Reimagining Rural Healthcare With Paul Rosen

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Stewart Gandolf
Welcome to the Healthcare Success Podcast, I’m Stuart Gandolf, your host. And right this moment my visitor is one other previous buddy that I’ve met years in the past, I feel, via the Cleveland Clinic, affected person expertise summit. Dr. Paul Rosen. Welcome Paul.

Paul Rosen

Thanks a lot, Stewart, for having me.

Stewart Gandolf

Yeah, IT‘s nice to see you once more. Paul and I, Dr. Jim Merlino and others actually have been keen about issues like affected person security, affected person expertise for a very long time now, and this subject has all the time been kind of a you already know, precedence of mine, not simply from a enterprise standpoint, however simply from, you already know, doing good in drugs standpoint. So, I am blissful and excited to have Paul again.

So, Paul, you have been. I would such as you to. Paul’s coaching, I consider, was a pediatric rheumatologist, and that is once I met him. And however then, you already know, I type of misplaced observe for Paul. He went to this place referred to as CMS. CMS. What’s that? Precisely. So, Paul? Inform us about your I might love to listen to simply kind of beginning about you have had fairly a profession path. We’ll come again and dissect the assorted items of IT. However I would love to listen to one thing about type of your broad function at CMS. What you are doing as of late, and we’ll again up and discuss extra about CMS.

Paul Rosen

Nice thanks a lot, Stewart. Yeah, that is proper. I type of went off the map, Stewart, in 2017, and I used to be invited to work on a High quality Enchancment Venture at CMS, the place we labored with over 150,000 clinicians throughout the nation to enhance high quality and transfer practices in the direction of worth based mostly care.

In order that was only a nice studying expertise for me. I labored on that challenge for about 3 years, after which I am simply wrapping up my eighth yr at CMS, engaged on high quality and worth, after which kind of with my different time, I run 2 practices in pediatric rheumatology. So these are youngsters with autoimmune illnesses, and I run a follow in West Virginia. And I run a follow in New Mexico on an Indian reservation. So, contemplating I dwell on the East Coast. I am not. I am not the very best with geography, however anyway, IT‘s been preserving me busy, and I get pleasure from IT very a lot.

Stewart Gandolf

That is nice. So, we talked beforehand. And there is a lot to speak about right this moment. However I feel actually IT comes all the way down to high quality care broadly, but additionally actually offering care to rural populations. And so, Paul, we talked offline a bit bit about the place you began CMS, and the way you type of migrated from the, you already know, all 5,000 hospitals all the way down to rural. Inform us a bit bit extra about that, and you already know, as a result of you already know and also you had been additionally speaking about what number of docs truly work for CMS, so simply give us a bit little bit of background. So, our viewers understands your background, and we are able to dig into a few of your learnings.

Paul Rosen

Okay? Nice. Yeah. So, I am, like I mentioned, I am a pediatrician. And I joined CMS in in 2017. And you already know, there’s totally different facilities. There is a Middle for Medicare Middle for Medicaid, the Innovation Middle, and I used to be at CCSQ, the Middle for Medical Requirements and High quality, and I used to be placed on a challenge the first 3 years I used to be there to reap the very best practices across the nation. IT was largely targeted on ambulatory drugs. And you already know, we heard from physicians, nurses, social employees from throughout the nation on kind of what they had been doing to enhance care for his or her sufferers. After which we kind of gathered all that Information after which tried to unfold all the very best practices via the community. So, IT‘s the concept is you construct a studying neighborhood. And also you host occasions to listen to what everybody’s engaged on. And then you definately let kind of the very best practices, with the very best outcomes bubble as much as the highest so we did that for the first few years. After which the following program I used to be on was targeted extra on rural hospitals. So about 2,000 hospitals targeted on enhancing security and high quality, and that was occurring throughout the pandemic. So, there’s quite a bit to speak about there as effectively.

Stewart Gandolf

Nice. So, let’s begin with the primary mission the place you had been taking a look at simply finest practices and high quality primarily for ambulatory care. So how did you outline high quality? Was that security? Was that value effectivity, the triple goal like, how is high quality outlined? And I am particularly excited to be taught like what had been the conclusions you guys got here up with. There.

Paul Rosen

Yeah. So, we introduced this community collectively. My management introduced this community collectively, and we had companions from medical associations and universities, medical societies, after which recruiting all these practices into this system. And the main target was actually on the person follow to rework to a value-based care mannequin. And we checked out power illness administration prevention of pointless emergency drugs visits, pointless hospitalizations. And we actually simply heard what folks within the subject had been doing. So to provide you a pair examples. You already know. As you already know, hypertension, about 75% of sufferers with hypertension are uncontrolled. And we might communicate to household drugs physicians who would deploy care coordinators to verify on their sufferers on a weekly foundation, to remind them to take their drugs, to remind them to verify their blood strain. They usually went from a blood strain management help of, to illustrate, 50%. They usually moved IT above 90%. After which downstream. You already know, the sufferers would have lower in cardiovascular occasions, and IT would additionally generate value financial savings. So, there are examples like that. One. One other instance is an orthopedist who would do joint alternative surgical procedure. However earlier than bringing the affected person to surgical procedure he would make it possible for their underlying medical issues, diabetes, hypertension, had been below management. So, the surgeon would possibly delay the surgical procedure for a number of months to get their medical circumstances below management, and what that resulted in was a decreased probability of the affected person needing to be admitted to a talented nursing facility after surgical procedure. So these are among the practices that we heard about, after which we attempt to unfold them throughout the community.

Stewart Gandolf

Received IT. Received IT all proper. Effectively, let’s discuss then the main target right this moment actually is extra rural Health Care particularly, and rural Health Care throughout Covid could not have been very difficult in any respect. So, inform me about you already know that have and among the learnings from that have. And the way did you guys address, you already know, type of a loopy setting worldwide? Not simply within the rural communities.

Paul Rosen

Proper. So, you already know, we now have scopes of labor which final about 5 years, and we recruit contractors to assist us with the scope of labor, and we set targets for security and high quality. And you already know we set the targets. We had the contractors employed, after which, in fact, you already know, the pandemic hit. So, we actually, IT was simply as everybody was experiencing healthcare, you already know, every little thing was the other way up. We had been listening to from nursing properties, practices, and hospitals. So, I feel, on the follow facet at the moment, in the event you keep in mind, like sufferers weren’t going to the doctor very a lot. They had been staying residence and isolating. And the practices who had been fee-for-service based mostly actually took successful, particularly these in rural communities, and we noticed a whole lot of you already know. A few of them exit of enterprise, and I feel the learnings from the first challenge I used to be on with value-based care.

We heard from these practices that in the event that they had been in worth based mostly care throughout the pandemic, financially they had been doing high-quality however positively these practices that had been in fee-for-service. You already know, they took extra of a monetary hit throughout the pandemic. So, the practices had been struggling. After which, in fact the hospitals had been, both, you already know, slammed within the emergency division, or they had been experiencing, you already know, nursing shortages, as you already know, they needed to shut down some items, after which the agricultural Health within the rural Health house. We actually heard from management that you already know, they had been struggling to maintain items open, after which they had been pulling nurses from all around the hospital, like from high quality enchancment, or from their different kind of inhabitants Health applications and sending them to the bedside. And what we noticed throughout that point is that a whole lot of the positive aspects and security and high quality that had been revamped the earlier decade had been slipping as a result of everybody was simply kind of operating, you already know, operating round with this chaos. So, IT was a really troublesome time, as you already know.

Stewart Gandolf

Received IT. So, let’s discuss possibly extra particularly than simply among the challenges within the rural Health Care. As we speak. I imply you may have a follow now, and we’ll discuss your follow in a second. However this isn’t a subject that is new, proper. There’re truly conferences on rural healthcare. There are new fashions. However for the uninitiated, what makes rural Health Care so troublesome? What are among the most essential issues which can be traits that and I’ve obtained a number of. However I would like to listen to yours clearly first, and inform me what your expertise has been.

Paul Rosen

Yeah, I feel you already know. Actually, you already know, one challenge is simply recruiting and retaining healthcare suppliers within the rural house, and that may very well be major care, specialty care, you already know, obstetrics, most cancers care. So, there are these rural areas that actually have a scarcity of physicians and different clinicians, and so they could not have clinicians round for lots of of miles. So definitely, the scarcity of clinicians is a serious challenge. After which many of those, you already know, smaller rural hospitals are financially in a really fragile scenario, clearly after which, you already know, like, from the pandemic, we have seen a whole lot of of us go away the workforce and the way can we? How can we? How can we preserve folks engaged in healthcare? So these are just a few a few the problems. And you already know we are able to. We will go into extra element as effectively.

Stewart Gandolf

I am for positive. So, on the we talked about, there’s quite a bit to unpack there. So, let’s discuss in regards to the physician scarcity and the supplier scarcity. So, there are totally different fashions on the market. For instance. Clearly, telehealth might help. We won’t assist ship a child for you. Sometimes, I suppose you get a do IT your self, video, or one thing that is most likely not going to be sensible, however IT might help with routine comply with up, for instance. You already know, there’s different fashions the place firms like homeward are partaking and testing totally different fashions the place they’re delivering PAs and NPs to do routine care to assist preserve folks out of the hospital. Love to listen to your ideas about that or every other fashions to attempt to service folks. Provided that. There’s these ongoing shortages.

Paul Rosen

Yeah, completely. I imply, I feel we are able to positively use Technology extra. And in my practices, my West Virginia follow is 50% telemedicine. After which my Indian Health follow is 80% telemedicine. So, there’s positively a possibility to make use of the Technology to increase suppliers, and you already know, get the get the care to the sufferers the place they want IT. After which there’s challenges with that, for instance, within the Indian Reservation, the place I work, the Wi-Fi may be very poor, in order that we now have to determine that out. After which additionally in rural West Virginia, there’s some poor areas of entry to. So, I would say there’s much more alternative for Technology. However you already know we’re nonetheless not the place we should be but.

Stewart Gandolf

Have you ever been utilizing? And is IT related, distant affected person monitoring? Is that one thing that you just guys are taking a look at in addition to a part of the telehealth, or is that one thing separate? You simply ask them to make use of their very own blood strain monitor, or no matter.

Paul Rosen

Proper, I imply. For my follow, you already know, in the event that they’re at residence, they’ll definitely, you already know, get a weight or they’ll go to their, you already know, native, their native supplier, to get a blood strain. However you are proper. I imply, there’s you already know, there’s the usage of sensors. After which there’s kind of hospital at residence, look after individuals who want inpatient care, and that entire mannequin of sending the companies to the affected person’s residence and utilizing sensors however my, for my practices, IT‘s principally normal telemedicine.

Stewart Gandolf

Received IT, and what Let’s discuss. You already know we talked about physician entry, which is a troublesome one to beat. Proper? The traits are not moving into the precise route. There is a cap on variety of docs annually popping out. And you already know, for instance, in major care, there’s increasingly more curiosity on concierge drugs, which is the alternative of you already know, offering extra, you already know, care to rural areas, you already know. In order that’s 1 drawback that every other, every other applied sciences or breakthroughs. Do you suppose that may actually assist alleviate that? Or is IT simply recruiting? Or what can we? What can we do to, you already know? Assist with the entry facet of IT, which I will discuss in regards to the affected person facet in a second. However only for the entry facet.

Paul Rosen

Yeah, I imply, for my, you already know my follow in West Virginia. So, they did not have a doctor in my specialty earlier than. And that is the rationale why I went on the market in 2019, as a result of I needed to go to a state the place you already know I might actually be useful, and since I used to be working at CMS throughout the week, I used to be my hours restricted to the weekend. So IT was this example the place I needed to cowl numerous sufferers, however I actually solely had a number of hours to do IT. So, I had. We needed to provide you with simply kind of outdoors the field methods to service the sufferers. So that will be you already know, night time hours, you already know, weekend hours, and as a substitute of simply seeing the affected person, I began calling the sufferers prematurely to ask them a pair questions. Why had been they referred? What had been they nervous about? And simply to get to know the household for a pair minutes, which I discovered actually facilitated the in individual go to, or the telemedicine go to so and that enabled me to see a better quantity of sufferers. So, type of unbundling among the Information, you already know, outdoors of the particular encounter, and getting a bit little bit of a heads up with the household, you already know, earlier than coming in, and a whole lot of instances we discovered that possibly they had been referred to the unsuitable specialist, or after they drove 100 miles to the clinic, they wanted to see a few different folks. So, we did a few revolutionary issues like that.

Stewart Gandolf

Received IT. Received IT. So, let’s discuss IT will be difficult to achieve sufferers in rural areas, proper? They do not have sometimes the identical kind of medical IQ. They could not have as a lot training. What are among the is that your expertise? And you already know what are among the methods you utilize to beat them from a advertising and marketing standpoint, from a affected person communication standpoint.

Paul Rosen

Yeah, you already know, I feel, I feel I nonetheless have a whole lot of work to do, as a result of my expertise inside the pandemic is since I dwell on the East Coast. Though all of the state borders had been shut, and also you could not. You already know I dwell 300 miles away from the clinic. So, throughout the pandemic I wasn’t allowed to drive to the hospital, and that type of compelled me right into a full telemedicine supply mannequin. And what I discovered is, you already know, on this subject you can also make a prognosis, and you may, you already know, provide therapy. However I feel IT was additionally studying for the households, as a result of I do not suppose that they had a lot expertise with telemedicine earlier than, and I feel that they discovered that may very well be helpful. And you do not essentially have to come back to the physician’s workplace. So, I feel, primary, I discovered how you can work in a telehealth setting and quantity 2. I feel the households discovered in regards to the worth of telehealth, and I feel we had been all shocked when, because the pandemic had been on, we noticed that telehealth numbers taking place, I feel a whole lot of us thought that. Oh, you already know, as soon as the pandemic’s over, telehealth will undergo the roof, and the clinics will likely be empty. However, you already know. What we see is that the sufferers are returning again to the workplace, regardless that they’ve the telehealth choice.

Stewart Gandolf

Yeah, IT‘s attention-grabbing. I’ve a telehealth comply with up appointment tomorrow, and so they provide me the inpatient, like what, you are nuts. I feel I do telehealth, however not everyone thinks like I do. IT seems so…

Paul Rosen

Yeah, I imply, earlier than, you already know, I used to be simply within the workplace, like, you already know, these households that dwell, to illustrate, 5 hours from the clinic, and you already know, mountainous, snowy terrain. They might drive hours, and generally they’d e book a resort and keep in a single day, after which I might see them within the workplace. They usually actually simply had, like one query that I might reply in a couple of minutes. They usually principally spent like 16 hours and a number of other $100. So, I simply felt like IT was a possibility like to save lots of. You already know, sufferers, money and time, and simply make IT simpler. However I do not suppose, you already know we have we obtained the phrase out but that you already know in regards to the worth of telehealth.

Stewart Gandolf

Yeah. So, what led you to open the follow? You talked about a bit bit the Indian Reservation. What led you to open that? How did that evolve over time? And why did you try this?

Paul Rosen

I principally took place from a telephone name I had, I used to be. I used to be on the telephone with the management from the Indian Health service via my CMS work as a result of we had been engaged on tribal Health and high quality enchancment. And you already know, one of many leaders mentioned, oh, you already know you are a pediatric rheumatologist, you already know. We have no of these in Indian Health, and our youngsters wait a yr to be seen, and so they’re touring, you already know, 8 hours and I had my expertise in West Virginia, the place I noticed the worth of telehealth in Western Virginia. So, I simply mentioned, effectively, you already know, I might begin seeing these children subsequent week, you already know, on from the East Coast. And so, IT labored out that the hospital in Shiprock, New Mexico, you already know, provided me a place and provided to open up the brand new clinic. So, I used to be their 1st pediatric specialist on the reservation and the first pediatric telehealth clinic, so New Mexico is about 2,200 miles from the home. So, I began flying on the market, however each solely each 6 months, after which doing a month-to-month telehealth clinic within the meantime. So, I principally see all of the sufferers on telehealth. And if we will not resolve the problem, or you already know they want an in individual go to. I am there as effectively. However IT‘s obtained an ideal reception from the AIA and neighborhood and people are simply actually appreciative to have a specialist, and, you already know, have me come on the market. In order that’s been an ideal expertise.

Stewart Gandolf

Yeah, what number of, Paul, I keep in mind from you telling me like way back, IT‘s round 450 pediatric rheumatologists, one thing like that. Not that.

Paul Rosen

That is proper.

Stewart Gandolf

For positive. So, determine how you can leverage that mind of yours in a means that makes financial sense and like time and house sense, I suppose, and I type of jumped forward there with the Indian reservation. How did you become involved with West Virginia? How did that evolve in an analogous means.

Paul Rosen

Yeah, you already know, IT was I used to be seeking to kind of have extra influence with my medical profession. And I wanted a part-time follow due to, I used to be, you already know, tied up on the Authorities throughout the week, and so they had been seeking to rent a full-time pediatric rheumatologist. So, the numbers are that for about each 1 million inhabitants you want one full time pediatric rheumatologist. So, there’s nearly 2 million folks in West Virginia. They really want 2 full-time folks, however once I name them I mentioned, I can solely work part-time as a result of I am tied up with my different job and you already know they? They mentioned, half time is best than zero. So, they had been very versatile and open minded. And we, simply, you already know, found out a approach to kind of you already know. Prolong my attain as a lot as potential.

Stewart Gandolf

So, you already know, type of as we get near the top right here, like, what are the what is the massive image takeaways like? What have you ever discovered from working at CMS? What have you ever discovered from working and preserving in thoughts that we now have a fairly broad, various viewers? Proper? We work with multi-location suppliers. We work with Health methods and hospitals. We work with some non-profits, and you already know different kinds of healthcare entities. However in the event you needed to say, you already know, based mostly upon my distinctive experiences working with CMS and likewise rural healthcare. What are among the issues that ought to be useful to a fairly broad spectrum of viewers.

Paul Rosen

Yeah, no, I feel some you already know, some key takeaways, at the very least from what I’ve discovered from working at CMS is effectively, to start with, I actually simply had very inspiring management throughout my, throughout my 8 years there, and I labored with some nice folks all targeted on the identical aim which is to enhance high quality and security for sufferers. However I would say for that 1st challenge I described about enhancing worth and high quality. All of the clinicians mentioned to us, This is among the biggest issues they had been collaborating in. IT was massive scale. IT was being in a studying neighborhood, and IT was actually, you already know, effervescent up the very best practices from psychology and radiology and emergency drugs and surgical procedure, and everybody was sharing, you already know what they had been doing from throughout the nation so and that that was carried out with a automobile referred to as a Cooperative Settlement, the place IT‘s extra a extra versatile contracting than kind of your normal contract. So, I would say, simply, you already know, constructing that studying neighborhood and letting folks do their factor after which report IT out, after which highlighting the very best practices after which spreading throughout the neighborhood. In order that was very helpful. After which I would say, from the West Virginia follow IT‘s you already know. Sure, I dwell 300 miles away. However I can nonetheless make an influence from a distance, and the telehealth is actually only a complement to that to type of, you already know, lower my journey, however then additionally lower the household’s journey. And you actually get to see, you already know, in the event you see a affected person of their residence on telemedicine, you get a bit glimpse of you already know what their social setting is like, too. And likewise, I would say, you already know, when you’ve got a cranky toddler who missed their nap coming to the workplace versus they’re of their mother’s lap of their lounge, you would possibly even get a greater examination on telehealth than you’d within the workplace. After which I would say the lesson from the Indian Reservation is that, you already know, step. One is simply me going on the market and opening the follow after which step two is I am hoping to unfold throughout a number of places. After which after that I am hoping we convey in additional pediatric specialists to serve extra of these youngsters who do not have entry to specialty care. So, that is a piece in progress, and I’ve nice companions there who we’re attempting to. We’re attempting to make that imaginative and prescient occur.

Stewart Gandolf

Yeah, IT‘s attention-grabbing, as a result of there’s most likely having labored with, you already know. Personally, I counted IT up as soon as, like hundreds of docs that I’ve labored with through the years. There is definitely quite a bit that most likely are fairly blissful residing in. I do not know Chicago however nonetheless wish to assist in different methods. And so, IT‘s an attention-grabbing means that telehealth could also be a means for to provide again and to nonetheless be employed or provide you with an employment settlement, have the ability to give to these communities in a sensible, lifelike means. And definitely, there is a want on the market. I feel IT‘s nice that you’ve got been engaged on. The standard is all the time one thing that we work with and wish to see enhance. You already know. I do not know in the event you ever learn the Guidelines Manifesto, however one thing easy like Atul Gawandi’s e book on that like, How can we enhance high quality? IT does not all the time must be troublesome. IT does not all the time must be. However you simply must do IT proper. So, I respect your time, Paul. That was wonderful. I feel that I love your profession, and thanks for our friendship and thanks for being on our podcast right this moment.

Paul Rosen

Thanks a lot for having me, Stewart.