Episode 7: John Roberts intersects healthcare, tech, rural-urban dynamic

 


     

 

 

Rural healthcare access, overall wellness in rural areas and the future of rural hospitals are consistently present challenges discussed in the national narrative. In this episode, Dr. Connie asks John Roberts, Executive Director of the Nebraska Rural Health Association, to weigh in on these areas, but also talk about the opportunities of the future. As a member of the board of directors of the National Rural Health Association and with more than 35 years of experience in rural healthcare, John’s perspective on policy, technology and rural-urban collaboration is important for all of us to consider and understand as we shape the future of healthcare as a country. For example, did you know that rural hospitals are actually penalized for incorporating wellness centers? Did you know that rural healthcare providers earn the same level of outcomes in their areas of service but at 4 percent less cost than urban counterparts? Educating our rural leaders and residents along with our urban partners is critical, John says.

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“Too many times I think we focus in on urban or rural, and you really can’t separate the two. Rural providers need urban counterparts for specialty services or services we can’t provide in rural settings and vice versa. When urban areas are being moved to this value based system, too, their incentives shift to try to make sure they get the patient back to rehab or other areas of rural Nebraska because they can do it as well and cheaper.“  
John Roberts
Executive Director, Nebraska Rural Health Association

About John

     

John Roberts is the Executive Director of the Nebraska Rural Health Association. He has more than 36 years of professional healthcare experience. John has been President of Midwest Health Consultants, Inc. for the past 16 years. He is responsible for the overall management and technical expertise of the consulting firm including business development & strategy, marketing, customer service and over-all project management

 

Show Notes

Hello and welcome back to the Rural Futures Podcast. I’m your host Dr. Connie. And joining us today is John Roberts who has over 38 years of professional healthcare experience and serves as the Executive Director of the Nebraska Rural Health Association, and he’s done that for the past 14 years. But John, I want to hand it over to you. Tell us a little bit more about yourself.

Well I’ve started my career in hospital administration back in 1980. I graduated from the University of Nebraska Medical Center with a health services administration degree. Went from there from Omaha to a little town in western Nebraska which was Ogallala Community Hospital and spend six years there as business manager, eventually the system administrator. It was a great way to get your feet wet, and I learned a lot about rural healthcare. And I think that’s really where my passion begins to develop and really love the people in rural areas. I really believe what rural providers do and the quality of life that they can create for their communities. So I left there in 1986 and came back to Lincoln, Nebraska. I worked for Nebraska Hospital Association as one of their lobbyist and your point person on small rural healthcare issues. And did that for about 12 years and then left there and started my own consulting company. We managed a couple of different associations. As you mentioned we managed the Rural Office Association, and I also managed the Dental Hygienist Association of Nebraska. So we do a lot of work with those organizations, do a lot of work with communities all across the state of Nebraska. I think I worked in every rural hospital in the state over the last 30 years or so so labor of love for sure. I also served on the board of directors of the National Rural Health Association. We’re critically involved with policy and things that are happening at the federal level and legislation and hopefully to improve the condition of rural health across the country.

Now we’re gonna get into more of that in just a second. And that’s a lot of the serious stuff about John Roberts. But I want to know too, I know our listeners want to know, what do you do for fun? Because I know there are some things that you do that I think everybody would be very interested in hearing about.

Well I like the usual stuff like golf and I do a lot of wood working in the winter time. But I love playing with my nine grandchildren who range in age from two to twelve.

I know you love the great outdoors and your family has a cabin on Lake McConaughy which is also Nebraska. One of our wonderful bodies of water. So I know you have that compassion for rural and hospitals but also this experience of rural and what that has to offer.

Yeah, I love getting out to western Nebraska. There’s a certain beauty to the Sandhills of Nebraska that you just cannot find anywhere else in the country, and I just love the culture. I love the communities in the greater part of Nebraska.

Well, here at the Rural Futures Institute, one of the things we’ve been exploring this last year are the questions of why rural, why now? You know, why should anybody care about rural that doesn’t live in rural? Rural population across the U.S. and in other places around the world is much smaller than it is when we compare to those urban centers. But I think your enjoyment of those great outdoors and the natural resources and beauty rural has to offer is part of the answer to that question. You can’t go just anywhere and have the experience that you can have in Nebraska Sandhills which I agree as is like a great secret, right? But if you truly want to experience the outdoors and what nature has to offer, that’s one of the great places Nebraska has to offer in terms of rural. With this question of why rural, why now, you know, rural health is definitely part of the huge conversation around rural right now. Why should we continue to have all of these hospitals or should we? What does the rural population need to look like and how do we provide health access and health care to them with those dwindling populations? So when you work throughout Nebraska and throughout the nation, how do you frame that? Why is investing in rural important and specifically in healthcare sector?

The way I look at it is that agricultural part of what happens in ruralnot only rural Nebraska but in rural America—is critical to our infrastructure and our way of life in the United States and, quite frankly, around the world. Rural areas of this country, including Nebraska, basically feed the world and the amount of agricultural food that comes out of rural areas is very important. And we’ve got to be able to support people who live in those rural areas, who serve them rural agricultural economy. And we need good healthcare for those folks in addition to the good schools and other things, we just need to have the infrastructure there to be able to allow those people to do what they do.

And speaking of the rural scene right now and healthcare, how would you describe yourself as a leader in this space?

I really think of myself kind of as a servant leader. My philosophy of leadership is unless you’re willing to serve those you’re leading, you’re probably not the most efficient and effective leader. So I really view things through that lens and I think that allows my leadership style to be able to get in and do the work and not really care about who gets the credit for it. But to really focus in on the outcomes and we want to get for rural America and creating a better and more sustainable rural health in Nebraska.

And speaking of that. I know you’re one of the leaders in Nebraska that’s really working on reinventing our rural healthcare sector. Please speak about some of the innovations in the leadership going on in that space right now.

About a year ago, several of us thought leaders in the state got together informally and started to talk about what we saw currently with the healthcare system in Nebraska and across the country, and then more importantly, what we could do about that as we move forward. We’re currently in a situation where, over the last five to six years because of several different policy changes at the federal level, we’re seeing a pretty rapid decline in the profitability and sustainability of many of our rural healthcare providers. And so we took a look at that and thought we can continue to go down this road we’re on, which the future doesn’t look real bright for many rural providers. Or we can do what Nebraska is kind of known for doing, and that is how do we collaborate together to create a better system? One that has higher quality and lower cost because that’s what government. That’s what business—that’s what insurance companies—they’re all looking for that and that’s what we’re seeing, a major shift in the last several years at the federal level. And I think we’re seeing a lot of states getting into this innovation of how can we recreate and build a better system?

So when you think about recreating and building that better systemI actually just published a paper called Strategic Foresight Leadership and the Future of Rural Healthcare Staffing in a journal, and part of that is to think about the disruption of healthcare, in particular rural healthcare. This is a three trillion dollar industry that the tech firms are getting involved with. You know, we see a lot of entrepreneurship, growth in the healthcare sector but a lot of it not necessarily focused on rural. A lot of it is focused on technology and technological solutions, and we’d love to see a little more innovation in the rural sector around some of this, particularly our rural areas and of course we’re focused on Nebraska because we’re both working and living here in many ways could be such a great playground of innovation for what could happen. Not just in rural but in urban settings as well, because there is so much going on in healthcare. So if you would look in your crystal ballI can always look in mine as a futurist. But if you look in yours John, how would you see our rural healthcare sector changing in the next three to five? What would that ideal future look like?

Well we’re definitely on a path of what we call volume to value which is changing the payment system for rural providers—not only rural providers but all providers across the country. And it goes back to this issue that we have a healthcare system spending that’s not sustainable over the long term. So we’ve got to look at ways we can increase the quality and the outcomes that we give for our patients, while at the same time lowering the cost of care for those outcomes. And so, we’re really seeing this big shift in looking at how providers can be reimbursed and incentivized to be able to take this value idea and provide high quality outcomes and high patient satisfaction, and when they do that, they will get reimbursed accordingly. The opposite effect too is if you’re not meeting those outcome standards and the patient satisfaction standards, you’ll be penalized. And so the incentives are beginning to change pretty quickly over the next probably three years.

So is that why I keep getting all those patient surveys after I visit a doctor? (laughing) Is that what’s going on there John?

Yes that’s part of it.

That’s what I’ve heard. But the one thing I wondered, and I’m sure you can shed some light on this is because it is shifting to more of a values based sort of approach and method, could we be using things like artificial intelligence, big data to help us understand those outcomes more broadly and more robustly? Are there some things happening in that space that you know about that are emerging?

If you look at over the last five years the number of venture capital that’s gone into healththese aren’t health related organizationsthey’re data and information systems, people like Microsoft, Sysco, a lot of different folks are looking at the issues you just talked about, on how we can use this data and information to do a better job with what we’re trying to accomplish and that’s high quality outcomes for our patients.

What advice would you give to somebody like a Rural Futures Institute? We’re part of the University of Nebraska, we’re system wide, and we know that healthcare is one of the—if not themajor issue facing our rural communities today. Now what advice would you give us in terms of how we could help organizations like the Nebraska Rural Health Association and others, to help find some innovative ways to provide solutions for our citizens and help keep people where they want to live and live the high quality lives in our rural communities?

I think slowly but surely rural health providers are understanding what we have to do to make this shift. But what we really need probably and probably what the organization could help us with is we really need to help communities understand what the shift is and what things might look like in the future. And that includes rural hospital boards, government leadership, community organizations to be able to make this transition and be able to do some innovative things in the state. I think we need the support of those community leaders and board of directors to be able to step out of the comfort of what they know and really start to look at what could be and how could we really redesign this system to better fit our communities. That may mean that all communities may not have a hospital, there may be different services that can provide in different regions of the state and that all takes a lot of time and energy to kind of sort through. And you have to have at least a basic understanding of where we’re trying to get to and how communities and leaders across the state can help us get there.

I appreciate that insight. I know that you’re a big proponent of sort of the co-creation with communities and having communities be part of this process and that’s so important for that innovation to happen. The future will look different then the present, and we all have a voice and a contribution to making that space. I was really interested when we had our pre-convo to get ready for this podcast, you mentioned that when a hospital puts in a wellness center they are penalized and so thinking about hospitals as economic drivers but also as center points for communities. I think it’s so important but then when you shared that with me, I thought wow. You know, here we have a lot of hospitals that are really trying to focus more on wellness not just sick care, thinking about what that might look like. But the system isn’t quite set up for that yet is it?

No, it’s really discouraging because I think everybody understands we need to move to this value based system. There needs to be more emphasis put on prevention, care coordination, chronic care management, all those types of things and yet. Currently, our reimbursement systems, mostly by the federal government because you have to remember a typical rural Nebraska hospital, 75 to 85% of their business will be Medicare and Medicaid. And so whatever reimbursement policies are implemented in those two programs has a tremendous effect on what we do and how we do it and how we get paid. The difficult part is making that transition to this new system where we might look at things like home healthcare or other types of wellness or preventative activities. But when we do that as rural providers right now, we’re penalized under the rules that currently preside over this reimbursement system. And so even if we have hospitals that want to make the right decision to do right for what’s in their community, they’re penalized for doing that. That’s the things we want to change as we’re moving forward.

You know John, I just think that’s so critical. You talked about the importance of communities and leaders being involved in embracing sort of this change in innovation, but it’s also the policy, right? And so I think that point you’re making is critical. I think it’s really great for listeners to hear that and think about that even as we see hospitals wanting to transition, sometimes the policies that they’re needing to abide by and live with are not really supporting an area of wellness and more positive living and lifestyles and that’s where we need healthcare to go.

We’re really interested in approaching the federal government which in this case is the Centers for Medicare and Medicaid, their innovation part of their department looking to develop a plan in Nebraska to really approach them to say give us an opportunity to make the changes that make sense for our state and our communities to try a different path of reimbursement system and policy and let’s see if it works and let’s see what we learn from it and take those learnings and apply those to other states across the country. We’ve seen that in a couple of states here in the last couple of years. Maryland has gone to a global budget and a policy. They are in their second year of that innovation project. And they’ve really produced some pretty meaningful results. The other state is Pennsylvania who just started in January 1 of 2017 in their innovation project and they’re gonna work over the next few years to try to get 30 rural hospitals to participate in their program and again it’s a global budget concept. It shifts the incentives for what providers do and like we talked about. Those incentives shifts go towards more prevention, more case management, looking at the things I think we need to go to.

I think it’s so great to have leaders in our state and around the nation really focused on innovation in this space. I actually have worked with several rural hospitals—one in particular in southeast Nebraska—did a year long leadership engagement with them focused on innovation. How do we, as leaders within those hospitals, innovate? Because we have leaders in those hospitals, and a lot of our hospitals do provide great paying professional jobs, they are a hub of our communities. They’re an economic driver as I said before and I think so much of the conversation about rural has been if the school closes we lose a community. I’m not disputing that there are challenges around that, but I think if people were concerned about depopulation before, if we see a closing of a lot of hospitals with nothing else to replace it and people don’t have access to healthcare, we’ll see even more people need to move to areas that have that healthcare access or choose to live there in any case and not choose to locate in a rural community.

Yeah, absolutely. Over the last 10 years about 80 to 85 rural hospitals closed across the country, and that’s more than we’ve seen in the last 20, 25 years. And a lot of those have happened in the deep south and so when you look at states like Georgia, where they’ve had probably 10 to 12 rural hospitals close, when you go back and look at those communities later, it has a devastating effect on their culture, their community, access to healthcare. But as you mentioned, most of the time hospitals are either the first or second largest employer in the community and they draw money from outside sources into those communities. And so it’s really devastating to the community to lose their hospital and lose access to those healthcare services.

I often think of our hospitals and healthcare systems as places where people can connect as well. When my father in law had to start dialysis they could no longer live on their farm in southeast Nebraska, and it was hard for them to uproot everything they knew, everyone they knew, their whole community to relocate. Not that other communities aren’t great but when you’ve lived somewhere for your whole life and then suddenly have to make a change like that just to have access to healthcare, it has other consequences for your mental and emotional and psychological well being as well.

You know, we can tally the direct cost of a hospital closing in a community, but there’s also the secondary or the intangible costs of driving an hour or two to get the medical care, taking off work to be able to do that. All those things are cost to not having those providers in your community. And the other aspect of it is data at the national level that shows that for the services we provide versus urban. It’s usually right around 4% less in cost and yet we produce the same kind of outcomes. And so when we see these rural hospitals close, you’re shifting people to other higher cost services which cost the Medicare and Medicaid program even more over the long term so that’s why we think there’s a significant policy that needs to be worked on at the federal and state level to kind of insure that these rural providers have the opportunity to be successful and sustainable long term.

You know that’s really fascinating just think about the interplay between rural and urban in terms of healthcare. I think there’s a technological aspect of that where technology is developed in urban can be used in rural and that’s a lot of the conversation around this but you bring to light something completely different. And that’s thinking about if we can keep people in rural and have that positive ROI in those rural facilities. It actually benefits the rural community but also the urban communities that don’t have to take on those additional loads so the work load is distributed a little bit differently. But then also federally in terms of the financial ROI to the government but ultimately the taxpayer is even better. So that’s a great piece of information for us to all learn and know about in terms of why rural, why now? How urban and rural work together in so many ways but also how this is a larger ecosystem in play here and I think so many times we separate rural and urban. But as we thought about it more here as the Rural Futures Institute, we really see it as a dynamic ecosystem where we all need each other. And what you’re talking about there really proves a point even in the area of healthcare so going beyond agriculture.

You’re absolutely right. Too many times I think we focus in on urban or rural and you really can’t separate the two. Rural providers need urban counterparts for specialty services or services we can’t provide in rural settings and vice versa. When urban areas are being moved to this value based system too, their incentives shift to try to make sure they get the patient back to rehab or other areas of rural Nebraska because they can do it as well and cheaper if you’re on a fixed budget.

 

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Let’s dive into the technology aspect just a little more here in the conversation. What role do you see in terms of this technology being developed in healthcare? We know it’s a huge space right now, a lot of investment in this space. How do you see the potential of holograms, for example, used in rural healthcare?

Yeah, I think we’re on the verge of some major changes. We’ve gone quite a ways with what we call telehealth services in rural areas of the country which helps us provide services that we may not normally be able to provide or allows us to get consultation from outside experts which really helps our rural providers feel like they have a backup in Nebraska. We’ve implemented quite a few of what we call tele-emergency services where if you come and present yourself in a rural hospital emergency room, they can connect that to urban facility where you have a specialty physicians that are board certified in emergency medicine, consult on the patient and be able to provide those rural providers with consultation on how best to treat the patient. The other thing I think is gonna be really disruptive as we move forward is the whole smartphone technology. We’re seeing some real major trend shifts in rural areas of the country of people dropping their home internet services and relying strictly on cell phones, smart phones or their information and internet connection and again as I mentioned earlier, we’re seeing a lot of investment by folks in this area looking at how they can use technology to improve the health of people across the country.

Yeah, I think that’s really exciting. We have dropped our land line at home actually several years ago. We live in a rural area and our internet still isn’t that fast, and we thought it was gonna get a lot faster, still not that fast. My cell phone is my best source of connectivity, so I’m really excited about things like Doctor on Demand, lab-on-a-chip technology where you could potentially even diagnosis something in your home. I think that’s a tremendous development and seeing more of his happen at home is really exciting. Singularity University is a group I follow quite intently and they have this whole XPRIZE concept where they get this big purse of money together and crowd source from all over the world people that can develop it. And one of the things that they had actually funded, Qualcomm actually funded the purse, but a team actually developed the first tri-quarter. So if people remember back to Star Trek when you could scan your body with this instrument and it tells you what’s wrong and so now the first prototype has been developed and launched and they will continue to make that better and it’s actually developed for home use. It’s not necessarily, the intent wasn’t just for hospitals, it’s to have cheap accessible affordable healthcare wherever you are. And so thinking about the smartphone and other tools like that and how that could potentially help people all over the world and specifically in our rural communities when they don’t have access to a lot would be awesome or even in those crowded and congested urban areas where you can’t always get into the provider. Because we do have such a shortage of doctors and healthcare professionals around the world, technology could be a huge help.

I ran across the dermatology app not too long ago and thought, well I’ll give it a shot, see how it works. So I took a picture of my skin or some imperfection and sent it off to someone and within 24 hours I had a diagnosis of what it was, what the treatment was. It took care of the situation. I didn’t have to go to my primary care physician. I didn’t have to be referred to a specialist. I didn’t have to take time off work. What started as kind of curiosity at the end of it was really looking at wow that worked pretty well and I probably would do it again.

Oh absolutely. I mean I think anything that can save time and money but then also just create more accessibility and affordability is such a huge win. So I think healthcare is one of the most exciting spaces right now in terms of innovation in the future because we all need our health. Health is the basis of life and I think to be healthy is such an important part of who we are. We take that for granted a lot of times until something does happen and suddenly you’re sending a picture to a lab or getting a procedure performed or you find yourself on crutches and you forget how important health is. I think sometimes until something like that happens and it inconveniences you or worries you or even thinking about more long term challenges such as a cancer diagnosis. You know health is life and I think keeping that at the top of our mind is so important. That’s why making sure we have investments and great leaders like yourself in innovation. The space is so important. We thank you for that important work John.

Yeah we’re excited. I think one of the things that Nebraska is known for around the country is our collaboration with each other with providers and different communities, something we take for granted in Nebraska that a lot of other states just don’t have and we’re really gonna use that and test that as we look at how we can develop innovation to really solve these issues as we’re moving forward in rural health.

Well I would just make a plug for Nebraska out there to anyone that might be listening in the tech space. We’re a small population which actually makes us kind of like a start up for a state. I think our small population is actually an advantage right now and we are highly collaborative as you’ve mentioned, John. So thinking about how do we position Nebraska to be the place where innovation and rural healthcare happens and in a big way? So it starts here but actually can then expand to other states and other nations as well. You know we have a strong medical center, we have a lot of research but we also have a lot of people and a lot of leaders who are willing to do some innovative creative work around this to provide access to people and to communities.

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I’d love for you to leave our listeners with sort of your top three leadership tips that they could use in their lives.

You know I think that when I’m counseling a lot of our providers and when I go to across the state, one of the things that they need to do is to get comfortable with being uncomfortable. We know we’re gonna go through a pretty major change in the next three to five years and not only rural Nebraska but across the country. And I truly believe that it won’t be the strongest that make that transition the best or the one’s that are most financially strong at this point. I really believe it’s gonna be the ones who can adapt to change the best and who are able to manage that change as we go through this process. So that’s one of the tips I kind of give them. The second one is to really look at what it is we need in our communities and really go back to that. Trying to break down our mental models of what we think the way things should be. For instance, we know that we can provide additional services outside of what we would call a traditional hospital. And to really begin to look at what is it that people really need? And how can we provide that? And get away from kind of the mental models that we’re kind of used to. And then the final thing is, I mentioned earlier is getting everybody in the community and across the state to really think about what’s happening. How we could take this apart and put it back together in a way that works for our communities and works for our state? And hopefully eventually can be a model for other states across the country as we make this transition to this value based system in healthcare.

I so appreciate your philosophy about the co-creation of the future with communities with people, with those end users and partners involved and I think definitely in this area of disruption of healthcare. That’s such an important piece of all of this. So thank you John.