Good morning. Thank you for joining us on this snowy, chilly Sunday morning. Chilly for Chicago? I don't know, but I'm here from Phoenix, so it's a little cold. So we're going to spend some time talking about the trade-offs, the difficulties in terms of providing radiological services in rural areas. But let's start with something we all know. Healthcare is a very demanding, it's a very tough business. I find it very difficult. Most of us find it very difficult and stressful coming back at the end of the day with record profits, record stock prices, and then having to make your way through that. And you're like, what are you talking about? Oh yeah, that's for the health insurers. They're doing fantastic right now. Big Pharma's doing the same. I'm sure most of y'all have gone to the exhibit hall. If not, you should check it out. It's pretty fantastic. You can find device manufacturers. They're doing fine too. So what does that have to do anything? Well, but I think if we're talking about you guys out here in the audience, you'll recognize that, well, it's probably been never more difficult to be a radiologist. As you know, recent study in the Journal of American College of Radiology found that Medicare fee-for-service radiology has fallen 25 percent, the reimbursements, RVU cuts, conversion factor cuts. They've been very asymmetric, very different for primary care. They're actually benefiting a bit from this. But for radiologists, 25 percent of your incomes have fallen, right? And of course, commercial rates, key off of the Medicare rates. So you're finding it well across the broad base of what you're doing. And that's very key when you're thinking about rural or urban. What does this create? Creates this RVU hamster wheel. I had a lot of fun using Chaz UBT's AI, so I could generate one with a radiologist in the middle, right? Working, running twice as fast, twice as hard, so you can stay in the same place as far as your compensation and reimbursements, right? So it's a tough business, and it's never been tougher for a radiologist. But that's for all radiologists. We also have what's called a nationwide physician shortage. Something to think about, right? Sure, it's a nice pretty graph here, except that the red is bad. But I'll talk about what this means after we zoom in, because what we're really focused on in today's session is rural radiology. So let's take a look at my good friends in Alabama. You can see the green areas happen to be nice population centers. Birmingham right in the middle, Montgomery a little further south, a little further north is Huntsville, down by the Gulf you've got Mobile. And then you've got all of these red areas. And what is this? This is a map of every county in Alabama. So at some point, we took a collection of claims data where we had both the zip code of the patient and the zip code of the physician. And that's what builds this map. You can aggregate all the reimbursements, all the actual payments. So not charges, but actual payments from the insurers and from the patients that they paid for medical services in a county. And we can also aggregate all of the actual revenues those physicians received in that county. And you can put them together and come up with a nice little ratio. The first one's going to look at spending. Inside one of these green areas, what we're saying is all of the providers in that county received more revenue than the patients who lived in that county paid for medical services. Where's that revenue coming from? Well, let's look at the red counties, right? These are counties where all the revenues received by all the providers in that rural county is less than the health care spending from the patients who lived in that county because they're leaving or going to the city. So that's a huge problem right there. It's not just having enough providers. You've got to actually keep your patients local. And we'll have to talk about why that's an issue and the trade-offs involved. Now, you could say, okay, great, you're doing it with dollars. It makes sense. You know, cancer is very expensive. You're not doing that in a rural area. Let's do it with procedures. I have maps where we do it with just primary care services. And unfortunately, when I was putting my slides together, I couldn't find where I put the map with just radiology services. They all look the same, right? So that's the fundamental problem we face here. You've got people migrating for care. You have a need in rural communities for care. And usually what my focus has been, it's been on the supply side, trying to understand what does it take to actually provide care? What provides the incentives for a hospital, a small practice, a radiologist to actually be willing to provide care in these rural communities because there is a shortage. But let's be clear, and as I'll show, just because there is a shortage doesn't mean there's maybe enough of a patient panel in that narrow area to where you could satisfy. You know, it's a statewide shortage. It's a broad shortage for all of these interconnected rural areas. So again, this is the question. A little apologies to Charles Shorts. Why is the doctor out? Where is that rural radiologist? Well, let's talk about the factors that could drive why you would have practices in rural areas. The first and primary one we have to look at, and I'm a healthcare economist myself, is thinking about what we call economies of scale. This is the simple notion that if you don't have a large enough patient panel and a large enough patient panel that meets the needs for what you do, you simply can't spread these costs out enough to make it profitable and worthwhile to do the things you need to do and provide those services in a rural community. You know, you need to have enough patients for that core practice infrastructure. And you think, well, we've always had folks who put a shingle out there, opened up an office, hired some staff. Yeah, but that's not really what we're talking about. That's real PPE, property plant equipment for the MBAs in a crowd who wants to think about the accounting. It's really the next two that truly matter. These systems, requirements to have million-dollar EMR systems, right? Requirements to be able to integrate with the systems of perhaps multiple healthcare systems, because you want to integrate with the local community hospital, but maybe you need to integrate with another hospital in the city. So, you have to make sure, you know, you're compliant with all of that. Complexities of modern scheduling and billing, right? Are you actually buying these systems yourself? Are you outsourcing these services to someone like Zotac or someone? You have to have enough patients to amortize this out. This is no longer the day where we think about the rural physician. I've got a rural practice. Anna sits at the front desk and keeps track of the appointments for me. We file a couple billing claims out there, and you've got a million other rules, which is where we go next. What the real problems are, regulation and compliance, right? Okay, are you dealing with MIPS? Are you now, is your system, even though it's a rural system, it's part of a larger integrated statewide network, and they really want your ACO patients that they signed up to be in, and you've got to now manage them within their ACO perspective. What is the cost of that compliance? I mean, the rural physician is not, was an expert, was really a small business owner in the past, and even as they've grown over time, it's still fundamentally a small business where you've got the physician and maybe a business manager trying to grapple with all of these, but the complexity of meeting the regulations of modern health care, and these are important regulations unless you want your payment reimbursement rates cut nine percent at the end of the year, or the other various trade-offs and carrots and sticks you have. So again, if you don't have enough patients to staff up a large enough practice, a large enough staff, expensive EMRs, meeting expensive regulatory requirements, right? How about something basic? Are you a in a rural area? Is your data going to the National Homography Database? Is that free? Right? It's not. So that's a huge part of what happens in rural areas. It's not just about can you get a provider to move there, but can you actually afford to practice in a rural area, which is a trade-off, because what's the alternative? Join a large system, right? Can you have enough volumes to be the local contact for that? Have private equity absorb your practice and let them streamline it for you? And when I used to run the Nieman Institute, let me tell you, every month I had a new physician from somewhere in the country call me up and say, yeah, we just sold our practice to a hospital system network, private equity. But the funny thing is, could you give me an RVU benchmark? Because in my rural community, you know, I was running maybe 10, 12,000 RVUs a year, but they say I need to make 15, 18, 20,000 now. And you could live as a rural physician with a relatively low RVU benchmark. But what happens when, you know, you've got your private equity masters, you've got your large healthcare system, and they're benchmarking you to the folks in the urban trauma center, where there's just different reads and very complex reads all day long, and all they see is your labor input, and this is the RVU benchmark that you need, right, to get your bonus, to stay competitive. So it's not an easy game to say, well, okay, fine, let's just go and bigger it up, except that you're dealing with the patient population in your rural area. So it's a challenging thing to think about, either way. Let's talk about recruitment and retention. We've all seen city mouse, country mouse that says, you know, there's no wonderful panacea where one side of the world is better than the other, but it doesn't change the fact that living in a rural area is not the same as it used to be. I grew up in South Georgia myself before we moved to Atlanta in high school. I could go back to the same town I grew up in, and there's not nearly as much there as it used to be. It's well documenting. Rural areas are hollowing out, and have been hollowing out tremendously. So you've got not nearly the vibrancy. You don't have the county fairs or city fairs there anymore, much fewer amenities. But let's talk about just as a practicing radiologist, right, professional isolation. Are you actually meeting with other radiologists until you come to RSA once a year? Challenging things to think about. Recruiting staff is increasingly a problem. You've got the brain drain from rural areas, right? You've got lower pay there. Why should someone stay there and be your staff? And let's be clear, there's a lot of literature right now. It's a very hot topic talking about relaxing scope of practice for PAs and nurse practitioners, because they're going to solve the health care shortages. They're going to provide the workers you need. But let me tell you as someone who's written three or four papers on this at this point, there is literally zero credible evidence that when you expand scope of practice for these mid-level providers, advanced practice clinicians, that they actually pick up and move to a rural area. That's the promise that people say, oh yeah, we'll do this and they'll fill that gap. Actually turns out they like to live in the city like the rest of us. It's just kind of one of those things. So that's really not the answer there. But those are important things in terms of these trade-offs. How do you convince folks to stay? You know, really hope you have someone like me who wakes up every now and then and says, well thank god I'm a country boy. And this is fun, right? But for the modal physician out there, that's not a compelling enough reason when you're realizing, you know, we could just shop at the grocery store in town. Now we drive an hour away. A little challenging. Amenities, professional isolation, very different sort of patient mix. Let's talk about that next. Sub-specialization of, you know, pimping a little bit of my own work with Rich Duzak as well, we found looking at some data that radiologists practicing strictly as a sub-specialist increased 20 percent in the five years of our sample. And it's continuing to increase. And it's happening for many reasons. It's not just compensation. It's simply because radiology is so much more complex. All of medicine is so much more complex. So it's pretty clear that people often want to really get into those kinds of cases. But think about this for a minute. You're the rural radiologist. And something we found in our study was that you don't find as much of this in rural areas because even if you had a specialized, sub-specialization fellowship, even if you locate in a rural area, you don't have enough patients in your observed workload to classify as a sub-specialization beyond your self-reported, I'm a neuro-rad or etc. Because if you're in rural Kansas, you're taking all comers. A lot of plain film, you know, a few CTs, but not a lot of sub-specialty work. And so if you're part of the group, you know, younger, you know, younger generation of radiologists who are increasingly sub-specialized, it's not very attractive to want to be a rural practitioner if you want to be a sub-specialty because you're going to spend most of your time doing general diagnostic services, which raises those trade-offs. How do you look at the balance between sub-specialty care and general care? Some solutions could be just have the, you know, the generals local and anything advanced, as you see in other parts of medicine, go to the hub and spoke, go to the city. But at the same time, if you have growing numbers of radiologists choosing to sub-specialize, that means you have fewer people willing to even be the general radiologist locally. So that's an interesting conundrum. You can't just solve it by saying, okay, well, the generalists will come here. Are there enough generalists to actually satisfy that need? Great questions. And again, that raises questions of balance. And I think the other speakers will talk about in terms of how do we balance the trade-offs of meeting the school population, but also providing an attractive work environment where radiologists can feel comfortable working in that environment. So you can even provide that locally. And let's not forget the most important thing you need as a radiologist, right? You need images. You need something to read, right? Where are these images coming from? You know, we've had a mass constantly in the health policy press in terms of the rash of rural hospital closures. Rural hospital closes, there goes the CT, there goes maybe the MRI, where now the local radiologist has a lot of plain film to read. And is that going to induce them to stay in the rural area? So it becomes this interesting cycle in terms of, are you a private equity? Or maybe you're a radiologist in here who is thinking about standing a rural imaging center. Well, that's costly as well. Okay, the hospital is shut down. We'll set up an independent imaging center on our own. We've got the same regulatory compliance. You know, maybe if you want to get paid by insurers, you're going to have to get ACR accreditation. And I think we all know, for those who have that, it's not like those gold seals are free either. So now you need a big enough patient population to continue to pay for all of that as well. So you have to have a reasonable infrastructure to provide enough patient volumes in terms of images to read across a broad range of modalities if you really want to have a vibrant local community radiologist. So just to wrap it up, what have we learned? Primary. First and foremost, the biggest challenge, and that's what I would set up here to do, to sort of set up the challenges of it. And then our following speakers can talk about some solutions for how we can address this. But we have these conundrums, and it's not an easy silver bullet. You need to have enough patient volumes. You need to be able to spread the cost, not just over your facility, but primarily over the increasing complexity of meeting CMS and government regulatory compliance, at least if you don't want payment reductions coming into play. And that's really the most challenging part of setting up in rural areas and why you might find affiliations with larger radiology groups. And then you have the fundamental recruitment and retention problem that every industry in America has as we find the hollowing out of rural areas. And again, it's not just RADS. It's a whole team. You need a whole team to have a practice, and you need to have the labor for that. You want to have subspecialists, or at least you want to have people who are willing to live there recognizing that it may be an awful lot of volume of not their subspecialty. And then finally, understanding do you really want to live in a rural area as they're continuing to shrink because they become increasingly less attractive over time? So with that, thank you so much. Good morning. I'm Catherine Everett. I'm a private practice radiologist in North Carolina. I'm going to talk about three things, rural health care, private equity, and where radiology fits in there. First of all, a basic tenet, the social contract of health care. That is an expectation that safe, effective, and equitable services will be made available to a community. So here's some facts about rural hospitals. This information came from Shep's Center of Research at the University of North Carolina. It's widely quoted in the literature. 30 percent of rural hospitals are at immediate risk of closing, and a significant number, as Dr. Hughes said, have closed in the last few years. Why is this? Low financial reserves, inadequate revenue, usually poor payer mix, and workforce shortages. Nobody wants to work in a rural area. Note that some of these things are self-inflicted, particularly the lack of Medicaid expansion, which happened to be voted against in multiple of the poorer states, including my own. And there are some federal programs that designate certain rural hospitals for specific bonuses, but this still doesn't cover the gap. So why does it matter? Well, 20 percent of our U.S. population is rural, 60 million people. The rural population is older and poorer, less insured, and with greater health morbidities. eBirth reported at the RSNA in 2015 that 23 percent of the rural population is eligible for lung cancer screening compared with only 15 percent of urban patients, yet only 22 percent of rural population is within an hour of a screening facility and 83 percent of urban population is. So also these country folks, and I'm one of them, drive hours to the city for their screening. They face parking garages and pay for parking, which is another deterrent for people seeking health care that's not emergent. So this is a picture of an abandoned tobacco barn in Martin County, North Carolina, where I grew up. At 8 a.m. on August 3rd this year, the community, hospital staff, patients, physicians, were told that the doors of the hospital were closing at 5 30 that afternoon. First warning. It's a devastating loss to the county, losing one of the largest employers as well as all the health care services. That was it. So now we go to private equity. An investor buys a stake in a private company with the hope of ultimately realizing an increase in value of that stake. What's key? Well, private's key. So it's not publicly traded, so you can't really read about all the transactions. PE firms do expect a large stake in the business and typically do not wish to be mere passive minority investors. They use the position to try and make the company more valuable so that it can sell its interests later for significant profit. So what's not in there? Social contract of health care. But PE firms are buying rural hospitals, now owning approximately 7% of all of them. It's a small number led by primarily three firms. Rural hospitals are going broke, but PE firms are buying them. Why? Number one, property. A lot of the property these hospitals own are more valuable than the enterprise itself. So property gets sold and it's leased back to the operations. Government subsidies. 65% of these designated critical access hospitals, sole community hospitals, Medicare-dependent hospitals, are owned by private equity. I'm sorry. The ones owned by private equity, 65% of them meet those designations. Also remember the COVID funds. Private equity still got millions of dollars from the private equity fund, but the private equity fund still got millions of dollars from these small hospitals. They also have service companies such as nursing leases and contractors with billing management and use those to sort of pull the money out of the small hospitals. So why do the hospitals do it? Cash, manpower, better management, skills, better supply contracts, and just to stay open. So the results. We know there's some really bad actors. I just talked about that. Several hospitals in Missouri, two were closed after the private equity sold the property, leased it back at exorbitant price, took all the COVID money, and then ran the hospital into the ground. Same thing happened in Arizona. But Harvard Business Review also confirms that there are, there's a good side to private equity in small hospitals. They improved margins, maintained quality, and even for some cardiac care, the quality was actually better in the hospitals that were owned, small hospitals that were owned by private equity as opposed to not. So, rural medicine's in the crisis, private equity, the jury's out on that, but what about rural radiology? This is from Eric Friedberg in one of the ACR bulletins. The best way to classify the state of radiology in rural areas today is that it goes from the very challenged to outright crisis. Small radiology practices that serve rural hospitals are going away. From 2014 to 2018, the number of practices with three to nine members went down by 45%, while practices larger than 100 increased by 50%. Small, as Dr. Hughes said, can't recruit. The generalists are all retiring, no IR services, higher expectations, compliance and regulations. Is there a way that we can combine private equity, rural hospitals, and radiology and have a good outcome? We'll quote Rich Heller, radiology is the fulcrum of healthcare. Almost all acute care decisions involve imaging. Our patient providers rely heavily on imaging for management and appropriate screening exams or standard of care. How can radiology supported by private equity or other large provider systems improve these services to benefit the rural hospital and provide quality and appropriate care? I'm going to take a theoretical example here. Scotch bonnet imaging, and you can see what they're, they have a big hospital, a medium-sized hospital, and a really small rural hospital. But they're classified as rural. They have a lot of pressure for coverage because of lack of subspecialty coverage during the, after hours, 24-7 coverage, nobody wanted to live in the coast of North Carolina, IT sources were very unreliable and expensive, and there were multiple large practices that were interested in taking over this practice. So the small practice evaluated several of these big practices and looked at PE-backed practices, and ultimately signed with the latter. What were they looking for? These four things I'm going to talk about. Infrastructure, personnel and operations, best practices, and radiologists support. So, infrastructure, the practice immediately solved the problem of 24-7 coverage with internal NIHOG for the national practice. Also, subspecialty reads were available, and imaging sharing was very easily available for the referrals. The other thing which Dr. Hughes didn't mention is the subspecialists in the practice could also read for the bigger entity, and therefore get more job satisfaction out of having more of their subspecialty to read. There were, of course, problems, inconsistency of interpretations, and the platform conversion was extremely painful. What about support personnel? Certainly, there's a value of scale and expertise for many of these operations. IT support was regional, though not as good as the local daytime, but at least it was there 24-7. Credentialing support was key. We had one hospital, theoretically, that the credential specialist was only there two days a month, so it was very difficult to get a patient's credential, I mean, a physician's credential. Support and education on the portal, we developed a robust lung cancer screening program at the smallest hospital, which was a county right in the middle of Tobacco Road. And when COVID-19 hit, the docs were really happy that there was someone other than them to take care of the financial and HR issues. But again, national IT support isn't consistent and doesn't handle real local problems. Credentialing is a problem with large numbers of physicians, and grants don't like to lose control. What about best practices? That was a real plus, was implementing protocols designed by the National Sub-Specialty Board. These upgraded the inconsistent ones that were in place and were great for teaching of techs who were isolated. An internally developed AI tool was launched where best practice recommendations, such as pulmonary nodule and thyroid nodule work, immediately came up with the tool, so the RAD was prompted to put the correct follow-up in the recommendation. And just recently, AI algorithms from a national company were deployed to all the RADs in the practice, including the small practice, for evaluation of intracranial hemorrhage, rib fractures, C-spine fractures, and pulmonary embolus. Last, and not least, is real radiology support. So national recruiting with huge resources for identifying potential practice fits, both remote readers to help with volume and also on-site SEAL team RADs that could fill in when we had general radiologists or our radiologists on vacation or out for some reason. Still, there's some issues. Recruiting targets are different for small practices. Prudential's not always an issue, and on-site RADs are very expensive. So one little feel-good story about this. This is not this practice, it's a different practice in Western Kentucky, Dr. Bruce Burton's practice, RP, Kentucky. 17 RADs, six hospitals, and in December, two days, there was an EF4 tornado that went 128 miles through his practice area for one mile, and it was extreme devastation in the rural area with overwhelming mass casualty event. These hospitals were not used to seeing this kind of destruction or trauma or human injury. What happened? He called in the troops, he got all his guys in, but he also called in MATRIX, which is the internal reading side of the national practice. Over two days, between the two, they read over 650 trauma cases, which is pretty amazing for a bunch of small rural hospitals. So in summary, rural healthcare delivery is in trouble, private equity may have a role in supporting it, and large-scale radiology organizations can mitigate the loss of rural radiology services and practices. Doesn't necessarily have to be private equity, it could be a large medical center like Pittsburgh Medical Center, or even a large radiology practice, like I used a radiology associates in North Texas as an example. Thank you. Good morning. Harry may have oversold me a little bit asking me to talk about how to improve access to imaging in rural America. I do not have all of the answers, but we'll be sharing with you some of my stories in the year and a half that I've been at the University of Mississippi Medical Center. So a little bit about my journey of sort of how I got into my experience here. After spending 18 years in private practice, took a position at Emory University, and one of the things those of you who've recognized that as you are leaders in health systems, in urban areas, you will frequently be asked to either take care of or coordinate the care for some VAPs within your area. The CC, whatever letter O, of one of your regional corporations is somebody you will be not infrequently seeing or helping coordinate care for without violating any HIPAA. There is a very prestigious person who has publicly received care at Emory University, and so it is a very different view of what the world looks like when you're practicing in a urban environment, particularly if you're in a well-connected community. The other thing during that time that I had a lot of opportunity to do, starting with Dr. Hughes immediately to my right, is start up the Harvey Neiman Health Policy Institute and doing a lot of good things. And as our portfolio expanded, we started spending an increasing amount of time getting grants about access to care and looking after vulnerable and underserved populations, got awards for research for looking after underserved populations. Both of us gave a lot of lectures where people paid our honorary and travel expenses for speaking about underserved populations. One of the epiphanies I had as we got more and more into that space is if we're getting grants and awards and travel dollars for studying and talking about underserved populations, are we really helping them or are we helping ourselves in that scenario? So that led a little bit to some of my transition to take a position starting in 2022 with the University of Mississippi Medical Center. We're the only academic medical center in the poorest state in the country. We're the primary safety net hospital in that state, which has a population of about three million people, so about half the population of my hometown of Philadelphia, Pennsylvania, with a land mass that's bigger than my home state of Pennsylvania. And so a little bit about the state and our population. This is the current flag of Mississippi. I'll talk in a few moments about what our flag looked like two and a half years ago, quite different. Some statistics here, back to some of Harry's points from my title. We rank number one per capita basis for diabetes. We rank number five for obesity. We rank number five for cancer mortality and number 50 out of all states for life expectancy. So really sick population overall. Back to the title that I was asked to talk about, which is race and poverty. We rank number one in the nation with people who live below the poverty level as federally designated and on a per capita basis have the largest black population in the United States. So it's really been an interesting journey for me looking at social determinants of health in all of these things combined here. I've spent a lot of time thinking about how do you improve a radiology practice, and some of this goes back to some of the things when Danny and I were probably in this room 10 years ago talking about a lot of things that were of interest to value-based payments, and people were talking about how do you define value, and usually we tag team it in this, and he'd talk about the cost side of things as the economist, and I'd talk about the quality side. I'd spend a lot of time using this equation, which is admittedly a conceptual one, not perfect, but I think a really useful one for me by Gary Kaplan looking at defining what is quality. How do we advance quality of imaging? And so we wanna focus on improving our outcomes, improving our service, reducing our waste, and I think the one that I spent a lot of time on, I know the college has spent a lot of time on, the American College of Radiology, is appropriateness. Our appropriateness, our criteria, our efforts in computerized clinical decision support, because if the test wasn't appropriate in the first place, if you didn't need to do it at all, then have you really advanced quality for that patient? Again, in some of my journey from any of these models here, all models are wrong, some of them are just more useful than others, I realized that there was a void within this, and that's a second A in this equation. And that A stands for access, which is really, again, Harry's topic for this session, because if you don't have access to patient care, if you don't have access to screening mammography, if you don't have access to the highest quality staging MR for your hepatobiliary tumor, then there really is no quality because you didn't get that service at all. Danny and I, again, have worked together a lot, so some of this is our heat mapping, but these were some measures where we looked at the radiologist supply across the country by county. In blue here is, does that county have a subspecialist based upon a primary zip code in that area? Green is, do they have one other radiologist, meaning a general radiologist? And white, meaning there is no local radiologist in that area. Those services may be covered by TELI, but there's nobody to do the tumor conferences, interact with the techs on a regular basis. This is the color map of Mississippi, which we pulled out from that. Mississippi, as you'll see in this map, is a very white state, and I'm not talking from a racial perspective. This is talking from a void of local radiologists. You'll see where we are in the Jackson area. We've got the biggest density of radiologists within the state, but a lot of people, as a proceduralist, I find patients driving three hours to me for things like a liver biopsy of a mass this big for a paracentesis because there is no local rural care. That map that Catherine showed of closing of rural hospitals, we're really in the epicenter of this. This is not our work, but looking at interventional radiology, patient access, again, my bias as an interventionalist is sort of where do we stand? Mississippi is dead last for a variety of these reasons. Hospitals don't have IR services. Why? Because they don't have IRs. Why? Because they can't staff a radiology practice. So this is a little bit of when I walked into UMMC about a year and a half ago, and our vice chair for clinical operations, Robert Morris, is in the audience, and Robert gets a lot of credit for a lot of the initiatives here, looking at how do we improve our access. This was a year and maybe a year to year and a half ago, the wait. If you called in as one of our oncologists, one of our internists for a study within our department for days. So five zero days, 50 days, seven weeks to get an MRI. You know, a screening mammogram a month to get on out. Through a lot of efforts, we've reduced those numbers pretty substantially. PET-CT, I can talk about in the Q&A if you want to because it's high capital resource. But some pretty dramatic improvements in our wait times to get patients in. And I think the other thing that's worth pointing out with this when I talk with some of this a little bit more is as well, even though the waits were huge amounts, the amount of no-shows were incredible within our department. And I'll talk about that a little bit. In our IR section, we have one of our IR residents, Dr. Ling-LeBlanc's in the audience, so he can disagree with me, but I think this is an accurate representation based upon the numbers. We've really worked on a lot of efforts to improve our throughput. A year and almost a half ago, we were doing 380 cases a month. Now we're up to 675 cases a month. And our techs and our docs are still typically going home the same time. Why? A lot of operational efficiencies. I can talk about room turnover. A lot of business initiatives here. So what is it that we're doing at UMMC Radiology? Some of this, this is not a secret sauce here. I'm not giving away any proprietary information. This is one of my favorite quotes from Herb Kelleher, the former CEO of Southwest Airlines, when people asked him about what's your strategic plan? We've got a strategic plan. It's called doing things. We don't talk about it, we do it. Or the Walt Disney, if you can dream it, you do it. And so I would submit to you that one of the ways that we can improve rural access is to stop talking about it and actually doing things. Get our practices invested in these areas, work with our legislatures, work with folks within our communities, encourage our trainees to support practices in these areas. So I'll walk with you a few of the steps that have been some of our approach towards some of the improvements. And believe me, we've got a long, long way to go in this space here. But a few pieces here is number one, you've heard Dr. Hughes talk about the economics of rural hospitals and underserved communities. I mean, there's a lot of red ink on your balance sheet. So the first piece here is you've got to cut down on the red ink. You may not turn it into black ink here, but you've got to make your dollars go a lot further. And a simple thing, I think a lot of those of us who serve in underserved safety net hospitals sort of have this culture of learned helplessness. Oh my gosh, we're never going to get all this business stuff right. And that becomes a culture in a lot of places like that. And I've seen this in a lot of institutions as well. So I think there's a few pieces here. Number one, look at cutting costs. Because if you want to get the support of your administration and ask for more money, it's a much better sales pitch to say, hey, we reduced our IR inventory loss by five to six figures per month, which is true for us there. And look, if you can give me some money to do something else, I will be a good steward of your resource in other areas. Start measuring productivity as well. I think those of us who practice in county hospitals or VAs have seen a very different room turnover model, very different throughput than we've seen in my 18 years in private practice as well. And to start making that some of the culture of improving access. In a lot of places, this is what you're doing to improve your bottom line. But if your goal is to improve patient access, it's the very same things that improve the throughput in your practice. I think you've got to recognize some of the reasons that you are having problems with access. So this is a cartoon of a jalopy here. Why do I say this? The most common reason when I'm on an IR day and a patient is calling in or not showing for their appointment is one thing. I didn't have a car. I didn't have a ride. We've got people driving from three hours in the poorest state in the country. Guess what? They're relying upon their friend or their mom or somebody else's car. They ran out of money for gas. So thinking about transportation, having our schedulers work with Medicaid transport, not everybody's eligible. Calling people the day before with some of the check-in and say, just confirming, do you have a ride? Why? Because if they're not going to be able to do it, I can't send an Uber out to Philadelphia, Mississippi to pick somebody up with our budget. But I do have a wait list of other patients that we can work on in to get that wait time down and improve access to other people who are in the queue. I can't read this gibberish. You can't either. But this is what your patient instructions look like if you're illiterate. So one of the things you have to recognize in rural communities and poor communities is that illiteracy is rampant. And there's shame in illiteracy. Patients are not going to tell you, hey, doc, I'm illiterate. So when they get the text with their instructions or their time and it's all gibberish to them, it doesn't mean anything. You might as well have thrown a bottle in the ocean here. We've implemented still a lot of work to go of saying, you know what, we need to start calling patients here or confirming your appointment tomorrow. And a lot of folks who don't keep calendars. And so calling them five days in advance, like the text I get from my dentist, doesn't help me as an anal compulsive person who doesn't help them as it does me, an anal compulsive person who has everything in my Outlook server as well. It's calling them the day before. Your appointment's tomorrow. You've got to drive. Make sure you're here on time. Also as well, if you can't read or you're medically illiterate, saying stopping your Coumadin when you're on five different pills doesn't help. So some of this is working. And this continues to be a journey of getting those folks to say, you know what, let's look it up in Epic and say, stop taking your red pill or your green pill. But we still want you to take your purple pill or whatever color pills they are. And I don't know that. That's why I've got really smart people that know this stuff and could look it up so that they are taking, for example, their antihypertensives. This is what our flag looked like in the state of Mississippi two and a half years ago. So I think acknowledging the past of some of these areas, Dr. Hughes picked on Alabama, we definitely have some racial issues that we are still working through in the poor South in particular. And I think those of us who are trying to improve patient access need to realize we need to rebuild trust. There are people who, for a lot of good reasons, are distrustful of a historically white enterprise of health care in there. And we can't fix that overnight. But I think those of us who are leaders in these practices need to be thinking about driving our cultural competence. It's great to say that we've got a workforce that looks like the population. But the reality is when you've got bad schools and you've got poverty and things like that, to expect that the people that are coming up in all of those to get through and excel and become physicians and nurses, it's just not going to happen very quickly. Probably not in my lifetime. I think it's aspirational to continue because it's a very long pipeline. But I think we do need to make sure that our staffs, whether they're our schedulers or front desk folks or physicians or nurses, are cognizant of some of the cultural competence needs so that people feel comfortable with us. And you say, hey, here's why I want to follow up. That it's not, oh, it's some doctor who wants to make more money. It's a doctor who's genuinely concerned about me as a patient and wants to do the right thing for me. And that takes some time to just have that conversation. It's hard to do when you're really busy. But to sit down with a family for five minutes after a procedure and say, here's what we did, here's what we're going to do, goes a long way. Certainly a lot better than giving them instructions they can't read here. Some of this also, as well, is in anything. You could be talking about a department in a wealthy suburb or wherever, but some of this is also going to be building, inspiring, and motivating teams here. And as a leader, you've got to just smile and say, oh, yeah, we're going to get there. And it's hard. It's hard to do when you've got a lot of challenges up against you. I think a lot of it is fighting for the staff to be able to make sure that they're sufficiently compensated. Dr. Hughes talked about some of the differential pay within some of our rural communities, as well, to be able to demonstrate, hey, we've done things to get some cost savings, to be able to get that back. And here's where we want to reinvest it, goes a long ways. And I think, as well, asking folks for ways that they have ideas to help improve the system goes a long way, whether it's your MR tax, your CT tax, our nurses in IR. Hey, that's a great suggestion you've got. And some of them are not going to be great suggestions, but the folks on the front lines are there seeing things and being able to implement them can go a long way. I think some of the things more broadly are advocating and leading. We are one of the states that is not a Medicare expansion state there. I think things are changing within the state, within the culture. Our governor's election was a few weeks ago, and it was the closest Republican-Democratic split in a couple decades, as well. And I think a lot of that was related to a difference in the candidates with regard to their support for expanding access for patients, as well. And so we can't do that institutionally as faculty, but I think there are a lot of individuals who are working with our state medical association to do things in that area. The other piece, as well, is for folks to actually get engaged and say, you know what? Rural care sounds like this is interesting. I've never even considered living in one of these communities, as well. And again, if you're thinking about it, grab Dr. Everett, grab me afterwards, and we can talk about what work looks like within these scenarios. And so as I get wrapping up here, again, back to Harry's ask to me, how to improve patient access in rural America, I think some of this is the Nike imperative. I think we just need to start doing it. Talking about it's great, but I think if you really are committed to this, and you are in an urban environment, and I'm not saying move to North Carolina, move to Mississippi, move to Alabama, but there are ways to think about how your practice can help, how you can work with state networks, how you can work on the advocacy front within your areas, as well. Thank you.

radiological services

rural healthcare

Medicare reimbursements

physician shortages

private equity

cultural competence

operational efficiencies

healthcare access