Can Telehealth and a Little Creativity Help Solve the Rural Healthcare Crisis?

Stewart Gandolf
Welcome to the Healthcare Success Podcast, I am Stuart Gandolf, your host. And today my guest is another old friend that I've met years ago, I think, through the Cleveland Clinic, patient experience summit. Dr. Paul Rosen. Welcome Paul.

Paul Rosen

Thanks so much, Stewart, for having me.

Stewart Gandolf

Yeah, it's great to see you again. Paul and I, Dr. Jim Merlino and others really have been passionate about things like patient safety, patient experience for a long time now, and this topic has always been sort of a you know, priority of mine, not just from a business standpoint, but just from, you know, doing good in medicine standpoint. So, I'm happy and excited to have Paul back.

So, Paul, you've been. I'd like you to. Paul's training, I believe, was a pediatric rheumatologist, and that's when I met him. And but then, you know, I kind of lost track for Paul. He went to this place called CMS. CMS. What is that? Exactly. So, Paul? Tell us about your I would love to hear just sort of starting about you've had quite a career path. We'll come back and dissect the various pieces of it. But I'd love to hear something about kind of your broad role at CMS. What you're doing these days, and we'll back up and talk more about CMS.

Paul Rosen

Great thanks so much, Stewart. Yeah, that's right. I kind of went off the map, Stewart, in 2017, and I was invited to work on a Quality Improvement Project at CMS, where we worked with over 150,000 clinicians across the country to improve quality and move practices towards value based care.

So that was just a great learning experience for me. I worked on that project for about 3 years, and then I'm just wrapping up my 8th year at CMS, working on quality and value, and then sort of with my other time, I run 2 practices in pediatric rheumatology. So those are children with autoimmune diseases, and I run a practice in West Virginia. And I run a practice in New Mexico on an Indian reservation. So, considering I live on the East Coast. I'm not. I'm not the best with geography, but anyway, it's been keeping me busy, and I enjoy it very much.

Stewart Gandolf

That's great. So, we talked beforehand. And there's a lot to talk about today. But I think really it comes down to quality care broadly, but also really providing care to rural populations. And so, Paul, we talked offline a little bit about where you started CMS, and how you kind of migrated from the, you know, all 5,000 hospitals down to rural. Tell us a little bit more about that, and you know, because you know and you were also talking about how many doctors actually work for CMS, so just give us a little bit of background. So, our audience understands your background, and we can dig into some of your learnings.

Paul Rosen

Okay? Great. Yeah. So, I'm, like I said, I'm a pediatrician. And I joined CMS in in 2017. And you know, there's different centers. There's a Center for Medicare Center for Medicaid, the Innovation Center, and I was at CCSQ, the Center for Clinical Standards and Quality, and I was put on a project the 1st 3 years I was there to harvest the best practices around the country. It was mostly focused on ambulatory medicine. And you know, we heard from physicians, nurses, social workers from across the country on sort of what they were doing to improve care for their patients. And then we sort of gathered all that information and then tried to spread all the best practices through the network. So, it's the idea is you build a learning community. And you host events to hear what everyone's working on. And then you let sort of the best practices, with the best results bubble up to the top so we did that for the 1st few years. And then the next program I was on was focused more on rural hospitals. So about 2,000 hospitals focused on improving safety and quality, and that was going on during the pandemic. So, there's a lot to talk about there as well.

Stewart Gandolf

Great. So, let's start with the first mission where you were looking at just best practices and quality primarily for ambulatory care. So how did you define quality? Was that safety? Was that cost efficiency, the triple aim like, how is quality defined? And I'm especially excited to learn like what were the conclusions you guys came up with. There.

Paul Rosen

Yeah. So, we brought this network together. My leadership brought this network together, and we had partners from medical associations and universities, medical societies, and then recruiting all these practices into the program. And the focus was really on the individual practice to transform to a value-based care model. And we looked at chronic disease management prevention of unnecessary emergency medicine visits, unnecessary hospitalizations. And we really just heard what people in the field were doing. So to give you a couple examples. You know. As you know, hypertension, about 75% of patients with hypertension are out of control. And we would speak to family medicine physicians who would deploy care coordinators to check on their patients on a weekly basis, to remind them to take their medicine, to remind them to check their blood pressure. And they went from a blood pressure control aid of, let's say, 50%. And they moved it above 90%. And then downstream. You know, the patients would have decrease in cardiovascular events, and it would also generate cost savings. So, there are examples like that. One. Another example is an orthopedist who would do joint replacement surgery. But before bringing the patient to surgery he would make sure that their underlying medical problems, diabetes, hypertension, were under control. So, the surgeon might delay the surgery for a few months to get their medical conditions under control, and what that resulted in was a decreased chance of the patient needing to be admitted to a skilled nursing facility after surgery. So those are some of the practices that we heard about, and then we try to spread them across the network.

Stewart Gandolf

Got it. Got it all right. Well, let's talk about then the focus today really is more rural health care specifically, and rural health care during Covid couldn't have been very challenging at all. So, tell me about you know that experience and some of the learnings from that experience. And how did you guys cope with, you know, kind of a crazy environment worldwide? Not just in the rural communities.

Paul Rosen

Right. So, you know, we have scopes of work which last about 5 years, and we recruit contractors to help us with the scope of work, and we set targets for safety and quality. And you know we set the targets. We had the contractors hired, and then, of course, you know, the pandemic hit. So, we really, it was just as everyone was experiencing healthcare, you know, everything was upside down. We were hearing from nursing homes, practices, and hospitals. So, I think, on the practice side at that time, if you remember, like patients were not going to the physician very much. They were staying home and isolating. And the practices who were fee-for-service based really took a hit, especially those in rural communities, and we saw a lot of you know. Some of them go out of business, and I think the learnings from the 1st project I was on with value-based care.

We heard from those practices that if they were in value based care during the pandemic, financially they were doing fine but definitely those practices that were in fee-for-service. You know, they took more of a financial hit during the pandemic. So, the practices were struggling. And then, of course the hospitals were, either, you know, slammed in the emergency department, or they were experiencing, you know, nursing shortages, as you know, they had to close down some units, and then the rural health in the rural health space. We really heard from leadership that you know, they were struggling to keep units open, and then they were pulling nurses from all over the hospital, like from quality improvement, or from their other sort of population health programs and sending them to the bedside. And what we saw during that time is that a lot of the gains and safety and quality that were made over the previous decade were slipping because everyone was just sort of running, you know, running around with this chaos. So, it was a very difficult time, as you know.

Stewart Gandolf

Got it. So, let's talk about maybe more specifically than just some of the challenges in the rural health care. Today. I mean you have a practice now, and we'll talk about your practice in a moment. But this is not a topic that's new, right. There’re actually conferences on rural healthcare. There are new models. But for the uninitiated, what makes rural health care so difficult? What are some of the most important things that are trends that and I've got a few. But I'd like to hear yours obviously first, and tell me what your experience has been.

Paul Rosen

Yeah, I think you know. Certainly, you know, one issue is just recruiting and retaining healthcare providers in the rural space, and that could be primary care, specialty care, you know, obstetrics, cancer care. So, there are these rural areas that really have a shortage of physicians and other clinicians, and they may not have clinicians around for hundreds of miles. So certainly, the shortage of clinicians is a major issue. And then many of these, you know, smaller rural hospitals are financially in a very fragile situation, obviously and then, you know, like, from the pandemic, we've seen a lot of folks leave the workforce and how do we? How do we? How do we keep people engaged in healthcare? So those are just some a couple of the issues. And you know we can. We can go into more detail as well.

Stewart Gandolf

I'm for sure. So, on the we talked about, there's a lot to unpack there. So, let's talk about the doctor shortage and the provider shortage. So, there are different models out there. For example. Obviously, telehealth can help. We can't help deliver a baby for you. Typically, I guess you get a do it yourself, video, or something that's probably not going to be practical, but it can help with routine follow up, for example. You know, there's other models where companies like homeward are engaging and testing different models where they're delivering PAs and NPs to do routine care to help keep people out of the hospital. Love to hear your thoughts about that or any other models to try to service people. Given that. There's these ongoing shortages.

Paul Rosen

Yeah, absolutely. I mean, I think we can definitely use technology more. And in my practices, my West Virginia practice is 50% telemedicine. And then my Indian health practice is 80% telemedicine. So, there's definitely an opportunity to use the technology to extend providers, and you know, get the get the care to the patients where they need it. And then there's challenges with that, for example, in the Indian Reservation, where I work, the Wi-Fi is very poor, so that we have to figure that out. And then also in rural West Virginia, there's some poor areas of access to. So, I'd say there's a lot more opportunity for technology. But you know we're still not where we need to be yet.

Stewart Gandolf

Have you been using? And is it relevant, remote patient monitoring? Is that something that you guys are looking at as well as part of the telehealth, or is that something separate? You just ask them to use their own blood pressure monitor, or whatever.

Paul Rosen

Right, I mean. For my practice, you know, if they're at home, they can certainly, you know, get a weight or they can go to their, you know, local, their local provider, to get a blood pressure. But you're right. I mean, there's you know, there's the use of sensors. And then there's sort of hospital at home, care for people who need inpatient care, and that whole model of sending the services to the patient's home and using sensors but my, for my practices, it's basically standard telemedicine.

Stewart Gandolf

Got it, and what Let's talk about. You know we mentioned doctor access, which is a difficult one to overcome. Right? The trends don't seem to be going in the right direction. There's a cap on number of doctors each year coming out. And you know, for example, in primary care, there's more and more interest on concierge medicine, which is the opposite of you know, providing more, you know, care to rural areas, you know. So that's 1 problem that any other, any other technologies or breakthroughs. Do you think that can really help alleviate that? Or is it just recruiting? Or what can we? What can we do to, you know? Help with the access side of it, which I'll talk about the patient side in a moment. But just for the access side.

Paul Rosen

Yeah, I mean, for my, you know my practice in West Virginia. So, they didn't have a physician in my specialty before. And that's the reason why I went out there in 2019, because I wanted to go to a state where you know I could really be helpful, and because I was working at CMS during the week, I was my hours limited to the weekend. So it was this situation where I had to cover a large number of patients, but I really only had a few hours to do it. So, I had. We had to come up with just sort of outside the box ways to service the patients. So that would be you know, night hours, you know, weekend hours, and instead of just seeing the patient, I started calling the patients in advance to ask them a couple questions. Why were they referred? What were they worried about? And just to get to know the family for a couple minutes, which I found really facilitated the in person visit, or the telemedicine visit so and that enabled me to see a higher volume of patients. So, kind of unbundling some of the information, you know, outside of the actual encounter, and getting a little bit of a heads up with the family, you know, before coming in, and a lot of times we found out that maybe they were referred to the wrong specialist, or when they drove 100 miles to the clinic, they needed to see a couple of other people. So, we did a couple of innovative things like that.

Stewart Gandolf

Got it. Got it. So, let's talk about it can be challenging to reach patients in rural areas, right? They don't have typically the same sort of medical IQ. They may not have as much education. What are some of the is that your experience? And you know what are some of the techniques you use to overcome them from a marketing standpoint, from a patient communication standpoint.

Paul Rosen

Yeah, you know, I think, I think I still have a lot of work to do, because my experience within the pandemic is since I live on the East Coast. Although all the state borders were shut, and you couldn't. You know I live 300 miles away from the clinic. So, during the pandemic I wasn't allowed to drive to the hospital, and that kind of forced me into a full telemedicine delivery model. And what I learned is, you know, in this field you can make a diagnosis, and you could, you know, offer treatment. But I think it was also learning for the families, because I don't think they had much experience with telemedicine before, and I think that they learned that could be valuable. And you don't necessarily have to come to the doctor's office. So, I think, number one, I learned how to work in a telehealth environment and number 2. I think the families learned about the value of telehealth, and I think we were all surprised when, as the pandemic were on, we saw that telehealth numbers going down, I think a lot of us thought that. Oh, you know, once the pandemic's over, telehealth will go through the roof, and the clinics will be empty. But, you know. What we see is that the patients are returning back to the office, even though they have the telehealth option.

Stewart Gandolf

Yeah, it's interesting. I have a telehealth follow up appointment tomorrow, and they offer me the inpatient, like what, you're nuts. I think I do telehealth, but not everybody thinks like I do. It turns out so…

Paul Rosen

Yeah, I mean, before, you know, I was just in the office, like, you know, these families that live, let's say, 5 hours from the clinic, and you know, mountainous, snowy terrain. They would drive hours, and sometimes they would book a hotel and stay overnight, and then I would see them in the office. And they really just had, like one question that I could answer in a few minutes. And they basically spent like 16 hours and several $100. So, I just felt like it was an opportunity like to save. You know, patients, time and money, and just make it easier. But I don't think, you know we've we got the word out yet that you know about the value of telehealth.

Stewart Gandolf

Yeah. So, what led you to open the practice? You mentioned a little bit the Indian Reservation. What led you to open that? How did that evolve over time? And why did you do that?

Paul Rosen

I basically came about from a phone call I had, I was. I was on the phone with the leadership from the Indian health service through my CMS work because we were working on tribal health and quality improvement. And you know, one of the leaders said, oh, you know you're a pediatric rheumatologist, you know. We don't have any of those in Indian health, and our kids wait a year to be seen, and they're traveling, you know, 8 hours and I had my experience in West Virginia, where I saw the value of telehealth in Western Virginia. So, I just said, well, you know, I could start seeing those kids next week, you know, on from the East Coast. And so, it worked out that the hospital in Shiprock, New Mexico, you know, offered me a position and offered to open up the new clinic. So, I was their 1st pediatric specialist on the reservation and the 1st pediatric telehealth clinic, so New Mexico is about 2,200 miles from the house. So, I started flying out there, but every only every 6 months, and then doing a monthly telehealth clinic in the meantime. So, I basically see all the patients on telehealth. And if we can't resolve the issue, or you know they need an in person visit. I'm there as well. But it's got a great reception from the AIA and community and folks are just really appreciative to have a specialist, and, you know, have me come out there. So that's been a great experience.

Stewart Gandolf

Yeah, how many, Paul, I remember from you telling me like long ago, it's around 450 pediatric rheumatologists, something like that. Not that.

Paul Rosen

That's right.

Stewart Gandolf

For sure. So, figure out how to leverage that brain of yours in a way that makes economic sense and like time and space sense, I guess, and I kind of jumped ahead there with the Indian reservation. How did you get involved with West Virginia? How did that evolve in a similar way.

Paul Rosen

Yeah, you know, it was I was looking to sort of have more impact with my clinical career. And I needed a part-time practice because of, I was, you know, tied up at the Government during the week, and they were looking to hire a full-time pediatric rheumatologist. So, the numbers are that for about every 1 million population you need one full time pediatric rheumatologist. So, there's almost 2 million people in West Virginia. They really need 2 full-time people, but when I call them I said, I can only work part-time because I'm tied up with my other job and you know they? They said, part time is better than zero. So, they were very flexible and open minded. And we, just, you know, figured out a way to sort of you know. Extend my reach as much as possible.

Stewart Gandolf

So, you know, kind of as we get close to the end here, like, what are the what's the big picture takeaways like? What have you learned from working at CMS? What have you learned from working and keeping in mind that we have a pretty broad, diverse audience? Right? We work with multi-location providers. We work with health systems and hospitals. We work with some non-profits, and you know other kinds of healthcare entities. But if you had to say, you know, based upon my unique experiences working with CMS and also rural healthcare. What are some of the things that should be helpful to a pretty broad spectrum of audience.

Paul Rosen

Yeah, no, I think some you know, some key takeaways, at least from what I've learned from working at CMS is well, first of all, I really just had very inspiring leadership during my, during my 8 years there, and I worked with some great people all focused on the same goal which is to improve quality and safety for patients. But I'd say for that 1st project I described about improving value and quality. All the clinicians said to us, This is one of the greatest things they were participating in. It was large scale. It was being in a learning community, and it was really, you know, bubbling up the best practices from psychology and radiology and emergency medicine and surgery, and everyone was sharing, you know what they were doing from across the country so and that that was done with a vehicle called a Cooperative Agreement, where it's more a more flexible contracting than sort of your standard contract. So, I'd say, just, you know, building that learning community and letting people do their thing and then report it out, and then highlighting the best practices and then spreading across the community. So that was very valuable. And then I'd say, from the West Virginia practice it's you know. Yes, I live 300 miles away. But I can still make an impact from a distance, and the telehealth is really just a supplement to that to kind of, you know, decrease my travel, but then also decrease the family's travel. And you really get to see, you know, if you see a patient in their home on telemedicine, you get a little glimpse of you know what their social environment is like, too. And also, I'd say, you know, if you have a cranky toddler who missed their nap coming to the office versus they're in their mom's lap in their living room, you might even get a better exam on telehealth than you would in the office. And then I'd say the lesson from the Indian Reservation is that, you know, step. One is just me going out there and opening the practice and then step two is I'm hoping to spread across multiple locations. And then after that I'm hoping we bring in more pediatric specialists to serve more of those children who don't have access to specialty care. So, that's a work in progress, and I have great partners there who we're trying to. We're trying to make that vision happen.

Stewart Gandolf

Yeah, it's interesting, because there's probably having worked with, you know. Personally, I counted it up once, like thousands of doctors that I've worked with over the years. There's certainly a lot that probably are quite happy living in. I don't know Chicago but still want to help in other ways. And so, it's an interesting way that telehealth may be a way for to give back and to still be employed or come up with an employment agreement, be able to give to those communities in a practical, realistic way. And certainly, there's a need out there. I think it's great that you've been working on. The quality is always something that we work with and want to see improve. You know. I don't know if you ever read the Checklist Manifesto, but something simple like Atul Gawandi's book on that like, How do we improve quality? It doesn't always have to be difficult. It doesn't always have to be. But you just have to do it right. So, I appreciate your time, Paul. That was excellent. I think that I admire your career, and thanks for our friendship and thanks for being on our podcast today.

Paul Rosen

Thanks so much for having me, Stewart.