Stewart Gandolf
Welcome to the Healthcare Success Podcast, I’m Stuart Gandolf, your host. And immediately my visitor is one other outdated good friend that I’ve met years in the past, I believe, by means of the Cleveland Clinic, affected person expertise summit.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 is 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 matter has all the time been type of a you recognize, precedence of mine, not simply from a enterprise standpoint, however simply from, you recognize, doing good in medication standpoint. So, I am joyful 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 recognize, I form 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’d love to listen to simply type 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 form of your broad position at CMS. What you are doing nowadays, and we’ll again up and speak extra about CMS.

Paul Rosen

Nice thanks a lot, Stewart. Yeah, that is proper. I form 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 primarily based care.

In order that was only a nice studying expertise for me. I labored on that venture for about 3 years, after which I am simply wrapping up my eighth yr at CMS, engaged on high quality and worth, after which type of with my different time, I run 2 practices in pediatric rheumatology. So these are youngsters with autoimmune illnesses, and I run a observe in West Virginia. And I run a observe 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 has been retaining me busy, and I take pleasure in it very a lot.

Stewart Gandolf

That is nice. So, we talked beforehand. And there is a lot to speak about immediately. However I believe 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 somewhat bit about the place you began CMS, and the way you form of migrated from the, you recognize, all 5,000 hospitals all the way down to rural. Inform us somewhat bit extra about that, and you recognize, as a result of you recognize and also you had been additionally speaking about what number of medical doctors really work for CMS, so simply give us somewhat little bit of background. So, our viewers understands your background, and we will 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 recognize, there’s completely different facilities. There is a Middle for Medicare Middle for Medicaid, the Innovation Middle, and I used to be at CCSQ, the Middle for Scientific Requirements and High quality, and I used to be placed on a venture the first 3 years I used to be there to reap the very best practices across the nation. It was principally centered on ambulatory medication. And you recognize, we heard from physicians, nurses, social staff from throughout the nation on type of what they had been doing to enhance care for his or her sufferers. After which we type of gathered all that data after which tried to unfold all the very best practices by means of the community. So, it is the thought is you construct a studying neighborhood. And also you host occasions to listen to what everybody’s engaged on. And then you definately let type 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 subsequent program I used to be on was centered extra on rural hospitals. So about 2,000 hospitals centered on bettering security and high quality, and that was occurring throughout the pandemic. So, there’s so much to speak about there as properly.

Stewart Gandolf

Nice. So, let’s begin with the primary mission the place you had been taking a look at simply greatest 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 observe to remodel to a value-based care mannequin. And we checked out power illness administration prevention of pointless emergency medication visits, pointless hospitalizations. And we actually simply heard what folks within the subject had been doing. So to present you a pair examples. . As you recognize, hypertension, about 75% of sufferers with hypertension are uncontrolled. And we’d communicate to household medication physicians who would deploy care coordinators to test on their sufferers on a weekly foundation, to remind them to take their medication, to remind them to test their blood stress. They usually went from a blood stress management support of, for instance, 50%. They usually moved it above 90%. After which downstream. , the sufferers would have lower in cardiovascular occasions, and it might additionally generate value financial savings. So, there are examples like that. One. One other instance is an orthopedist who would do joint substitute surgical procedure. However earlier than bringing the affected person to surgical procedure he would guarantee that their underlying medical issues, diabetes, hypertension, had been underneath management. So, the surgeon would possibly delay the surgical procedure for just a few months to get their medical situations underneath 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 a few of the practices that we heard about, after which we attempt to unfold them throughout the community.

Stewart Gandolf

Acquired it. Acquired all of it proper. Nicely, let’s speak about then the main target immediately actually is extra rural well being care particularly, and rural well being care throughout Covid could not have been very difficult in any respect. So, inform me about you recognize that have and a few of the learnings from that have. And the way did you guys deal with, you recognize, form of a loopy atmosphere worldwide? Not simply within the rural communities.

Paul Rosen

Proper. So, you recognize, now we 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 recognize we set the targets. We had the contractors employed, after which, after all, you recognize, the pandemic hit. So, we actually, it was simply as everybody was experiencing healthcare, you recognize, all the pieces was the other way up. We had been listening to from nursing houses, practices, and hospitals. So, I believe, on the observe facet at the moment, when you keep in mind, like sufferers weren’t going to the doctor very a lot. They had been staying house and isolating. And the practices who had been fee-for-service primarily based actually took successful, particularly these in rural communities, and we noticed quite a lot of you recognize. A few of them exit of enterprise, and I believe the learnings from the first venture I used to be on with value-based care.

We heard from these practices that in the event that they had been in worth primarily based care throughout the pandemic, financially they had been doing fantastic however undoubtedly these practices that had been in fee-for-service. , they took extra of a monetary hit throughout the pandemic. So, the practices had been struggling. After which, after all the hospitals had been, both, you recognize, slammed within the emergency division, or they had been experiencing, you recognize, nursing shortages, as you recognize, they needed to shut down some models, after which the agricultural well being within the rural well being area. We actually heard from management that you recognize, they had been struggling to maintain models open, after which they had been pulling nurses from all around the hospital, like from high quality enchancment, or from their different type of inhabitants well being packages and sending them to the bedside. And what we noticed throughout that point is that quite a lot of the features and security and high quality that had been remodeled the earlier decade had been slipping as a result of everybody was simply type of working, you recognize, working round with this chaos. So, it was a really troublesome time, as you recognize.

Stewart Gandolf

Acquired it. So, let’s speak about perhaps extra particularly than simply a few of the challenges within the rural well being care. At this time. I imply you might have a observe now, and we’ll speak about your observe in a second. However this isn’t a subject that is new, proper. There’re really conferences on rural healthcare. There are new fashions. However for the uninitiated, what makes rural well being care so troublesome? What are a few of the most essential issues which can be traits that and I’ve obtained just a few. However I would like to listen to yours clearly first, and inform me what your expertise has been.

Paul Rosen

Yeah, I believe you recognize. Actually, you recognize, one subject is simply recruiting and retaining healthcare suppliers within the rural area, and that could possibly be main care, specialty care, you recognize, obstetrics, most cancers care. So, there are these rural areas that actually have a scarcity of physicians and different clinicians, they usually might not have clinicians round for a whole bunch of miles. So actually, the scarcity of clinicians is a significant subject. After which many of those, you recognize, smaller rural hospitals are financially in a really fragile state of affairs, clearly after which, you recognize, like, from the pandemic, we have seen quite a lot of people go away the workforce and the way can we? How can we? How can we hold folks engaged in healthcare? So these are just a few a few the problems. And you recognize we will. We will go into extra element as properly.

Stewart Gandolf

I am for positive. So, on the we talked about, there’s so much to unpack there. So, let’s speak concerning the physician scarcity and the supplier scarcity. So, there are completely different fashions on the market. For instance. Clearly, telehealth will help. We will not assist ship a child for you. Sometimes, I suppose you get a do it your self, video, or one thing that is in all probability not going to be sensible, however it may possibly assist with routine observe up, for instance. , there’s different fashions the place firms like homeward are participating and testing completely different fashions the place they’re delivering PAs and NPs to do routine care to assist hold folks out of the hospital. Love to listen to your ideas about that or every other fashions to attempt to service folks. On condition that. There’s these ongoing shortages.

Paul Rosen

Yeah, completely. I imply, I believe we will undoubtedly use know-how extra. And in my practices, my West Virginia observe is 50% telemedicine. After which my Indian well being observe is 80% telemedicine. So, there’s undoubtedly a possibility to make use of the know-how to increase suppliers, and you recognize, 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 could be very poor, in order that now we 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 know-how. However you recognize 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 simply 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 stress monitor, or no matter.

Paul Rosen

Proper, I imply. For my observe, you recognize, in the event that they’re at house, they will actually, you recognize, get a weight or they will go to their, you recognize, native, their native supplier, to get a blood stress. However you are proper. I imply, there’s you recognize, there’s using sensors. After which there’s type of hospital at house, take care of individuals who want inpatient care, and that complete mannequin of sending the providers to the affected person’s house and utilizing sensors however my, for my practices, it is principally normal telemedicine.

Stewart Gandolf

Acquired it, and what Let’s speak about. we talked about physician entry, which is a troublesome one to beat. Proper? The traits are not moving into the appropriate route. There is a cap on variety of medical doctors every year popping out. And you recognize, for instance, in main care, there’s increasingly curiosity on concierge medication, which is the other of you recognize, offering extra, you recognize, care to rural areas, you recognize. In order that’s 1 downside that every other, every other applied sciences or breakthroughs. Do you assume that may actually assist alleviate that? Or is it simply recruiting? Or what can we? What can we do to, you recognize? Assist with the entry facet of it, which I will speak concerning the affected person facet in a second. However only for the entry facet.

Paul Rosen

Yeah, I imply, for my, you recognize my observe in West Virginia. So, they did not have a doctor in my specialty earlier than. And that is the explanation why I went on the market in 2019, as a result of I wished to go to a state the place you recognize I may 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 case the place I needed to cowl numerous sufferers, however I actually solely had just a few hours to do it. So, I had. We needed to give you simply type of exterior the field methods to service the sufferers. So that will be you recognize, night time hours, you recognize, weekend hours, and as an alternative 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 the next quantity of sufferers. So, form of unbundling a few of the data, you recognize, exterior of the particular encounter, and getting somewhat little bit of a heads up with the household, you recognize, earlier than coming in, and quite a lot of instances we discovered that perhaps they had been referred to the incorrect 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

Acquired it. Acquired it. So, let’s speak about it may be difficult to achieve sufferers in rural areas, proper? They do not have sometimes the identical type of medical IQ. They might not have as a lot training. What are a few of the is that your expertise? And you recognize what are a few of the methods you utilize to beat them from a advertising and marketing standpoint, from a affected person communication standpoint.

Paul Rosen

Yeah, you recognize, I believe, I believe I nonetheless have quite a 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. I dwell 300 miles away from the clinic. So, throughout the pandemic I wasn’t allowed to drive to the hospital, and that form of pressured me right into a full telemedicine supply mannequin. And what I discovered is, you recognize, on this subject you may make a analysis, and you can, you recognize, provide remedy. However I believe it was additionally studying for the households, as a result of I do not assume that they had a lot expertise with telemedicine earlier than, and I believe that they discovered that could possibly be useful. And you do not essentially have to come back to the physician’s workplace. So, I believe, primary, I discovered methods to work in a telehealth atmosphere and quantity 2. I believe the households discovered concerning the worth of telehealth, and I believe we had been all stunned when, because the pandemic had been on, we noticed that telehealth numbers happening, I believe quite a lot of us thought that. Oh, you recognize, as soon as the pandemic’s over, telehealth will undergo the roof, and the clinics will probably be empty. However, you recognize. What we see is that the sufferers are returning again to the workplace, though they’ve the telehealth possibility.

Stewart Gandolf

Yeah, it is attention-grabbing. I’ve a telehealth observe up appointment tomorrow, they usually provide me the inpatient, like what, you are nuts. I believe I do telehealth, however not everyone thinks like I do. It seems so…

Paul Rosen

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

Stewart Gandolf

Yeah. So, what led you to open the observe? You talked about somewhat 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 cellphone name I had, I used to be. I used to be on the cellphone with the management from the Indian well being service by means of my CMS work as a result of we had been engaged on tribal well being and high quality enchancment. And you recognize, one of many leaders mentioned, oh, you recognize you are a pediatric rheumatologist, you recognize. We haven’t any of these in Indian well being, and our youngsters wait a yr to be seen, they usually’re touring, you recognize, 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, properly, you recognize, I may begin seeing these youngsters subsequent week, you recognize, on from the East Coast. And so, it labored out that the hospital in Shiprock, New Mexico, you recognize, supplied me a place and supplied 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 recognize they want an in individual go to. I am there as properly. But it surely’s obtained a fantastic reception from the AIA and neighborhood and folk are simply actually appreciative to have a specialist, and, you recognize, have me come on the market. In order that’s been a fantastic expertise.

Stewart Gandolf

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

Paul Rosen

That is proper.

Stewart Gandolf

For positive. So, determine methods to leverage that mind of yours in a approach that makes financial sense and like time and area sense, I suppose, and I form of jumped forward there with the Indian reservation. How did you become involved with West Virginia? How did that evolve in the same approach.

Paul Rosen

Yeah, you recognize, it was I used to be seeking to type of have extra impression with my medical profession. And I wanted a part-time observe due to, I used to be, you recognize, tied up on the Authorities throughout the week, they usually 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 virtually 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 recognize they? They mentioned, half time is healthier than zero. So, they had been very versatile and open minded. And we, simply, you recognize, discovered a technique to type of you recognize. Lengthen my attain as a lot as potential.

Stewart Gandolf

So, you recognize, form of as we get near the tip right here, like, what are the what is the large image takeaways like? What have you ever discovered from working at CMS? What have you ever discovered from working and retaining in thoughts that now we have a reasonably broad, numerous viewers? Proper? We work with multi-location suppliers. We work with well being techniques and hospitals. We work with some non-profits, and you recognize different kinds of healthcare entities. However when you needed to say, you recognize, primarily based upon my distinctive experiences working with CMS and likewise rural healthcare. What are a few of the issues that ought to be useful to a reasonably broad spectrum of viewers.

Paul Rosen

Yeah, no, I believe some you recognize, some key takeaways, at the least from what I’ve discovered from working at CMS is properly, initially, I actually simply had very inspiring management throughout my, throughout my 8 years there, and I labored with some nice folks all centered on the identical objective which is to enhance high quality and security for sufferers. However I would say for that 1st venture I described about bettering worth and high quality. All of the clinicians mentioned to us, This is among the best issues they had been taking part in. It was massive scale. It was being in a studying neighborhood, and it was actually, you recognize, effervescent up the very best practices from psychology and radiology and emergency medication and surgical procedure, and everybody was sharing, you recognize what they had been doing from throughout the nation so and that that was performed with a automobile referred to as a Cooperative Settlement, the place it is extra a extra versatile contracting than type of your normal contract. So, I would say, simply, you recognize, 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 useful. After which I would say, from the West Virginia observe it is you recognize. Sure, I dwell 300 miles away. However I can nonetheless make an impression from a distance, and the telehealth is actually only a complement to that to form of, you recognize, lower my journey, however then additionally lower the household’s journey. And you actually get to see, you recognize, when you see a affected person of their house on telemedicine, you get somewhat glimpse of you recognize what their social atmosphere is like, too. And in addition, I would say, you recognize, if in case you have 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 recognize, step. One is simply me going on the market and opening the observe after which step two is I am hoping to unfold throughout a number of areas. After which after that I am hoping we convey in additional pediatric specialists to serve extra of these youngsters who haven’t got 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 is attention-grabbing, as a result of there’s in all probability having labored with, you recognize. Personally, I counted it up as soon as, like hundreds of medical doctors that I’ve labored with through the years. There is definitely so much that in all probability are fairly joyful residing in. I do not know Chicago however nonetheless need to assist in different methods. And so, it is an attention-grabbing approach that telehealth could also be a approach for to present again and to nonetheless be employed or give you an employment settlement, be capable of give to these communities in a sensible, reasonable approach. And positively, there is a want on the market. I believe it is nice that you’ve got been engaged on. The standard is all the time one thing that we work with and need to see enhance. . I do not know when you ever learn the Guidelines Manifesto, however one thing easy like Atul Gawandi’s guide on that like, How can we enhance high quality? It would not all the time must be troublesome. It would not all the time must be. However you simply must do it proper. So, I admire your time, Paul. That was wonderful. I believe that I love your profession, and thanks for our friendship and thanks for being on our podcast immediately.

Paul Rosen

Thanks a lot for having me, Stewart.

Stewart Gandolf
Welcome to the Healthcare Success Podcast, I’m Stuart Gandolf, your host. And immediately my visitor is one other outdated good friend that I’ve met years in the past, I believe, by means of 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 is 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 matter has all the time been type of a you recognize, precedence of mine, not simply from a enterprise standpoint, however simply from, you recognize, doing good in medication standpoint. So, I am joyful 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 recognize, I form 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’d love to listen to simply type 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 form of your broad position at CMS. What you are doing nowadays, and we’ll again up and speak extra about CMS.

Paul Rosen

Nice thanks a lot, Stewart. Yeah, that is proper. I form 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 primarily based care.

In order that was only a nice studying expertise for me. I labored on that venture for about 3 years, after which I am simply wrapping up my eighth yr at CMS, engaged on high quality and worth, after which type of with my different time, I run 2 practices in pediatric rheumatology. So these are youngsters with autoimmune illnesses, and I run a observe in West Virginia. And I run a observe 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 has been retaining me busy, and I take pleasure in it very a lot.

Stewart Gandolf

That is nice. So, we talked beforehand. And there is a lot to speak about immediately. However I believe 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 somewhat bit about the place you began CMS, and the way you form of migrated from the, you recognize, all 5,000 hospitals all the way down to rural. Inform us somewhat bit extra about that, and you recognize, as a result of you recognize and also you had been additionally speaking about what number of medical doctors really work for CMS, so simply give us somewhat little bit of background. So, our viewers understands your background, and we will 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 recognize, there’s completely different facilities. There is a Middle for Medicare Middle for Medicaid, the Innovation Middle, and I used to be at CCSQ, the Middle for Scientific Requirements and High quality, and I used to be placed on a venture the first 3 years I used to be there to reap the very best practices across the nation. It was principally centered on ambulatory medication. And you recognize, we heard from physicians, nurses, social staff from throughout the nation on type of what they had been doing to enhance care for his or her sufferers. After which we type of gathered all that data after which tried to unfold all the very best practices by means of the community. So, it is the thought is you construct a studying neighborhood. And also you host occasions to listen to what everybody’s engaged on. And then you definately let type 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 subsequent program I used to be on was centered extra on rural hospitals. So about 2,000 hospitals centered on bettering security and high quality, and that was occurring throughout the pandemic. So, there’s so much to speak about there as properly.

Stewart Gandolf

Nice. So, let’s begin with the primary mission the place you had been taking a look at simply greatest 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 observe to remodel to a value-based care mannequin. And we checked out power illness administration prevention of pointless emergency medication visits, pointless hospitalizations. And we actually simply heard what folks within the subject had been doing. So to present you a pair examples. . As you recognize, hypertension, about 75% of sufferers with hypertension are uncontrolled. And we’d communicate to household medication physicians who would deploy care coordinators to test on their sufferers on a weekly foundation, to remind them to take their medication, to remind them to test their blood stress. They usually went from a blood stress management support of, for instance, 50%. They usually moved it above 90%. After which downstream. , the sufferers would have lower in cardiovascular occasions, and it might additionally generate value financial savings. So, there are examples like that. One. One other instance is an orthopedist who would do joint substitute surgical procedure. However earlier than bringing the affected person to surgical procedure he would guarantee that their underlying medical issues, diabetes, hypertension, had been underneath management. So, the surgeon would possibly delay the surgical procedure for just a few months to get their medical situations underneath 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 a few of the practices that we heard about, after which we attempt to unfold them throughout the community.

Stewart Gandolf

Acquired it. Acquired all of it proper. Nicely, let’s speak about then the main target immediately actually is extra rural well being care particularly, and rural well being care throughout Covid could not have been very difficult in any respect. So, inform me about you recognize that have and a few of the learnings from that have. And the way did you guys deal with, you recognize, form of a loopy atmosphere worldwide? Not simply within the rural communities.

Paul Rosen

Proper. So, you recognize, now we 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 recognize we set the targets. We had the contractors employed, after which, after all, you recognize, the pandemic hit. So, we actually, it was simply as everybody was experiencing healthcare, you recognize, all the pieces was the other way up. We had been listening to from nursing houses, practices, and hospitals. So, I believe, on the observe facet at the moment, when you keep in mind, like sufferers weren’t going to the doctor very a lot. They had been staying house and isolating. And the practices who had been fee-for-service primarily based actually took successful, particularly these in rural communities, and we noticed quite a lot of you recognize. A few of them exit of enterprise, and I believe the learnings from the first venture I used to be on with value-based care.

We heard from these practices that in the event that they had been in worth primarily based care throughout the pandemic, financially they had been doing fantastic however undoubtedly these practices that had been in fee-for-service. , they took extra of a monetary hit throughout the pandemic. So, the practices had been struggling. After which, after all the hospitals had been, both, you recognize, slammed within the emergency division, or they had been experiencing, you recognize, nursing shortages, as you recognize, they needed to shut down some models, after which the agricultural well being within the rural well being area. We actually heard from management that you recognize, they had been struggling to maintain models open, after which they had been pulling nurses from all around the hospital, like from high quality enchancment, or from their different type of inhabitants well being packages and sending them to the bedside. And what we noticed throughout that point is that quite a lot of the features and security and high quality that had been remodeled the earlier decade had been slipping as a result of everybody was simply type of working, you recognize, working round with this chaos. So, it was a really troublesome time, as you recognize.

Stewart Gandolf

Acquired it. So, let’s speak about perhaps extra particularly than simply a few of the challenges within the rural well being care. At this time. I imply you might have a observe now, and we’ll speak about your observe in a second. However this isn’t a subject that is new, proper. There’re really conferences on rural healthcare. There are new fashions. However for the uninitiated, what makes rural well being care so troublesome? What are a few of the most essential issues which can be traits that and I’ve obtained just a few. However I would like to listen to yours clearly first, and inform me what your expertise has been.

Paul Rosen

Yeah, I believe you recognize. Actually, you recognize, one subject is simply recruiting and retaining healthcare suppliers within the rural area, and that could possibly be main care, specialty care, you recognize, obstetrics, most cancers care. So, there are these rural areas that actually have a scarcity of physicians and different clinicians, they usually might not have clinicians round for a whole bunch of miles. So actually, the scarcity of clinicians is a significant subject. After which many of those, you recognize, smaller rural hospitals are financially in a really fragile state of affairs, clearly after which, you recognize, like, from the pandemic, we have seen quite a lot of people go away the workforce and the way can we? How can we? How can we hold folks engaged in healthcare? So these are just a few a few the problems. And you recognize we will. We will go into extra element as properly.

Stewart Gandolf

I am for positive. So, on the we talked about, there’s so much to unpack there. So, let’s speak concerning the physician scarcity and the supplier scarcity. So, there are completely different fashions on the market. For instance. Clearly, telehealth will help. We will not assist ship a child for you. Sometimes, I suppose you get a do it your self, video, or one thing that is in all probability not going to be sensible, however it may possibly assist with routine observe up, for instance. , there’s different fashions the place firms like homeward are participating and testing completely different fashions the place they’re delivering PAs and NPs to do routine care to assist hold folks out of the hospital. Love to listen to your ideas about that or every other fashions to attempt to service folks. On condition that. There’s these ongoing shortages.

Paul Rosen

Yeah, completely. I imply, I believe we will undoubtedly use know-how extra. And in my practices, my West Virginia observe is 50% telemedicine. After which my Indian well being observe is 80% telemedicine. So, there’s undoubtedly a possibility to make use of the know-how to increase suppliers, and you recognize, 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 could be very poor, in order that now we 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 know-how. However you recognize 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 simply 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 stress monitor, or no matter.

Paul Rosen

Proper, I imply. For my observe, you recognize, in the event that they’re at house, they will actually, you recognize, get a weight or they will go to their, you recognize, native, their native supplier, to get a blood stress. However you are proper. I imply, there’s you recognize, there’s using sensors. After which there’s type of hospital at house, take care of individuals who want inpatient care, and that complete mannequin of sending the providers to the affected person’s house and utilizing sensors however my, for my practices, it is principally normal telemedicine.

Stewart Gandolf

Acquired it, and what Let’s speak about. we talked about physician entry, which is a troublesome one to beat. Proper? The traits are not moving into the appropriate route. There is a cap on variety of medical doctors every year popping out. And you recognize, for instance, in main care, there’s increasingly curiosity on concierge medication, which is the other of you recognize, offering extra, you recognize, care to rural areas, you recognize. In order that’s 1 downside that every other, every other applied sciences or breakthroughs. Do you assume that may actually assist alleviate that? Or is it simply recruiting? Or what can we? What can we do to, you recognize? Assist with the entry facet of it, which I will speak concerning the affected person facet in a second. However only for the entry facet.

Paul Rosen

Yeah, I imply, for my, you recognize my observe in West Virginia. So, they did not have a doctor in my specialty earlier than. And that is the explanation why I went on the market in 2019, as a result of I wished to go to a state the place you recognize I may 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 case the place I needed to cowl numerous sufferers, however I actually solely had just a few hours to do it. So, I had. We needed to give you simply type of exterior the field methods to service the sufferers. So that will be you recognize, night time hours, you recognize, weekend hours, and as an alternative 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 the next quantity of sufferers. So, form of unbundling a few of the data, you recognize, exterior of the particular encounter, and getting somewhat little bit of a heads up with the household, you recognize, earlier than coming in, and quite a lot of instances we discovered that perhaps they had been referred to the incorrect 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

Acquired it. Acquired it. So, let’s speak about it may be difficult to achieve sufferers in rural areas, proper? They do not have sometimes the identical type of medical IQ. They might not have as a lot training. What are a few of the is that your expertise? And you recognize what are a few of the methods you utilize to beat them from a advertising and marketing standpoint, from a affected person communication standpoint.

Paul Rosen

Yeah, you recognize, I believe, I believe I nonetheless have quite a 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. I dwell 300 miles away from the clinic. So, throughout the pandemic I wasn’t allowed to drive to the hospital, and that form of pressured me right into a full telemedicine supply mannequin. And what I discovered is, you recognize, on this subject you may make a analysis, and you can, you recognize, provide remedy. However I believe it was additionally studying for the households, as a result of I do not assume that they had a lot expertise with telemedicine earlier than, and I believe that they discovered that could possibly be useful. And you do not essentially have to come back to the physician’s workplace. So, I believe, primary, I discovered methods to work in a telehealth atmosphere and quantity 2. I believe the households discovered concerning the worth of telehealth, and I believe we had been all stunned when, because the pandemic had been on, we noticed that telehealth numbers happening, I believe quite a lot of us thought that. Oh, you recognize, as soon as the pandemic’s over, telehealth will undergo the roof, and the clinics will probably be empty. However, you recognize. What we see is that the sufferers are returning again to the workplace, though they’ve the telehealth possibility.

Stewart Gandolf

Yeah, it is attention-grabbing. I’ve a telehealth observe up appointment tomorrow, they usually provide me the inpatient, like what, you are nuts. I believe I do telehealth, however not everyone thinks like I do. It seems so…

Paul Rosen

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

Stewart Gandolf

Yeah. So, what led you to open the observe? You talked about somewhat 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 cellphone name I had, I used to be. I used to be on the cellphone with the management from the Indian well being service by means of my CMS work as a result of we had been engaged on tribal well being and high quality enchancment. And you recognize, one of many leaders mentioned, oh, you recognize you are a pediatric rheumatologist, you recognize. We haven’t any of these in Indian well being, and our youngsters wait a yr to be seen, they usually’re touring, you recognize, 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, properly, you recognize, I may begin seeing these youngsters subsequent week, you recognize, on from the East Coast. And so, it labored out that the hospital in Shiprock, New Mexico, you recognize, supplied me a place and supplied 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 recognize they want an in individual go to. I am there as properly. But it surely’s obtained a fantastic reception from the AIA and neighborhood and folk are simply actually appreciative to have a specialist, and, you recognize, have me come on the market. In order that’s been a fantastic expertise.

Stewart Gandolf

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

Paul Rosen

That is proper.

Stewart Gandolf

For positive. So, determine methods to leverage that mind of yours in a approach that makes financial sense and like time and area sense, I suppose, and I form of jumped forward there with the Indian reservation. How did you become involved with West Virginia? How did that evolve in the same approach.

Paul Rosen

Yeah, you recognize, it was I used to be seeking to type of have extra impression with my medical profession. And I wanted a part-time observe due to, I used to be, you recognize, tied up on the Authorities throughout the week, they usually 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 virtually 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 recognize they? They mentioned, half time is healthier than zero. So, they had been very versatile and open minded. And we, simply, you recognize, discovered a technique to type of you recognize. Lengthen my attain as a lot as potential.

Stewart Gandolf

So, you recognize, form of as we get near the tip right here, like, what are the what is the large image takeaways like? What have you ever discovered from working at CMS? What have you ever discovered from working and retaining in thoughts that now we have a reasonably broad, numerous viewers? Proper? We work with multi-location suppliers. We work with well being techniques and hospitals. We work with some non-profits, and you recognize different kinds of healthcare entities. However when you needed to say, you recognize, primarily based upon my distinctive experiences working with CMS and likewise rural healthcare. What are a few of the issues that ought to be useful to a reasonably broad spectrum of viewers.

Paul Rosen

Yeah, no, I believe some you recognize, some key takeaways, at the least from what I’ve discovered from working at CMS is properly, initially, I actually simply had very inspiring management throughout my, throughout my 8 years there, and I labored with some nice folks all centered on the identical objective which is to enhance high quality and security for sufferers. However I would say for that 1st venture I described about bettering worth and high quality. All of the clinicians mentioned to us, This is among the best issues they had been taking part in. It was massive scale. It was being in a studying neighborhood, and it was actually, you recognize, effervescent up the very best practices from psychology and radiology and emergency medication and surgical procedure, and everybody was sharing, you recognize what they had been doing from throughout the nation so and that that was performed with a automobile referred to as a Cooperative Settlement, the place it is extra a extra versatile contracting than type of your normal contract. So, I would say, simply, you recognize, 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 useful. After which I would say, from the West Virginia observe it is you recognize. Sure, I dwell 300 miles away. However I can nonetheless make an impression from a distance, and the telehealth is actually only a complement to that to form of, you recognize, lower my journey, however then additionally lower the household’s journey. And you actually get to see, you recognize, when you see a affected person of their house on telemedicine, you get somewhat glimpse of you recognize what their social atmosphere is like, too. And in addition, I would say, you recognize, if in case you have 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 recognize, step. One is simply me going on the market and opening the observe after which step two is I am hoping to unfold throughout a number of areas. After which after that I am hoping we convey in additional pediatric specialists to serve extra of these youngsters who haven’t got 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 is attention-grabbing, as a result of there’s in all probability having labored with, you recognize. Personally, I counted it up as soon as, like hundreds of medical doctors that I’ve labored with through the years. There is definitely so much that in all probability are fairly joyful residing in. I do not know Chicago however nonetheless need to assist in different methods. And so, it is an attention-grabbing approach that telehealth could also be a approach for to present again and to nonetheless be employed or give you an employment settlement, be capable of give to these communities in a sensible, reasonable approach. And positively, there is a want on the market. I believe it is nice that you’ve got been engaged on. The standard is all the time one thing that we work with and need to see enhance. . I do not know when you ever learn the Guidelines Manifesto, however one thing easy like Atul Gawandi’s guide on that like, How can we enhance high quality? It would not all the time must be troublesome. It would not all the time must be. However you simply must do it proper. So, I admire your time, Paul. That was wonderful. I believe that I love your profession, and thanks for our friendship and thanks for being on our podcast immediately.

Paul Rosen

Thanks a lot for having me, Stewart.