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179: Rural health challenges and opportunities, Part 2: The hospital administrators’ perspective

When we consider what it takes to improve the health of rural Americans and address rural health disparities, there's no one size fits all solution. Because, as the saying goes, if you’ve seen one rural community, you’ve seen one rural community.

 

In our latest podcast series, we are digging into rural health: the challenges, and the opportunities. We’re highlighting the diversity of rural communities and addressing common misconceptions..

 

In today’s episode, Health Disparities podcast host Sarah Hohman checks in with three people who work in rural hospital leadership and administration, doing incredibly important work, often with limited resources:

 

• Michael Calhoun, Chief Executive Officer/Executive Director for Citizens Memorial Healthcare, an integrated healthcare system serving over 130,000 residents in southwest Missouri. 
• Mandy Shelast, the  President of Marshfield Clinic Health System’s Michigan and Southern Regions, and the President of the National Association of Rural Health Clinics.
• Dr. John Bartlett, a practicing primary care physician and the Vice President of Medical Affairs for the Michigan Region of Marshfield Clinic.

 

Some of the biggest challenges are related to the health care workforce and staffing, in particular for specialty care.

“If we lose a chemo nurse in a town of 10,000 there's not five other ones looking for that job,” Bartlett says. 

“What I'm concerned about is just our aging population and how we're going to be able to train a workforce enough to be able to care for all the people that need it, that's a real concern,” Calhoun says. 

All three guests addressed common misconceptions about rural America, and emphasized the benefits of rural, including a slower pace of life and having providers who are passionate about the mission of providing excellent, personalized health care.

“The patients that we care for are our friends and our family and our community members,” Shelast says. “We take care of them on the very best days of their life — maybe when they're welcoming a life into the world — and on the worst days, when they're having a medical emergency or they've received a terminal diagnosis, and it is just such a great experience to be able to go up to that person and say, 'I'm here for you.’”

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The transcript from today’s episode has been lightly edited for clarity.

Michael Calhoun: I think that there's a perception that if a health system is rural, that it's second class. And so we're really challenging that mentality and saying we want to be known for not being the local healthcare organization, but being the safest healthcare organization, the place where you would go and trust the people that are caring for you, the highest quality, the best patient experiences. We really challenge our team every day to make sure that we commit to excellence, and there's a lot of reward in that. As you make the journey toward excellence and zero harm, we talk a lot about making sure that CMH is the safest hospital in America. 

Sarah Hohman: You're listening to the Health Disparities podcast from movement is life. I'm Sarah Hohman, a member of the Movement is Life Steering Committee, as well as the director of government affairs for the National Association of Rural Health Clinics. Rural America is incredibly diverse, so when we talk about what it takes to improve rural health and address health disparities in rural America, there's no one size fits all solution.

In our latest podcast series, we're digging into rural health, the challenges and the opportunities. We're highlighting the diversity of rural communities and addressing common misconceptions about rural health, and today, we're joined by three people who work in rural hospital, leadership and administration, doing incredible work, often with limited resources. 

Michael Calhoun is the Chief Executive Officer and Executive Director for Citizens Memorial Health Care, an integrated healthcare system serving over 130,000 residents in southwest Missouri. Mandy Shelast has been in rural healthcare for over 15 years and currently serves as the president of Marshfield Clinic Health Systems Michigan and Southern Regions, and as the President of the National Association of Rural Health Clinics. And Dr. John Bartlett is a practicing primary care physician and the vice president of medical affairs for the Michigan region of Marshfield Clinic. 

Dr. Bartlett, Mandy, Michael, welcome to the Health Disparities podcast. To start, Mandy and Dr. Bartlett, can you tell us a bit about the rural healthcare system you're part of?

Mandy Shelast: Yeah, sure. Thanks for having us, Sarah. We're really excited to be here today. Dr. Bartlett and I are representing Marshfield Clinic Health System. We're an integrated health system that actually started as a clinic system back in the early 1900s and now we have about 12,000 employees, 1600 providers and 170 specialties. And that sounds like it's big, and why am I on a rural podcast? But it's not so. Our biggest area of geography that we care for is in Eau Claire, Wisconsin, population of 69,000 and we also have a hospital in Park Falls, Wisconsin, population of 2000 so we have everything from a little bit of micro-urban down to very, very rural. So a really integrated health system. We have a research institute in arm as well as a health plan. So excited to be here today.

Dr. John Bartlett: And I can add on to that, the Michigan region. It seems unusual for a lot of people who aren't from the Midwest to say, why is Michigan part of Wisconsin with this health system? But we live in the Upper Peninsula, which from Iron Mountain to Marshfield is about less than three hours, where it is about an eight hour drive to Ann Arbor from that same destination. So it makes sense for our health systems. A lot of our patients and my patients from the Upper Peninsula, when they seek specialty care or further care, they head that direction. So we have, you know, a 49-bed hospital in Iron Mountain with multiple specialties there. And then it's a sole community hospital. And then we have clinics all around Iron Mountain. Our ER in Iron Mountain sees almost 20,000 patients a year. And then our clinic in Marquette, where I'm based, has primary care as well as neurology services.

Hohman: Wonderful. If you've seen one rural facility or one rural area, you've truly just seen one. So thank you for introducing us to what rural is to both of you. Michael, can you also give us a brief description of your hospital system and affiliated clinics, so our listeners can get an idea of the scope of your work and the patients that you serve.

Calhoun: Sure, thank you and glad to be here today. So CMH is a public hospital district in Bolivar, Missouri. We are in a town of about 12,000 people. We are about 30 minutes north of Springfield, Missouri, and so we serve the rural communities that are north of Springfield. Our largest community is Bolivar, which is 12,000 people. Our total service area is about 130,000 people in eight rural counties, and so that's how we're able to get enough patient volume to be able to be sustainable, because with all of our county population, we have enough patients to be able to bring specialty care to rural southwest Missouri. 

So we have a hospital that's 49 staffed beds. We see about 20,000 ER patients a year in our emergency department. We have an ICU and a birthplace and a geriatric wellness or behavioral unit at the hospital. And then we have a comprehensive clinic system of primary care and specialists, we have 14 rural health clinics, and then we have specialty care, and vast majority of the subspecialties that are available, we keep most of our patients here in Bolivar but we have good partnerships with the hospitals in Springfield for transfers, for levels of care that we don't support. And so one thing that's unique about CMH, we also have a comprehensive long-term care and home care system for post-acute care. We have six long-term care facilities, and then we have a home care and hospice division as well. So basically, all the care provided for our community, from birth to hospice care here in a lot of different very rural southwest Missouri communities.

Hohman: Wonderful. Thank you. So I now have the privilege of being an advocate for rural communities in Washington, DC, not rural. But I was born and raised in rural Pennsylvania, and I think that oftentimes, the way that rural communities are presented tends to be very negative, the older, poorer, sicker narrative, and little attention gets paid to why people choose to work and live and provide healthcare in those communities. So let's chat about that a little bit. Tell us about your rural communities where you live and work, and what drew you to those respective communities. Dr. Bartlett, let's start with you.

Bartlett: Sure. I grew up in Gladstone, Michigan, which is actually in the Upper Peninsula, and then I spent eight years, actually 12 years, in training in medical school and undergrad in lower Michigan and Michigan State University, and then in Grand Rapids. And when I was thinking about where I wanted to practice, I definitely thought about going back to a more rural area, and I wondered if I would miss some of the aspects of being in an academic center. Some of the benefits of our area, I get to actually teach medical students at Michigan State. When I graduated from medical school, you know, 25 years ago, there wasn't a lot of Physician Assistants or nurse practitioners, but now we get to teach those providers also. And then I love the idea that I could live on Lake Superior in a beautiful small town, but still get to teach. I can mountain bike, I can water ski, I can snow ski, I can now snow bike, like all of the fun things that we can do in a small area, and then the college atmosphere and the tech industry in these small towns that's been building also adds to things like theater and music and more cultural aspects.

Hohman: Wonderful. Mandy or Michael?

Shelast: Yeah, I'll jump in here. So when I was a little girl, you know, people asked, what do you want to do when you grow up? And some people say a ballerina or a lawyer, and I would always just say, like, I want to help people, and I want to make a difference. And as I came out of school, I had spent some time in rural communities, and I recognized that those, most of the times when I went to the grocery store, I knew the people in the grocery store. I knew who they were. So working in rural you know, you're not a number, the patients that we care for are our friends and our family and our community members, and we take care of them on the very best days of their life, maybe when they're welcoming a life into the world, and on the worst days when they're having a medical emergency or they've received a terminal diagnosis, and it is just such a great experience to be able to go up to that person and say, 'Hey, Sarah, I'm here for you' in a rural community, and I think that's why I continue to work in rural and probably always will.

Calhoun: You know, my experience has been that I've been able to work in a community that I call home. Whenever I, you know, graduated high school, I thought, you know, the best thing to do was to leave the small town, but I found that the small town is a great place to raise a family. We've got great schools, and you really build the true sense of community, which I think is what attracts a lot of people to our area, is because people are longing for that sense of community. I got into health care because my mom was an RN on the med surg floor, actually at CMH, and I thought I wanted to be, you know, I saw her put herself through nursing school, single mom with three kids. I admired the way that she did that. I admired the way she helped people. And so I thought I wanted to be a doctor, a pharmacist, or, you know, something like that. I started working in a pharmacy, and she helped me get my first job at CMH as a pharmacy technician. It wasn't very long working in the pharmacy that I realized that wasn't really for me, but I've got pretty good business acumen, and started working with our CFO on some various projects while I was in college, and just fell in love with the mission of our organization. 

And you really are caring for people. If they're not your friends and family, there's someone who knows' friends and family, and there's a lot of sense of duty to be able to help them when they're at vulnerable times. And so I've actually been at CMH for 25 years, and now the CEO there, and so I've seen it from very, very different perspectives. But I sell our community a lot to physicians that are considering to come and work here. And what I sell is that this is a place that you'll get to know people that you'll build lasting relationships with. We've got great schools that will share our values. We've got great people that are involved with them. You know, some of the best people in the world live in, you know, in rural areas in our country, and I relate well to them, and it's just been very rewarding, and my family's really thriving here in Bolivar and we love it.

Hohman: Thank you so much for sharing that. One thing I've learned from getting to know rural hospital administrators like yourselves is that you're forced to be innovative. You're doing such important work, often with limited resources, like we've mentioned, and I imagine your daily workload can be immense, wearing 100 hats, I often hear. So give us a glimpse into your world. What motivates you to persist when you confront challenges? Mandy, your thoughts?

Shelast: Sure, I think what motivates me is that sense of community. And you know, on any given day, there is 1100 people counting on myself and Dr Bartlett for a paycheck and to live in that community. And that is a tremendous honor to have that privilege and also a tremendous burden to carry. And I think that really motivates me to do the right thing for them, so they can do the right thing for our patients and keep them healthy. And I mean that comes from everything. Michael talked a little bit about long term care, you know, making sure that our employees are out there and able to do that. So that might be one thing we work on in the day to making sure a patient can either be transferred or cared for in our hospitals. So it is, one day is never like the next. It is always interesting. 

Hohman: Michael, anything to add about your day today and what motivates you?

Calhoun: Yeah, and I talk a lot about this, you know, we provide access to health care in places that otherwise wouldn't have it. But what motivates me is is not just that we provide access to health care, but we provide the very best health care that if they had to drive 100 miles, they couldn't get better health care than what they get in the communities. I think that there's a perception that if a health system is rural, that it's second class. And so we're really challenging that mentality and saying we want to be known for not being the local healthcare organization, but being the safest healthcare organization, the place where you would go and trust the people that are caring for you, the highest quality, the best patient experiences, we really challenge our team every day to make sure that we commit to excellence, and there's a lot of reward in that as you make the journey toward excellence and zero harm, we talk a lot about making sure that CMH is the safest hospital in America, and when I meet with, yesterday, I was In a residential care facility talking about our hospital expansion, and I just looked at these great people, and I thought, you know, they deserve not just to have a facility available to them, but when they come, they couldn't find a better one if they went 100 or 200 miles. And so to be able to have that level of excellence in our communities and people getting that care they deserve motivates me every single day, and I'm excited to keep making it better, because I know it makes such a difference in people's lives. 

Hohman: Wonderful, thank you. Let's talk a little bit more about the specific challenges that you deal with on a regular basis. As a rural health administrator, each of you are tasked with operating many healthcare facilities in rural areas, confronted with the very real possibility that you're one bad situation, policy decision, etc, away from a possible hospital or other facility closure. Would that be accurate to say? What's it like to live with that weighing on your mind? Mandy, we can start with you?

Shelast: Sure, it is a reality. What you mentioned is absolutely reality. I believe that a vital community, just a thriving community, needs a hospital. So every day, we have to make decisions to ensure, you know, against all odds, policy odds, you know, other odds that come at us, that our hospital can be there for the community. Because if it's not, I mean, we take our hospital up in Michigan, we're the only hospital in a large radius, and if we closed, there would be no access to higher level medical care there. And that means that the community, you know, will start to die. There was a hospital over in Michigan, and it closed, it creates the largest county in the state of Michigan, 4000 miles without emergency care. So if you're there, hiking or enjoying the outdoors or just a living, you have to take the risk that if you had a medical emergency, you might not make it, and that is not fair to rural America to have to make that decision. So that's why it's so important to me for the facilities that we lead to make sure that they can be there against all odds.

 

Calhoun: Yeah. I mean, you know, some of the top of mine, concerns that I have, you know, we operate on such thin margins that a policy change or a change in the rules about the way we get paid, or, you know, payer pressures, the the financial burden is really heavy because we run on such thin margins that small changes can make such an impact on our ability to be sustainable. And I really connect with what Mandy said. You know, we've got an eight-county area that would really be a healthcare desert if we weren't here, and so we have such an obligation to be here providing that care. 

And so we have to be very strategic about making sure that we're growing and continuing to provide services that people will use and they'll feel comfortable with, but also keeping the operations efficient enough that you can make it sustainable financially. So it's like that balance between the two is really tough, and healthcare, it's not about money. I mean, we're not in it for the money. None of us here came into healthcare for the financial reward. It's all about serving people, but we do have to really be very conscious of the financial implications of what we're doing to make sure that we're building a sustainable organization. And right now, there's a lot of pressures on that, and it comes from a lot of different angles, and it can really get to you if you let it. And so we try to stay positive and create solutions, but it is a real challenge in rural America that there's not unlimited resources, and healthcare is very expensive, and so how do we balance all of that with thin margins and making sure we can keep providing not just providing care, but providing excellent care for our communities? And that's a challenge. That's something we're all that we're all trying to do every day.

Hohman: Dr Bartlett, anything to add on this one?

Bartlett: Yeah, I was just going to say one of the big challenges that I have as the vice president of medical affairs is in medical staffing in these small communities where you often have a specialty that you know there may not be enough patients to have two or three, so you only can have one, but then that one provider is going to get burnt out if you don't have a way to to give them breaks, to give them help, and how do you pay for locums for that provider? But I think a lot of people don't realize that that trickles down to even, you know, a nurse that's an ICU nurse or a chemo nurse. If we lose a chemo nurse in a town of, you know, 10,000 there's not five other ones looking for that job. A respiratory therapist, you know, during a respiratory problem, how do you get a respiratory therapist? And if you have to pay locums for every one of those special care nurses or providers for nurse practitioners, then that bottom line that Michael's talking about gets even more narrow or maybe the wrong way. So I definitely agree with everything that both of them have said about those challenges that we deal with.

Calhoun: And I'm glad Dr Bartlett brought up the issue with people and workforce. If I didn't speak about the financial pressures, my next, my other subject would be just finding the resources to people to be able to care and like, like Doctor Bartlett said, you know, whether it's physicians or other providers or frontline staff, there's already a shortage. And what I'm concerned about is just our aging population and how we're going to be able to train a workforce enough to be able to care for all the people that need it. That's a real concern, and I'm not sure which one's the top concern. It's either the workforce concerns or the financial pressures, but those two are really, to me, the things that are always top of mind.

Bartlett: I love seeing people like you and Mandy, because one of the people that we need in small towns are administrators with passion for rural health that are top notch administrators. And it's fun to work with Mandy, and I see that you have, you share a lot of that same passion, Michael.

Hohman: Michael, I'd like to start with you on this one. What do you feel are some of the biggest misconceptions about life in rural America? We've heard about a lot of the positives of rural as well as the challenges that you all face, but for those that don't live and work in rural America, but are oftentimes making decisions that impact the lives of those that do what do you feel are some of those those misconceptions and what do you wish more Americans understood about where you live and work?

Calhoun: Yeah. So one of the things is that you have to forego to live in rural America, you have to forego some of the amenities of life that you would otherwise have. I feel like that the slower pace and the ability to get away can be a real win for people, if they let themselves slow down just a little bit, but not only that, but you do still have access now to a lot of the conveniences that you might not have had 10, 15, years ago in a rural community. Just the ability to travel is so much easier, and the ability to shop online and things like this really make it to where you can live in a rural area and still have access to some of the things that you might have historically given up. 

So I like to tell physicians that think about coming here, that you don't have to give up anything, but you get, you know, a slower pace. You get a place where you get a community where you know people, you know, and for us, that's one of the wins for our health system, is that you're 30 miles away from an airport to anywhere, you know, you're 30 miles to a restaurant of anything that you'd like lto eat's available to you, but you can live in a place that's not as high-paced and high-stress. And so I think that's one thing. I think there's a lot of misconceptions about rural communities. They really are a great place to live and great people. And I think sometimes people feel like, well, if I go to rural I'm just out here by myself, no one, no support. And that's just not true anymore. With technology, we've got a lot more opportunities to support physicians in rural communities.

Hohman: Mandy, misconceptions from your perspective?

Shelast: I think, Michael, you hit on this one earlier. I think one of the common misconceptions in our community about people that live in work in medicine in rural is that maybe they're not as good as those that work in urban. Or maybe the equipment that is doing tests isn't as good. Or maybe the folks that are behind the screens like this are only working in rurall because they can't get a job somewhere else. And I am here to debunk that. I mean, I choose to live and work in rural because of what Michael said. I embrace a little bit slower pace of life. I love that. And if you take a look, you know, our mammography machine at our hospital is the exact same one that you're going to have in the most urban in the entire country, and the qualifications of that team member that are performing that test are the exact same. So I want to debunk that. It's not true at all, and it's amazing quality health care,

Calhoun: And maybe even I'll add on to that, in some aspects, it's better, because not only do they have the technical skill and not only do they have the state of the art equipment, which we do, but they're also passionate about what they're doing and the people they're caring for. So I would say it's even better than what you can find in a lot of urban settings, because you get personal attention.

Hohman: Dr. Bartlett, you've continued to practice medicine while also serving in the administrator role. So any additional misconceptions that you would add from that perspective?

Bartlett: I would just add on to what both of them have said about you know, we can, a lot of us as providers, could practice anywhere, and I have patients all the time who go to large centers in lower Michigan or in Minnesota, and they come back and they say, Wow, I think you guys provide better care. It's more personal care. You know me better. Your office is well trained. The procedures I have done there I feel more comfortable with so yeah, I would echo what they have said for sure.

Hohman: Thank you. So in our opening episode of this Rural Health Series, we heard from folks at the CDC and at HHS who have a focus on the policy side of enhancing healthcare in rural America. But I'm curious, from each of your perspectives, what are your top policy recommendations, things that you feel would make the biggest difference for improving the health of rural Americans? Michael, we can start with you.

Calhoun: Well, you know, one of the things I think we need to solve is some ground rules related to payers and prior authorizations and the way that we work together. I think we all have similar goals at providing high quality, low-cost care, but there's differing perspectives that we see that, from a provider perspective and a payer perspective, and what I'm seeing now is delays and denial of care that really reach too far. And so I don't know that I necessarily would say that one side or the other is always right, but I think helping to be able to bridge that gap between provider and payer so that we've got some ground rules that we all play by and agree to would be a really helpful thing, because in the end, when we have complications with that, patients are the ones that suffer. They need care and can't get it, or they don't, you know, their insurance isn't paying for the care, and so that would be one thing I'd like for us to focus on, and I've talked some with our state and local associations, is just we need to engage in those conversations and bridge that gap, because I do think that's a concern that our community has, is that if they can't access it, and they thought they were going to be able to, that's a real problem. And also, how do we reduce the cost of care and make it more efficient? So I think there's some opportunities with both sides of that. 

Hohman: Mandy or Dr Bartlett?

Shelast: Sure, I'll jump in real quick. And I know Dr Bartlett has a few as well. One of the things I would love to see, not just rural, but probably the healthcare community, come together on, is a national licensing effort when it comes to rural. If you look at physicians, APCs, RNs, oftentimes we have facilities that are on border states, and a physician licensed in Michigan cannot be licensed in Wisconsin without going to the state level. And I think that's silly. I think it creates barriers where there's already resource shortages. And I'd love to see some energy around that.

Bartlett: I have lots of ideas. I would definitely tag on to what Michael said about prior authorization. So that's an issue every day in our primary care office, and there's been some efforts on so my office has led the state of Michigan on evidence based care reports for Blue Cross, Blue Shield as a primary care internal medicine office in pediatrics. We have, I've been the chair of our ACO in our area, and we've really worked on our quality initiatives. But a lot of times the providers are saying, what do I get out of this? Well, what if I can show that in my office I don't order extra X-rays or MRIs when they're not needed. I've got a history of doing that. I provide extra excellent quality care, and I provide generics more than other people. So then, when I'm ordering an MRI, if I have that history, and I'm scored in the top whatever on my evidence based care report, or my ACO, I shouldn't have to go jump through those same hoops. And so I know there's some places where you get a golden ticket or things like that, but that could be a policy initiative that I think would make a big difference. Another one that especially impacts rural health is is telehealth. So, you know, we've seen an amazing transformation on what we can do with telehealth since the COVID pandemic started. There's a lot of talk about some of those coming back and not being the same, and I would love for those payments to be permanent, so that my patient, who lives three hours away who has ADHD, I can do a telehealth visit with them to help them with their care or their hypertension. I don't need to have them drive through a snowstorm to see me for that. 

Hohman: Absolutely. Any others that you want to add, Dr. Bartlett?

Barlett: So I think it's really important the Affordable Care Act and the Medicaid expansion, you know, some of these places in my I was a board chair of a different hospital, and we looked at how much charity care we were providing. If there's no Medicaid in that area or people don't have insurance, your charity care goes way up. Mental health services, of course, for adults and pediatrics and extra funding. I also am very involved in obesity treatment for both adults and kids, and, you know, multi disciplinary clinics, GLP-1s are a huge issue right now their cost, I'm not sure where that falls, but they are beneficial medication, but yet the cost is crippling us in a lot of different ways. So those are some, some of my other issues.

Hohman: I appreciate you sharing. Is there anything else from any of our panelists that you'd like to add that we haven't touched on in this conversation?

Calhoun: You know, one thing I would maybe like to talk about also is just the need for us to think about, you know, long term care and the aging population, and that's a segment of the healthcare industry that really has not recovered, from a workforce perspective, CNAs and med techs, and we're just really still recovering from the pandemic. And just with the aging population and the demand that's going to be on our long term care system, skilled nursing, and the lack of staffing and the lack of funding in that area, quite frankly, you know, it's not really providers that are holding back on staffing. It's the fact that we can't get the staff and we don't have the funds to be able to issue increased wages for those frontline workers. 

And so I just think that's a real concern for me as I look forward that we're gonna have more people needing facilities for long term care, and there's not going to be access to it for various reasons. I think we need to address that from a payment perspective, probably is one of the things. And then also we need to figure out. Solutions for workforce development and getting more people in healthcare, because that's going to be a concern in the future across the board, but I think it because we do long term care, it really is concerning to me that we're still lagging so far behind with staffing in those areas.

Shelast: Yeah, Michael, I'm really glad you brought that up at the hospital in Beaver Dam that I lead, we have a robust long term care, health and hospice and same,it's very challenging for resourcing. The payment is tough, but it's a community service that's absolutely necessary, and it must be here in the future. So thank you for bringing that up.

Hohman: Wonderful. Well, you can learn more about each of these guests and the work that they do at the links in our show notes. I'd like to thank my guests so very much. Mandy, Michael, Dr. Bartlett, for joining us for this important discussion. Thank you so much for taking the time to be here today. I wish we could continue this all day, and I'd encourage our listeners to take an element of what you heard today and continue these conversations in your communities, whether rural or not, rural healthcare, rural way of life, matters to every single one of us. So that brings us to the end of another episode of the Health Disparities podcast from Movement is Life. I'm Sarah Hohman, until next time, be safe and be well.

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