’re listening. We want to listen. We need you, and if we work together, we will grow with you.” A lot of states, most States just don’t have that coming in. Again, I’m just going to start pulling some of these threads of hope, but before doing that, I’ve got to backtrack a little bit.

Bill Frist:                       Sam Quinones on A Second Opinion and came to town. He wrote a book called Dreamland, written in 2015. Everybody needs to read it. Tennessee actually plays a pretty prominent place in middle Tennessee, but around Tennessee in the early days of the opioid epidemic with this tar element, but you can read the book. But in the book he started as he marched through the opioid epidemic today, and by that, I also mean methamphetamine and fentanyl and these second waves. He started where you were born, where you grew up, where you went back to practice medicine. Where are we today, and his opioid epidemic still a big issue?

Dr. Sarah Choui…:        Absolutely. Where I was born and raised and went to med school is considered ground zero for the opioid epidemic. And interestingly, it started in the mid ’90s. I’m dating myself here, but that’s when I started medical school. So I was doing my training at the exact same time that this started. I think that really all that’s happened is it’s fallen out of the news headlines. It’s no longer sensational because sadly, it’s just kind of common news. It’s just happening everywhere. When you look at the numbers, is it still an epidemic? 2017, 12.5 million people were misusing opioids. In 2018, it’s 11.1 million people. That still sounds like a lot of people to me. So yes, we’re seeing it everywhere and in our communities, and I think that you talked about early intervention and education.

Dr. Sarah Choui…:        We’re a primary health center. We should be worrying about hypertension and heart disease and childhood immunizations. This is really our bread and butter, and instead, we’ve just partnered with an institute out of Arizona for a program that helps teachers, school-age teachers figure out how to help kids build resilience, how to self regulate because the adverse childhood events that these kids have suffered as a result of the epidemic is putting teachers in a place. So we talk about workforce. You think we’re going to talk about health care workforce, but we can’t keep teachers in classrooms in rural West Virginia. Absolutely, it is still a problem. I think that something I hope we’ll get back to is I don’t think that the solutions are hard. It’s really not like we need expensive technology. We don’t need to have a robot in a rural hospital to do a prostatectomy to solve this problem, right?

Dr. Sarah Choui…:        That can to big multimillion dollar health centers. What we need is we need boots on the ground, people who are addressing behavioral health problems. We get people who are addressing addiction. That medicine, it’s important that it’s done correctly, but primary care providers can do that medicine. Project ECHO, when we talk about telehealth, a lot of people, I think when you think about telehealth, you think about computers and rooms, you think about technology, you think about platforms, but Project ECHO, it was originally a Robert Wood Johnson grant out of New Mexico, but their slogan, don’t quote me, but it’s something like instead of moving people, in other words, instead of bringing specialists into areas, let’s move knowledge.

Dr. Sarah Choui…:        So, we have board certified family docs, nobody who’s done any special training who are treating hepatitis C in rural communities in West Virginia because we have to. That’s really through the transfer of knowledge, not because we somehow overpaid hepatologist to come to a rural community. When you look at workforce issues, it’s tough, schools, where are you going to put your kids in school? How are you going to get along in a rural community? This is a tough sell. One of the ways we recruit primary care doctors is they’re born and raised in these communities. The minute that these people hit medical school, we approach them and say, “Do you want to come home?” Because if you want to come home, we can start now building a conversation about what that can look like for you.

Dr. Sarah Choui…:        If you’re a person who wants to go into a specialty, you likely are aimed at going to a large hospital in a large city. We need those people too. But I think the conversation needs to turn toward really thinking about using primary care as a vehicle to solve a lot of these problems.

Bill Frist:                       Let’s down workforce a bit. You came home, you were on the West coast for college, and you ended up back at home and you started down your list. What does attract people to come back to a region? We have medical schools here in town, one of which, Mary, really almost focuses on rural health, non-urban health. East Tennessee, we have a fantastic medical school just the same. What brings people, and I’d like to hear from both of you as well on workforce. What brings people to rural areas? What makes it attractive to them?

Dr. Sarah Choui…:        Well, I think a huge part is if it is home, but also the impact that you can have. If you are in any way service minded, people in rural communities really are not going to the dermatologist for a little abnormal lesion on their arm. They’re coming to you. People who have chest pain for better or for worse are showing up in your office. So I think that it’s your ability to really be part of the fabric that makes a rural community sustainable. So, it feels like you are a key member of the community as opposed to it could be anybody.

Bill Frist:                       Yeah. The workforce issue is big. You could bring the to the community or you can use telehealth, telemedicine and not just educate, but also have virtual care. We’ll come to that in a second. Ballad has been very successful. A hundred new physicians being attracted to these 29 counties, include some specialists to take it from there. How have you been successful, what are the touch points, how do we increase that, and what’s your experience been?

Alan Levine:                 Since our merger two years ago, we’ve recruited 200 new providers into our region. We now have the most number of doctors practicing on our medical staff in the history of either legacy system. We now have cardiologists in Wytheville, Virginia, in Wise County, Virginia. We’ve just recruited an endocrinologist to Kingsport, a urologist. We had shortages in that area. It’s hard to get people to come to rural communities. In many respects, Ballad Health is subsidizing this. We invest almost $200 million a year of losses in the physician practices because we have to employ so many doctors because frankly, the deck is stacked against rural areas when it comes to physician supply because the payment system doesn’t reward you to go to rural areas, there’s not as much volume, not as much critical mass, it’s hard for a specialist to be able to survive.

Alan Levine:                 If organizations like Ballad or LifePoint or others aren’t out there providing those employment opportunities, there would be no doctors. Senator, may I tag on to one thing that Stuart said, because again, I think it’s every opportunity I have to point out where policy meets the market, I think we need to talk about that. This $250 million for mental health, Ballad, because we understand you can’t put counselors in every school in a rural area because there’s not enough and there’s no enough critical mass. We now have telehealth technology in over 108 schools now. We’ve already made the capital investment. So the incremental cost of hiring a cadre of counselors that are available via telemedicine in all of those schools, it will cost virtually nothing, but now you’ve got a partnership where we’re capitalizing it, and the state is investing in the sustainability.

Alan Levine:                 That is the kind of policy that it gives us the opportunity to use our innovative approach in the marketplace and know that there’s a business model to sustain it over time. We just started a dental residency program in rural Southwest Virginia that will also cover Northeast Tennessee. That program wouldn’t have existed if Ballad hadn’t been created. The labor issues, and I think you’re right, the reason we’ve been successful recruiting physicians to come in is, when I talk to them myself, what they tell me is they like what Ballad’s vision is, they like that we have a purpose and they want to be a part of that. We just recruited two pediatric surgeons in a region that has a rural children’s hospital, which there’s not a whole lot of those.

Alan Levine:                 The reason one of the pediatric surgeons is coming, he’s coming down from Minnesota, he’s a highly, highly respected pediatric surgeon. He said he could go anywhere. The thing that brought him to Ballad Health was when I explained to him the initiative to target children and moms so that in the first three years of life we can address adverse childhood experiences. He said, “That gives me a mission. That’s what I went to medical school for.”

Bill Frist:                       Other than that telemedicine, and again, you have 1.2 million people that you put together this multi-state regional approach community health as, you mentioned David as, David [Dell 00:36:20], as more hospitals and more rural areas than any hospital system in the United States of America. We’ve got expertise in this room to address these issues that are out there today. What’s exciting to me is starting to hear the problems coming through and then start putting some of these solutions together. So let me just mention telemedicine because both of you have mentioned it. It does seem to me, at this day and time that 1.4 billion doctor-patient interactions and only about a 10th of 1% today are by telemedicine, telephone, televideo virtual. It seems to me there’s huge capacity. It only makes sense at least when I think we were tracing up in Gregg County, Appalachia, Virginia, no hospital, no clinic, no cell towers.

Bill Frist:                       Now, a cell tower’s come in, and for the first time, you can talk to a doctor in Roanoke, that you got huge power, just out in Tennessee, and Stuart and I’ve talked, is not on the forefront of telemedicine. So our policy, we’re looking at policy to improve that today. But anything, other comments on telemedicine or virtual care to help because we’re not going to be able to get enough doctors … if 93% of tendencies is rural, we’re not able to get enough doctors to those areas in spite of everything we do. Anything else in telemedicine? Both.

Dr. Sarah Choui…:        I think the only thing I would say is, and you touched on this with policy is payment reform. A real issue is this whole business of an originating and a distance site. Really figuring out how we can turn virtual visits into absolutely the same as a face to face visit. I think that’s a key part of it. The other I think is being strategic. In one of our rural hospitals in West Virginia, there’s an eICU program, so they have only one bed, but being able to really have an intensivist there at the bedside, that’s when having this face to face, actually having the doctor in the room becomes really powerful and really game changing for patient outcomes.

Bill Frist:                       Just stay on telemedicine. I need your questions up. Raise your hand if you have cards and then the cards will come to me in about two minutes and we’ll start with your questions. Alan.

Alan Levine:                 On the telemedicine, we have an eICU in one of our hospitals in Greenville. You’re right. These are just investments we have to make because we can’t reach personally. But one shameless plug, when you’re talking about labor and labor shortages as it relates, not just to telemedicine but labor generally, the majority of our nurses are now millennial, and it’s an entirely different culture in terms of how you recruit and retain, it’s a huge issue for the industry. Shameless plug for Ballad Health. We were just named by Forbes Magazine as the 29th best place to work in the country for diversity, which surprised a lot of people. It didn’t surprise us because we’ve been focused on it, but diverse workforces, being focused on diversity is something that millennials care about. That has to be a part of the ingredients to success.

Bill Frist:                       You’ve got to have the need, the demand is huge. It is not just access to health care, but it’s much broader in terms of social determinants. To incentivize social determinants, somebody’s got to pay for it because I’m a hospital there. My heart would say I need to get involved in transportation and I’ve got to get involved in food and I’ve got to get involved in cyber bringing in the internet, but at the end of the day, you’ve got to keep the doors open. So, some way, alternative payment reform has to take place. We mentioned the importance of payment reform in telemedicine, and you mentioned it earlier, what sort of alternative payment reform is necessary as you move from a fee for service, most of us in the room are still fee for service, but to where we’re inevitably moving value-based care?

Alan Levine:                 This is an area that is both a great a success for us, but it’s also our greatest threat. We’re one of only 18 ACOs in the United States that has generated savings for the federal government in every year of the program, the Medicare Shared Savings program, which is great, except that money came out of our hospitals. Our business model, we do this self destruction of demand where we’re destroying our own revenue stream, and in rural areas, that’s toxic. In my view, I think the best way to sustain the rural hospitals as we move towards alternative payment models is for CMMI and for states to collaborate and go to rural systems and say, look, “How much did we pay you last year? We’re going to take some savings off the top. We’re going to give you a five-year bridge. Whatever you do differently to save money, you can keep, but you have to reinvest that money into things like diabetes clinics, CHF clinics, early intervention.”

Alan Levine:                 Things, to your point, when we go pay for transportation, or we go pay for homes, or we go pay for anything that keeps a patient out of the hospital, we’ve destructed our own demand, we’ve harmed our own business. The payment model has to incentivize behavior. In Nashville, you can go from 126 admissions per thousand down to 90 and the hospitals won’t feel it. They’ll still grow because you have population growth. In a rural community, when you’re going from 126 admissions per thousand to 90, and there’s population stagnation or decline, you will be out of business unless there’s a different payment model that builds that bridge.

Bill Frist:                       Sarah.

Dr. Sarah Choui…:        Well, I’m on the other side of the coin, right? So we are an outpatient clinic in a rural area and participating in an ACO. As the hospital outpatient urgent care volume drops, that business is coming in our front door. Same thing in sharing those savings across the board, but I think when you talk about payment reform, there is reforming the things that we are currently doing and changing the way that reimburse those. But there’s also really rethinking about different roles. You mentioned social determinants of health, community health workers. That word means a lot of different things. There are about a hundred definitions, but for us, what that means is a lay person. This person does not have any kind of healthcare training, no degree, but a person who can come in and meet with patients and really understand what the problem is.

Dr. Sarah Choui…:        Oh, if they have no heat, oh, the reason the kid’s in the ER for asthma every fifth day is because they burn coal, and that’s really what the problem is. Working on those social issues, I don’t think that it’s the role of the primary care physician, and maybe not even of our office, but I think when we talk about reforming health care, we have six community health workers on board. We could have 600 it feels like. They are among the very busiest people in our offices. They come back and report to the physician and said, “You want to know why their diabetes is uncontrolled?” And then the story [inaudible 00:43:21].

Bill Frist:                       Even that, it comes down to licensing, how much we empower people at what level. One of the things we learned from other countries is this community health worker, that you can train people who don’t have your training or my training in medicine and they can do 90%, 95% of what positions and nurses do. I said, it does come down to, again, policy in licensing. It’s why we all have to stay involved in government. A lot of times you see on TV, I don’t want to participate in government, but it’s why people like Stuart McWhorter left sitting where you are and going to government. And we have a governor. Again, this policy’s important. There’s several questions here on policy.

Bill Frist:                       The State of Tennessee has been successful recruiting industry, and Stuart, and bringing jobs to the state. Are their efforts to recruit companies to rural areas to address these larger issues of poverty, which we know will impact health and health care?

Stuart McWhorte…:     Yes. In this budget, we’re addressing that and looking with ECD, Department of Economic Community Development on how to actually add a premium to the incentive where we can get them to distress counties. We have distress counties in the state. Then we’ve got the 30 some odd that risk. We’re looking at it kind of a tiered approach because we … again, it’s the same, the theme that we’re talking about here. We got to bring jobs and industry to these rural parts of our state. In order to do that, we have to create more incentive. What we tend to hear is they want to come here or they want to be in middle Tennessee.

Stuart McWhorte…:     You can’t just make somebody go to these parts of the state unless you’ve got assets and certain investments made. Providing the incentives is a great way to have the conversation, but we have to be, as a state, we have to be making investments in our education system, in our healthcare system, in our criminal justice reform system, prison system. We talked about alternatives to prison for women going into these residential recovery courts and looking at alternative. It’s making these foundational investments that really change the trajectory from an economic development standpoint, but I guess the immediate is we’re having discussions about trying to create premiums for these particular parts of our state.

Bill Frist:                       I’ve got other questions. Really, we’ve touched on a lot. There’s many in here on social determinants and how you link social determinants to what we’re actually doing in care delivery. I think the alternative payment reform, Medicaid has a role there, clear role the Medicare does. Medicare is beginning to reimburse more for things like food and transportation, which two years ago didn’t at all. Then obviously commercial payers who, in many ways, were on the frontline of innovating, but the payment reform is critical. Technology, we talked about telemedicine, the limitations and talking about technology coming through. Let’s close, it’s frustrating to close cause it’s such an unbelievable broad, enriched topic. But let’s look for, and we haven’t prepped any of this as you can tell, any of it is, I want to find a solution, a policy, an optimism.

Bill Frist:                       Not overstated optimism, but it’s easy to leave something like this and say, “Good gosh, this is so complex. I just need to go back to my day job and do it,” but we can’t do that. I’m giving you a little time to be thinking as I’m asking this, but each of you take a minute and talk about one thing, it can be a policy, it could be something that you’re doing that people need to hear across Tennessee and across the country that could go to scale. Something that would give some hope amidst the opioid addiction, which you just said, it’s not getting a whole lot better. Making progress, but not a whole lot better. Who wants to go first? Stuart.

Stuart McWhorte…:     I think all of you know, and I’ve said it earlier, but our governor, Governor Lee is very focused on rural Tennessee and that’s a serious commitment. Everything that we do, regardless of it being health care, this topic is focused on rural Tennessee. I think we’re going to see a change from those 15 distressed counties. I think we’re going to see that draw, which is great. But what I would say is that we have a governor and a legislature that is committed to it. I think one of the greatest things that we can do as a state, not only can we convene, as I mentioned earlier, convene you all, convene the resources, convene the market and the assets to solve problems, but our job as well is to look within ourselves as state government and where we have regulation that makes it very difficult to set up something.

Stuart McWhorte…:     If we can look at how we can reduce the regulation while still providing quality care, that’s our job, is to try to do that because I’ve heard it. I heard it even today. The requirements that are placed on our organizations are such that it just makes it almost impossible, either from a cost standpoint or from a timing standpoint and understanding that these issues are right now and real and getting even more of a crisis.

Bill Frist:                       Great. Alan?

Alan Levine:                 Well, I’m, I’m optimistic because the governor is focused, not in word, but indeed on rural Tennessee and he has surrounded himself with a team of people who understand the issues in rural Tennessee. So it’s real to us out there in the field that there’s hope and the policies that are happening already are very supportive of what we’re trying to do out there. They’re not trying to take over what we do, they’re trying to add value to what we’re doing. I think that’s good for the tech. We care deeply about the people who need the services, but we also need to care deeply about the people who are paying for the services and making them efficient. I will tell you, I think the thing I’m most optimistic about is I think a lot of people nationally, just as we’re sitting here talking about it and the room is full, a lot of people nationally are trying to understand what are the dynamics that are causing rural hospitals to close.

Alan Levine:                 There’s a recognition that perhaps, maybe not every community needs a rural hospital, but they need something and that we need to build a bridge to get there. So, there’s actually agreement on that, and that gives me hope. Certainly, working with our partners like LifePoint, when you look at the capital flight from rural communities, there’s reasons why it’s happening, and so our partners in state and federal government recognizing it. Last thing I’ll say is 70% of our payer mix is uninsured Medicare and Medicaid. Only less than 25% is commercially insured. Of those that are commercially insured, most of them have a high deductible plan.

Alan Levine:                 Rural systems will not survive long-term without that bridge being built, but I’m optimistic for the first time in a long time that our state leaders and federal leaders get it, and we’re prepared to work in partnership with them and our other provider colleagues to get there.

Dr. Sarah Choui…:        Yeah, I would agree completely. I think that’s right. I think, of course, policy has to change, payment reform, it’s critical. But I think the thing I would want to leave with is for us, it’s an entirely grassroots effort. We have people in the field who know what to do. There are people in the hills and hollers of West Virginia who are building really incredible high quality, comprehensive pain management for rural patients. We’re launching an addiction recovery program. As part of that, we’re building a recovery school. Kids are going to spend half of their day in the classroom and half of their day in the recovery system.

Dr. Sarah Choui…:        We just made this up. We didn’t ask anybody, we didn’t study any research. We said, “What’s the problem and how do we fix it?” And it’s working. I think that my charge to all of you would be, the question that you should be asking is, what do they think? Because they, meaning the people out in the field, often see firsthand what the problems are and the solutions aren’t really hard as long as policy and payment reform both allow those things to happen. So it’s exciting. I don’t think that they are problems that don’t have a solution. I just think that we are tip of the iceberg in getting there.

Bill Frist:                       Well, that brings us to a close. Thank you for tuning into this special broadcast of A Second Opinion, with a special thanks to the Nashville Health Care Council and the Bipartisan Policy Center. Also, be sure to listen to our regular Monday broadcast. This episode of A Second Opinion was produced by Todd Schlosser, the Motus Creative Group and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcast, Spotify, or wherever you’re listening right now. You can also watch our interviews on YouTube and on our website.

Bill Frist:                       Be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show, it’s guests and sponsors at asecondopinionpodcast.com. A Second Opinion broadcasts from Nashville, Tennessee, the nation’s Silicon Valley of health services where we engage at the intersection of policy, medicine, and innovation.