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Michael Zervas: [00:00:01] I had a great conversation with Michelle Mills, CEO of the Colorado Rural Health Center. She explains the perfect storm that has been brewing, which has forced the closure of so many rural hospitals across the country.

Michael Zervas: [00:00:13] And she also discusses the steps we need to take to save the remaining systems. She’s very knowledgeable and she provided a lot of insight.

Narrator: [00:00:29] It’s time for the Health Care Huddle, simplifying the business of health care presented by Encompass Medical, devoted to helping organizations succeed with customized medical practice management services, visiting encompassmedical.com Today. Now here’s your host, Michael Zervas.

Michael Zervas: [00:00:55] I’m very happy to have Michelle Mills join the show today, Michelle is the CEO of the Colorado Rural Health Center.

Michael Zervas: [00:01:02] The Colorado Rural Health Center works with federal, state and local partners to offer services and resources to rural health providers, facilities and communities. So it’s a pretty big scope and the charter is pretty extensive and is one of only three nonprofit rural health offices in the country. Michelle has, I think, a very unique and all encompassing perspective about the challenges and opportunities in rural health.

Michael Zervas: [00:01:28] Michelle, I know you’re busy and so thanks for taking the time today.

Michelle Mills: [00:01:32] Yeah, thanks, Michael, for having me. Appreciate it.

Michael Zervas: [00:01:35] Of course, my thought the first thing that we might do would be for you to kind of explain to our listeners what that means in terms of offering services and resources and give them a better understanding of what your rural health center does, but maybe also give them an understanding of what? Rural health centers are due in each state.

Michelle Mills: [00:01:57] Sure, you bet. So like you said, Michael, there’s a state office of rural health in every state. And so Colorado is set up a little bit unique. And in that we are set up as a nonprofit versus being part of the state or a university system. And what that does for us is it allows us to be able to have policy be a part of our efforts that we do at the rural health center. So state offices of rural health really reach out to all rural counties in the state to be able to offer assistance to them. And so that assistance is primarily to hospitals and clinics, but it also includes public health and then the community at large. And so we offer out anything from helping them interpret rules and regulations to making connection to services, to offering programs and information that really help them do their jobs.

Michael Zervas: [00:02:59] Like I said, a big charter, you had mentioned there that one of the advantages of being a nonprofit is that policy can be within your scope. Right. But what’s a disadvantage to being a nonprofit.

Michelle Mills: [00:03:11] Yeah, there’s always an advantage and a disadvantage. So the disadvantages is that as a nonprofit, we run just like any other nonprofit, meaning that we have to find funding and and make money to be able to stay open to serve our missions. So most state offices of rural health receive a state appropriations so they don’t have to worry about things like fee for service and stuff like that, like we do.

Michael Zervas: [00:03:40] How much of your time do you think you spend working on the revenue side, securing funds, chasing dollars, trying to keep the enterprise afloat so that you can do the broad scope and big charter work that you guys do?

Michelle Mills: [00:03:55] Yeah, it’s a lot of time. I don’t know, maybe 20, 30 percent, something like that. If you take into account writing grants and even more, if you take into account to, you know, keeping those conversations up with the foundations and state partners and and others that we that we try to seek some revenue to be able to serve our mission.

Michael Zervas: [00:04:18] Yeah, that’s I would I would I was thinking 30 or 40 percent of your time, probably just having played in the non-profit world, I know how hard that is. I would be thinking about your charter specifically and your viewpoint, your perspective as it relates to this explosion, for lack of a better word of telehealth that we’ve seen as a result of the pandemic. And I’m kind of curious to see what you think about that. Have you seen the same kind of rapid and maybe almost exponential implementation of that as a result of the pandemic? Has that already been kind of pushing forward and in rural health environments? Give me give your perspective on that, that telehealth component.

Michelle Mills: [00:05:01] Yeah, telehealth is definitely picked up since covid hit prior to covid clinics, rural health clinics and critical access hospitals were working on initiatives to try to bring that up. But definitely with covid that accelerated it. We have some regulation issues thanks to the pandemic have been reduced. That allows an uptick for that telehealth to happen. But we weren’t able to provide that direct primary care from our rural health clinic out to the patient who was primarily the patient would come into the clinic and then there would be telehealth that would exist between the patient connecting to like a specialist, for example. And then when the when the pandemic happened, we were able to offer that direct care right from the clinic, primary care out to the patient. So that’s very different than how it was before. And again, we weren’t able to do that because of regulation restrictions around the rural health clinics. And so it was like kind of starting from ground zero to be able to get up to speed with that. And that involves things like equipment, making sure that people felt comfortable in having those conversations in our state. We were able to do do telehealth by telephone, which was great. So we didn’t have to bring up the video portion of it. But there’s definitely problems such as broadband access or adoption of telehealth in terms of behavior change, both on the patient and the provider side.

Michael Zervas: [00:06:49] So you had mentioned that there was some regulatory hurdles to get over.

Michael Zervas: [00:06:54] Was that primarily reimbursement challenges or were there other hurdles that were either lowered or remove that allowed this rapid adoption?

Michelle Mills: [00:07:03] Yeah, well, it was a payment, but even furthermore, it was a regulation that was suspended that allows rural health clinics now to offer that primary care via telehealth and be reimbursed for it. So prior to that, they weren’t able to offer it.

Michael Zervas: [00:07:21] Why was that prohibition in place in the first place?

Michelle Mills: [00:07:24] That’s a great question. I think it’s because really the rules and the regulations for rural health clinics have barely been updated since they were implemented back in the late 70s. And so they really haven’t kept up with the times in terms of this is the way that, you know, that people want to seek care now.

Michael Zervas: [00:07:44] And you had mentioned two other challenges, which is the ability to access broadband that sounds to those of us who work and live in either urban or suburban environments, that seems probably not even to be on our radar. But that’s a big deal out there, right?

Michael Zervas: [00:08:00] Because it’s either not available or it’s not fast enough or wide enough to allow for the the data.

Michael Zervas: [00:08:07] Is that the issue?

Michelle Mills: [00:08:08] Yeah. So broadband access is definitely a part of the issue. And so if you think about the clinic and the hospital might have adequate speeds to be able to do telehealth. But that doesn’t mean that somebody who’s, you know, clear up in the mountains or maybe down in the valley or the plains have that same broadband speed access. So that makes the video portion of it very difficult just because of the lack of speed. And then if you talk about especially during the pandemic, with more people working at home and kids being having school through home virtually. And so that’s taking up more broadband speed as well, therefore kind of diminishing what’s widely available. But I think some of the great things about this really has elevated the conversation to allow people to understand that having that connectivity is just so vital to our day to day life nowadays.

Michael Zervas: [00:09:14] It is and it’s interesting, we’re talking about rural health care and we’re talking about broadband infrastructure in the United States and it’s like, wow, we think we have a simple solution and then it’s attached to a pretty big lift.

Michael Zervas: [00:09:28] Yeah, and that seems to be the case in rural health care, that it’s never just one thing, it’s always threatened or attached to many other infrastructure issues. I don’t know if your perspective is the same on that, but this is just one example of encountered my health care career in rural environments.

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Michael Zervas: [00:11:02] I think that there is a pretty big trend where a lot of people are leaving the cities and because of the pandemic and I’m wondering if you think that might have an impact on our ability to recruit to rural environments as people seek to get away from congested urban environments, or do you think the problem’s going to exist of that recruitment problem regardless?

Michelle Mills: [00:11:24] Yeah, I think the recruitment problem is still definitely going to exist. But I think, like you said, having more people start to move out to rural communities is hopefully going to help continue to raise the awareness. So that way we can find some solutions to what might work for our rural communities, especially in terms of workforce. And we have an aging population which includes the aging population of our providers as well. And so, you know, I only see that getting worse, unfortunately.

Michael Zervas: [00:11:59] And I’ve noticed that the very providers that we don’t want to leave the workforce, we’ve got 30 years of experience under their belt, are tending to throw up their hands in the face of what they feel is increased regulations and hurdles.

Michael Zervas: [00:12:17] And it’s those highly experienced and educated and practiced practitioners that are saying, you know what, leave it to the next generation, but we don’t have the next generation necessarily. Right. Migrating in the same way as. Am I thinking about that. Right.

Michelle Mills: [00:12:34] I think yeah. Yeah, definitely. Ah, it’s such a crisis. But as far as our providers, like you said, that have, you know, 30 or more years start retiring, not only is it a problem of the lack of workforce but then it’s just a problem with continuity of care as well. So, you know, not everything can be done via telehealth. And we really need more people to be interested in rural health. And we need more of a focus on it. And in a drive that will help build that pipeline for people to go out to rural. And I think there’s some really great reasons as to why people would want to practice real medicine. They have a broader scope. They’re able to serve people that are from birth to death, and they really get to develop a relationship with folks. And when you’re in an urban location, that’s just not necessarily the case.

Michael Zervas: [00:13:33] It really isn’t, and I think you made a great point, and it kind of leads me to this next topic about real health that I’ve been thinking about is we talk about mental health specifically as it relates to these changing models of care delivery. And telehealth is one of them. And I’m wondering if you’ve seen or are aware of any other initiatives of changing the delivery of that care in rural health environments, or is that model pretty much the same and really telehealth is all that they’re doing to adapt to this kind of brave new world we’re living in?

Michelle Mills: [00:14:09] That’s a great question. I don’t know that I have a great answer for it, but telehealth, I think, is definitely emerging. But I think also the things that have come out maybe the last 10, 15 years around community medicine and, you know, and folks going out and specifically paramedics going out to people’s home to help take vitals and really ensure that there’s that continuity of care for them when maybe they don’t have to come in. And that helps keep patients out of the hospital and reduce readmissions. But it’s pretty hard to implement.

Michelle Mills: [00:14:46] And it’s and it’s costly, but it definitely is an avenue that can potentially help.

Michael Zervas: [00:14:53] It’s interesting that you said that, Michelle, when I was on Whidbey Island, working in a rural health system, we were trying to implement that and have our paramedics also going out and assessing for fall risk and all those other social determinants of health. Is there food in the cupboard? Is there all sorts of different things? And when it worked, it was amazing, but it was hard to get to work and it was hard to do it cost-efficiently, but I think there is some traction there. I think that there was a good opportunity there. And it’s interesting to me that as you talk about the recruitment problem, obviously there’s always the trailing spouse problem, but also some of the same issues of infrastructure.

Michael Zervas: [00:15:37] It’s like if you’re a well-educated medical professional and you can’t get a good school or you can’t get broadband access, that’s a deterrent. And at the same time, it also the turn to recruiting them. And it’s also at the same time, a deterrent for the patient to be able to be seen. And so it’s all woven together into this. You know, where do you start? Where do you start? Right. What’s the first thing? And so I’ve also seen where there is less of a of a hospital focus and more of an outpatient facility type focus and not so much the old hub and spoke model, but more independent medical centers for lack of a better term that can allow and then maybe to go into the home and do home visits. And we’re back all the way back to the 50s. Right. Have you seen any of that in Colorado?

Michelle Mills: [00:16:28] We’ve actually had somewhat of a trend of where we had quite a few independent rural health clinics, probably 10 years or so ago, that have transitioned more over to provider based clinics, meaning that the hospital owns and operates the clinics. And the providers that are on staff are actually on staff of the hospital system, for example. And a part of that, I think, is because what you were talking about earlier is just the administrative burden that continues to be accelerated year after year really deters people from trying to open their own practice and or to be able to really be successful in in a practice because people went into practice to help people not to do paperwork. Yeah.

Michael Zervas: [00:17:22] Or to worry about insurance and how to code this so that it’s going to be paid correctly. And it’s ridiculous.

Michelle Mills: [00:17:31] And I will say that one of the one of the super great things about rural health care is that everybody really works together in the community and to help make sure things are taken care of.

Michelle Mills: [00:17:43] And and so, I mean, we are much more able to see, for example, if somebody is homeless and when they their diabetes keeps getting out of control, there are solutions that can be worked on a community level to try and solve that problem, which is great because it’s a community, people helping community people.

Michael Zervas: [00:18:09] I agree with you, and it seems to me all too often is that legislation with the best intention often has numerous and unintended consequences deleterious to the rural environment because they can’t do the legislation well, maybe they could with a fine enough instrument to understand the differences in how care needs to be delivered and where the resources are not. And regulatory standpoint, do you think that these prohibitions on telehealth that have been repealed will stay repealed, that that was the impetus? Do you think there is enough energy around that to or do you think it’ll go back to the way it was?

Michelle Mills: [00:18:54] Well, I really I hope it doesn’t go back to the way it was.

Michelle Mills: [00:18:58] And I think there’s a lot of energy and a lot of organizations like ours, as well as national organizations that are really fighting to try to keep some of the regulation reductions in place going forward just because of how helpful they’ve been.

Michael Zervas: [00:19:18] Yeah, I hope so, too, do you have an opinion or have you seen the chart initiative by CMS rolled out in Colorado? Have you seen the results of that or do you know anybody that’s involved in the pilots or?

Michelle Mills: [00:19:30] Yeah, we don’t know that anybody in Colorado plans on applying. And partially that’s because it was such a low amount of funding available. Not that there was an opportunity to do things, but I think when Pennsylvania implemented, there’s a cost something like twenty five million to implement their model. And and the chart model was offering five million. And it’s just not enough to really try and work on everything you need to work on to try and change. I think there is an appetite by people to want to really look into different ways that and different models that work in different communities. But I don’t I don’t know that that’s going to be the way.

Michael Zervas: [00:20:14] It’s interesting to me, because it’s not only that there’s not enough dollars to give you a common sense return on investment. There’s also an opportunity cost of working on that versus something else. Right. And so you have to be sure that there will also be some significant long term benefits in return on that investment. And that’s hard to predict, depending on what legislation is passed year to year or what decisions are made. And so I think that also has a chilling effect on people’s desire to initiate or engage in these large scale projects, because it’s like two years from now, maybe this won’t be the flavor and it’ll be something else.

Michelle Mills: [00:20:59] Definitely. You know, we were anticipating that chart model to come out, but we were thinking it was going to come out more like the other CMS initiatives, where was something like 60, 70 million that you could apply for, which would really allow for a lot of innovation to happen. And Colorado is, I like to think is unique, but I’m sure other states would probably disagree with me. But, you know, I mean, we have the we have the eastern plains, which up there hospitals and communities operate very differently than the western slope. And we also have resort communities and we have a lot of tourism here in Colorado and we have a lot of farms. And so there’s just different answers. It’s not like one solution is going to fit every single community. And so I hope over time the CMS will continue to hear that and be able to really reward that with some innovation opportunities that are viable,

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Michael Zervas: [00:23:29] From your lips to Washington’s ears, I agree with you, it’s much needed and I think I agree with you from my limited perch, I see an appetite for it also. And but one could also say that there was this idea of doing the Medicare expansion and more than a few states chose not to engage in that. And what I’ve seen is that there’s a correlation, statistically significant, at least in my untrained eye, that many of the states with the most failing hospitals also are states that did not decide to opt into the Medicare expansion program. I don’t know if you’ve seen that same correlation or am I just looking at numbers and charts and getting looped?

Michelle Mills: [00:24:09] No, you’re absolutely right. The states that did not expand Medicaid definitely have have it worse than than the states that that didn’t. And in fact, when you look at some of those maps of the Chartist group comes out with it, it really does show that those are the states that have the most hospital closures. And in Colorado, we’ve been so fortunate to not have any real hospital closures. And and I really do believe in part that’s because of expansion of Medicaid.

Michael Zervas: [00:24:42] I agree with you and you can take a look at those charts, too, and if you drill down even a little bit deeper and start to look at what they consider at risk hospitals, they’re clustered in the same way as the closed hospitals. And so there is a there’s a pipeline and think of problems that we’re still having dealt with that are still on their way to us as a result of this. And it’s interesting to me, but it’s also sad because I’m going to be interested to look at over the course of 10 years what happened to those people and how many people didn’t get care, how many people didn’t get the right care at the right time? And do we see changes in morbidity or mortality? I hope that there won’t be. But my my fear is that we’ll also see that over time.

Michelle Mills: [00:25:31] Yeah, I think you’re right. And I think even with the effects of covid as well, you know, we saw people not seeking care. And I think we don’t even know what the implications of that are going to be. I think there’s also going to be further financial implications for our rural hospitals and clinics after everything settles with covid. And I mean, people have money now that came from the cares act, which is great. But when you have about 70 percent of your revenue come from your provider-based rural health clinic and then all of a sudden you go down to zero for several months and then you start to gradually see care, come back. You know, that’s that is still not at the level that it was prior to covid. That’s going to have a lasting effect. And, you know, I really just hope that people recognize that both at the state and the federal level to be able to offer some solutions that we can be innovative and work to create the infrastructure that allows our rural clinics and hospitals to really thrive because we serve definitely older, sicker, poorer population. And there’s no reason why people need to be driving two or three hours to seek care. That’s crazy.

Michael Zervas: [00:27:02] Agreed, and you know, the other thing that people maybe don’t think about is that oftentimes a hospital or a system in a rural community is the largest employer. Yes. And they’re driving many jobs and many high-paying jobs or good-paying jobs that feed the town or the community or that city. And so if that hospital goes away, there is another unintended economic consequence, independent of all the health care problems. And I just feel like I’m not sure why it’s so hard to create the attention and maybe it’s that the rural health don’t have enough.

Michelle Mills: [00:27:39] That’s a it’s a great question. And I feel like so many people over the years have continued to shout those things from the rooftops, just how rural health is, the infrastructure and the viability of a rural community. And you’re exactly right. When a real hospital goes away, it’s not just the access to care that goes away. It’s the jobs that go away. It’s the people that leave the town.

Michelle Mills: [00:28:11] It’s the small businesses that close and aren’t able to remain open and or they go to other towns to be able to have a better, thriving business and in life. And that’s just really sad to see when you once saw a thriving community and then you drive down a main street and you see things boarded up, it’s very sobering.

Michael Zervas: [00:28:36] It’s analogous to the old trope when the mill closed. Yeah, it’s the same thing a town where there is and dies then. And I’m curious, on a personal level, what’s the hardest part for you of your job? The scope is so big, the charter is big and the need is even bigger on a personal level. What’s the hardest part?

Michelle Mills: [00:28:57] Oh gosh, I love my job so much and I feel so, so fortunate for sure to be able to help. I think the hardest part is really that I always wish we could be doing more and more, more of everything that would that would really help all of our rural communities survive and thrive. And there’s just not enough of us and not enough money available to do all that.

Michelle Mills: [00:29:23] And so that, you know, that feels a little defeating sometimes. But I know at the end of the day that our rural communities really appreciate us and appreciate what we do. And so fortunate lucky to have an amazing staff that I get to work with every day that really believes in our mission. And so I really have no need to complain.

Michael Zervas: [00:29:47] Yeah. And certainly not a complaint, but just that it’s I bring it up because for many in health care, what you just articulated is the central challenge is most people in health care are doing the work that they’re doing because there’s an intrinsic desire to help. And the flip side of that is. An inability to help as many as you want to be able to help. And to some degree, we’re all powerless to affect the change that we so readily see to be able to widen that that safety net and that help.

Michael Zervas: [00:30:28] And so I don’t hear it as complaining. I hear it as a resonating challenge that everybody in health care faces. And whether it’s a provider on the front line, there’s a danger to all of that desire to help everybody and do more can lead to burnout.

Michael Zervas: [00:30:45] And then ultimately we lose some of our best leaders because they’re exhausted by the fight. And that’s another challenge I think, that rural health has, is that if we don’t provide solutions, sets in ways and opportunities to fix and grow and adapt and innovate, we lose. We have a brain drain of our best leaders in whatever capacity they’re leading, finally saying I can’t shovel against the ocean anymore. Right. Right. You see that?

Michelle Mills: [00:31:17] Yes. And boy, has the pandemic exasperated that for sure, people are are tired and they’re burned out there and they have such a connection to their community that these are real people that they’re seeing that they know they’re their friends and families and neighbors. And I think that’s just very taxing on people. And I think we’re going to definitely be facing a huge mental health crisis. We probably are now. It’s just not rearing its ugly head as much as it probably will once the dust settles a little bit here and we get better control on the pandemic. But I think there’s going to need to be a lot of resources put there into supporting everybody. And that’s not just the doctors and the nurses, the lab techs, but that’s the people that are the house housekeeping staff and the administrators and really everybody.

Michael Zervas: [00:32:22] These things seem to have a tail to them. The pandemic has this tail that you just described of mental health that we’re going to deal with our lack of allocation of resources to rural environments are creating, in my opinion, health deserts, just like we have food deserts in urban environments where no grocery stores are and the consensus is sometimes I think that, well, I can’t see it and it’s not a problem for me and so I don’t have to worry about it. But, you know, I think most people don’t understand the volume of patients that are classified as rural health, the amount of admissions that happen in a rural health environment.

Michael Zervas: [00:33:05] And if those resources go away, the people don’t. They have to go somewhere. Right. So we can deal with this problem today or we can wait and deal with it when it’s worse and harder and more expensive to fix. And so I need you on that policy side to get out there and fix this, Michelle.

Michelle Mills: [00:33:25] Yes, we definitely have on our radar to try to be working about. And I really neglected to mention our children, and I really think they’re such an important part of our of our community as well. And I think we don’t even know what kind of mental health effects this pandemic has had on them to know to be stuck at home, school and, you know, and not with their not with their friends or other family members as well. And so I think we definitely need some huge policy efforts towards providing resources. And I think telehealth is going to help with that in our real communities to make sure the people get the care they need and not feel stigmatized by it in terms of having to go in and show up at a location, because nobody wants to be judged for that. And I think that’s some other behavior change that we just need to change on a national basis.

Michael Zervas: [00:34:24] I think you’re right. Well, I’m looking at the clock and realized I’ve kept your past 30 minutes. There’s a lot in your head and I want to get it out for everybody. But I want to thank you for donating your knowledge and your time today. And if anybody wants more information or wishes to learn more about rural health, they can contact Michelle at info@coruralhealth.org. So that’s coruralhealth.org And that’s all one word. And or they can visit the website at coruralhealth.org. Michelle, thanks so much for your time. And I hope you’ll come back and we can kind of revisit and see what progress we’ve made.

Michelle Mills: [00:35:06] That sounds great. Thank you so much, Michael. I really appreciate it. Have a great year to take care.

Michael Zervas: [00:35:22] In talking with Michelle today, it got me to thinking with the closure of so many rural health hospitals, health deserts are being created throughout our rural health network. This is analogous to the food desert we see in our urban environments. The numbers are alarming. Since 2010 through 2019, one hundred and twenty rural hospitals have closed an average of 13 a year in 12, 19, 19 rural hospitals closed along. And I’m thinking 20, 20, given the current conditions we’re dealing with, will be just as bad or maybe worse. And to put these numbers in a bit of context, there are approximately 1,844 rural hospitals in the country. And one study deems that 453 of these are vulnerable to closure. That is close to twenty-five percent of the total. Twenty-five percent of our rural hospitals are going to potentially close. And these 1,844 hospitals represent approximately 30 percent of the hospital beds in the United States, and they provide close to 11 million admissions annually. That’s a big bite of our total health care system. So why is this happening? We have a perfect storm of regulatory inflexibility, political gamesmanship and a one size fits all mentality relative to reimbursement. There is a high correlation between the at risk hospitals operating in states that have elected to not adopt the Medicare expansion program. Less dollars mean greater risks. CMS often enacts rules to solve one problem that have unintended consequences and other areas.

Michael Zervas: [00:37:05] A perfect example of this is the rule to curtail multiple tests and one day to prevent artificial inflation or churning of charges. This makes perfect sense in an urban environment, but in a rural environment where patients often must travel great distances and as a result take time off from work to make that appointment. This is maladaptive and ultimately discourages patients from getting the diagnostic care they need. Additionally, there’s been a lack of emphasis on the social determinants of health. And because rural population skew older, less healthy and less wealthy, not focusing on early intervention guarantees the individual’s health problems grow to become more intractable. Over time, rural hospital boards often lack the health care experience to govern C Suite executives. In an unfettered environment, bad actors can do great damage, surprisingly slow or no broadband access decreases or eliminates the ability to deliver telehealth. And as the pandemic has shown us, telehealth is a great way to stay connected with patients at a fraction of the cost. So I have a modest proposal. CMS needs to collect data from those rural hospitals that are thriving and distill common best practices found in those winners. Then incentivize those behaviors for all rural hospitals. We need to redesign rural hospitals c suite so that much more of it is tied to hospital performance and less is embedded in a contractual base. Variable comp encourages innovation and performance and based comp discourages the same. We need to incentivize at home visits by mid-level practitioners.

Michael Zervas: [00:38:45] Delivering care to where is needed helps reduce skipped visits and allows for onsite evaluation of those social determinants of health. And finally, here’s a big one, the moonshot. We need to invest in rural broadband and then encourage telehealth, adoption and reimbursement. Unless we think this is not our problem because we live in urban or suburban environments, we should remember that our Rural Hospital Service, 60 million people within their catchment areas. In the long run, we will pay in one form or another to help our sick neighbors. The choice we have is when studies show that when rural hospitals close, average inpatient mortality increases by almost nine percent, with Medicaid and racial minorities seeing even higher rates. So we can help our neighbors find the water they need in these health care desert, or we deal with the problem when they come to us dying of thirst.

Narrator: [00:39:49] You’ve been listening to the health care huddle, simplifying the business of health care for more information, show notes, guest profiles and more visit encompassmedical.com And subscribe to the podcast at Apple iTunes, Overcast, Google or wherever you get your podcast.