Taking Healthcare by Storm: Industry Insights with Skip Gjolberg

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Skip Gjolberg, FACHE, President and CEO WVU St. Joseph's Hospital.

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This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-GEN-040524-GK

Transcript

Welcome to Taking Healthcare by Storm, Industry Insights, the podcast that delves into the captivating intersection of innovation, science, compassion, and care.
 
 In each episode, Quality Insights Medical Director, Dr.
 
 Jean Storm, will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys.
 
 Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania, and the nation.
 
 Subscribe now, and together, we can take healthcare by storm.
 
 Hello, everyone, and welcome back to Taking Healthcare by Storm.
 
 This is Dr.
 
 Jean Storm, and I am the Medical Director at Quality Insights.
 
 Today, I am pleased to bring this guest on as his take, his inspiring views about healthcare in West Virginia have really changed my perspective and just the short conversation I had with him.
 
 We are joined today by Skip Gjolberg, who is the President and CEO of WVU St.
 
 Joseph's Hospital, which is a critical access hospital, and we're going to talk more about his other positions during the podcast.
 
 But Skip, thank you so much for joining us today.
 
 I'm super happy to be here.
 
 Thank you.
 
 So just let's dive in.
 
 Tell us about your background and how you arrived in your current position.
 
 I am not your typical track to become a CEO.
 
 My background, I started an exercise phys.
 
 Actually, I started engineering.
 
 I was on scholarship with the Navy at Texas A&M and decided I didn't want to go in the Navy after doing a summer cruise and change majors into exercise physiology from engineering.
 
 Because I really like training.
 
 I was competing in powerlifting and Olympic weightlifting for the college.
 
 But I got out and I couldn't find a really good job at the time.
 
 They just weren't hiring people in that position.
 
 But I got a job at a physical therapist clinic as a tech.
 
 I'm like, I like this physical therapy thing.
 
 So I took a few more prereqs, got into PT school, graduated, and started working in a private outpatient clinic in Temple, Texas.
 
 I was there about three years, and then I got an opportunity to become the rehab director at my first St.
 
 Joseph's Hospital back in Aggieland in what's called Bryan, Texas, and Bryan College Station are these sister cities that are basically right next to each other.
 
 So I was the rehab director there for 11 years, and had no intention of doing anything beyond that.
 
 Just want to be a great therapist.
 
 But the sisters kept having me manage more and more stuff.
 
 And I got a master's degree in actually in safety engineering and ergonomics and biomechanics.
 
 But I thought God's plan for me is maybe not to be a rehab guy, but to be an administrative guy because I was managing all these other departments.
 
 So I started looking and ended up going to Wisconsin.
 
 My first administrative job as a assistant administrator at a large nine-story tertiary hospital.
 
 I was there about six and a half years.
 
 Started working with a lot of rural hospitals, kind of help bringing our specialists out there or creating relationships between our specialists and the primary care doctors out in these rural areas.
 
 So they could have faces with names when they were sending their patients to the city to get to care for cardiovascular or neuro or whatever.
 
 Then I went to work at a critical access hospital in Prairie du Chien, Wisconsin.
 
 I was there for about three years and just loved it, and really loved rural and living in the country.
 
 Then I got my first CEO job back in Texas, and I was there about three years, and then I got my job here at St.
 
 Joseph's.
 
 I wanted to get, Texas was just too hot.
 
 Too hot, fire ants, and spikers, and scorpions, and cockroach.
 
 I started looking back north, and I can't remember if I mentioned, but I grew up in Williamsburg, Virginia.
 
 My parents were still there, my daughters were going to a college in Front Royal, Virginia, so that was going to put me really close to them.
 
 Hadn't been by them my whole career after getting out of high school.
 
 I came to St.
 
 Joseph's, and I've been here now eight years, and absolutely loved Buchanan.
 
 The community is super welcoming, and it's a great place.
 
 It's a beautiful town.
 
 We have a great Main Street here in Buchanan, with lots of things happening.
 
 We have one of the best, it's the Hallmark Main Street, I call it.
 
 I will tell you, when I first talked to you, I just assumed that you were from West Virginia because you're really passionate about what you do and obviously, about healthcare, the healthcare environment in West Virginia.
 
 You fooled me.
 
 When I was in high school, I used to go ski at Snowshoe.
 
 Me and my buddy would leave at two in the morning, it was a seven-hour drive, and we'd be there by nine o'clock and we'd ski all day long.
 
 I can't remember, did we sleep in the car or did we try to drive back?
 
 But yeah, it wasn't like I wasn't familiar with West Virginia, but it's a beautiful state.
 
 There's so many outdoor things to do if you like being outside and we're close to other things.
 
 We're in Pittsburgh a couple of hours, we're in DC in four hours.
 
 We can get to some really nice big cities if you want to do that thing.
 
 Absolutely.
 
 So do you feel that West Virginia faces unique health care challenges compared to the rest of the country?
 
 Yeah.
 
 Well, I think sometimes we are at the bottom, unfortunately, of a lot of lists.
 
 We have, I think, the third highest death rate, unfortunately, in West Virginia, and we have the highest death rate from heart disease of any of the 50 states.
 
 So I know at one of the Hospital Association meetings, year before last, our annual conference, Clay Marsh was speaking and he was comparing one of our counties to a county in Colorado.
 
 And he might have picked maybe the best county there or the best county in the US.
 
 But basically, the age difference for life expectancy was 17 years.
 
 And that just blew me away that we had such a discrepancy in life expectancy between those two counties and those two states.
 
 So we see cancer, about one in seven West Virginians have cancer.
 
 We have the third highest overall cancer prevalence in the United States.
 
 We have problems with diabetes.
 
 We have problems with obesity.
 
 I know, thank goodness for Alabama, I think they are a little worse than we are.
 
 And so, it is something that we need to focus on.
 
 And I know we had a meeting between us and the Western Indian Medical Association.
 
 And we talked about what could we as a group focus on?
 
 What one or two things that we could really laser focus on?
 
 And one of those was obesity with adolescents.
 
 And so, we're trying to kind of put together a team to focus on that and try to see what we can do to move the needle there.
 
 Yes, definitely needed.
 
 So, you were in West Virginia during the pandemic.
 
 You said you've been there since 2016.
 
 So, how, in your opinion, how has the health care landscape changed in West Virginia kind of through the pandemic and since the pandemic?
 
 Yeah, so there's, I think, a number of things.
 
 One is, and you probably hear this, it's the labor force.
 
 The labor force seems reduced.
 
 You know, people exited out of their jobs.
 
 They figured out how to live on less because they weren't either working or got some kind of entitlement thing.
 
 But we just don't have the workforce in health care and in other industries in the state, you know.
 
 And that seems to maybe start to get a little better, but it's still, we're still struggling.
 
 And health care providers, before the pandemic, you know, we were like trusted up there with like, you know, priests and librarians and health care workers.
 
 And then after the pandemic, it seemed like we kind of went down near the bottom of the list.
 
 Like they didn't trust us anymore.
 
 You know, we kept families apart because we didn't want contagious diseases to spread and people were dying without their families for some period.
 
 That got rectified.
 
 But, you know, during part of that, and that kind of created some animosity, I think.
 
 And then we've seen here and I think we've seen it across the country, people got this real skepticism about vaccines.
 
 You know, the COVID vaccine, people just they thought there was something nefarious going on.
 
 And that's kind of been translated now that the vaccines that have been around with us for 50 years or more.
 
 Even here in West Virginia now, there's a bill effected at one o'clock.
 
 Right now, I think the Senate is meeting about this.
 
 And there's going to be a vote on HB 5105.
 
 And that is basically allowing, you know, it's a religious exemption.
 
 Originally, it started for people that were going to homeschool their kids using the public school homeschool option.
 
 But I think it's been expanded to like anything.
 
 It's going to create an exemption so big you could drive a Mack truck through.
 
 And I think we're going to start seeing problems like Kentucky and Florida have had outbreaks of measles and other things that are actually have killed some children, you know, unnecessarily because their parents are not getting their kids vaccinated.
 
 Yeah, it's really unfortunate the how fear is really run rampant.
 
 Yeah, it's the skepticism.
 
 And, you know, it's yeah, it's it's very unfortunate.
 
 So you're the president and CEO of a critical access hospital, as I mentioned.
 
 So what role do critical access hospitals play in West Virginia?
 
 Well, so in West and really in any state, a critical access hospital is it's a it's a payment classification, which we'll we'll talk about.
 
 But they are going to be your hospital that's in your more rural communities.
 
 Cities of maybe 2000 to Buckhannon is fifty five hundred.
 
 That's just the city.
 
 County obviously is much larger.
 
 But we're going to be kind of your first stop for your health care needs.
 
 We're going to be providing primary care and emergency care for sure in all critical access hospitals.
 
 Not all offer obstetric care.
 
 We do.
 
 We're a larger, a little more robust critical access hospital.
 
 We've been blessed with being able to get additional services here.
 
 And we do about three hundred and thirty to three hundred sixty babies a year.
 
 But it's going to be the place, you know, where you're going to go first for your regular care.
 
 But if you have some emergency, you're going to be brought here.
 
 You're going to be stabilized, possibly treated here.
 
 We we transfer out a few every day, but we keep quite a few as well.
 
 But it's going to be it's going to be the stopgap.
 
 Otherwise, you're traveling, you know, in some areas like Wyoming and more rural communities like Idaho and stuff here.
 
 You could be an hour to two hours to the next hospital.
 
 And so if your hospital isn't there, it can be quite devastating.
 
 You're delivering a lot of babies every year, I was going to say.
 
 We do.
 
 We are.
 
 We're busy doing babies.
 
 Some some days we we have no moms.
 
 And some days like last week, we had six moms.
 
 And the population of West Virginia is aging and older people, they don't like to have to drive to the big cities.
 
 And I look at Bridgeport and Morgantown.
 
 To me, that's not that big of a city, but to a lot of people, that's a big city.
 
 And you have to park way out in the parking lot.
 
 You got to walk quite a distance to get in to see your doctor or go to the hospital for a test.
 
 And being here, it's local.
 
 You just drive down the road.
 
 You're here at St.
 
 Joe's, a little parking lot inside your yard getting your x-ray, your lab test, whatever it is you're getting.
 
 So I think we help people get access to their care and help reduce health inequities.
 
 That's huge.
 
 That's so important.
 
 So I don't think we talked about the difference between critical access hospitals and then a term that I just learned, PPS, which is prospective payment system hospitals.
 
 So years ago, like pre 1980s, I think most, if I understand, most hospitals were all cost-based reimbursed.
 
 Then the government came out with what they call the DRG system, Diagnosis Related Group System.
 
 And basically, they did that because the Medicare pyramid kind of flipped upside down.
 
 So when Medicare was created, very few people using Medicare, a lot of people paying in.
 
 But as the baby boomers have moved through, you've got way more retirees happening today.
 
 And so the pyramid is upside down.
 
 You have less people paying in and a lot of people using Medicare and Medicaid.
 
 And so the government's like, hey, we're going to run out of money.
 
 We've got to figure out some other ways.
 
 So they created the DRG system, which is kind of these buckets that different diagnoses go in.
 
 And they said, okay, Hospital X will pay you $5,000 to do this knee replacement.
 
 And if you can do it for five or four, if you can do it for four, you'll make a thousand.
 
 If you do it for six, you're going to lose a thousand.
 
 And we're kind of sorry, you just figured out.
 
 And so hospitals in larger areas that had more volume, you get economies of scale and they were able to adjust and make corrections and do that.
 
 But in more rural communities where you didn't have the volumes, those hospitals started closing and there were over 400 hospitals closed across the United States kind of in the late 80s and into the 90s.
 
 And so community members were like, oh my gosh, I don't have my hospital anymore.
 
 Now I've got to drive this great distance.
 
 What happens if I have an emergency or I'm going to have a delivery or whatever?
 
 And so they started going to their senators and their delegates and they said, you guys got to fix this.
 
 And so they got together and they created the critical access hospital legislation.
 
 It was part of the Balanced Budget Act of 1997.
 
 And it created what's called cost-based reimbursement.
 
 And so there are things on our cost report that are considered what's called an allowable cost.
 
 And we get paid, the formulas like this, we get paid 101% of allowable cost minus sequestration, which is minus 2%.
 
 So right now we get 99% of allowable cost.
 
 And so they'll look at your payer mix.
 
 So if 60% of our customers are Medicare, Medicaid, then 60% of our cost are reimbursed at 99%.
 
 And then the rest of your payer mix typically is commercial insurances or people without any insurance.
 
 And so what that allows for is if I have, say, we staff four nurses all the time up on OB, whether we have zero moms or we have six moms.
 
 And when we have zero moms, obviously, we're not making any money on that.
 
 And so the cost-based reimburse allows me to get paid to keep those nurses up there.
 
 Same with the ER.
 
 If I have my ER doctor, I have a 24-7 ER doc.
 
 I have two APPs, not 24-7, but on different schedules, and whether I have five ER patients or 15 ER patients.
 
 So it helps rural hospitals have a sustainable payment model so they can deliver the services in the communities where you don't have the volume.
 
 Does that make sense?
 
 Yes.
 
 Yes.
 
 I mean, and they're needed.
 
 And they are needed.
 
 And even with that, there's still critical access hospitals that close because they still– just because you're getting paid costs, not every cost is allowable.
 
 And to get 99% of your cost, it's not going to cover your cost.
 
 And so your commercial insurance has kind of helped make up for that.
 
 And you remember the days I talked about cost shifting, where you take money from the higher payers to help cover the losses you have on like your Medicaid patients.
 
 So that still happens.
 
 But it is a way– and prospective payment system, again, they're under that kind of that DRG model where it's kind of a per click.
 
 Like you do this, you treat this patient, you get this amount of money and need more volumes to make that sustainable.
 
 So what are some unique challenges that you're facing running a critical access hospital?
 
 Probably the biggest right now is staffing, you know, staffing challenge.
 
 We could do more if we had more nurses, more respiratory therapists, scrub techs, circulators in the operating room, things like that.
 
 So we bring in travelers and travelers are just killing our budget because they're two to three times the cost.
 
 They were very, very expensive during COVID and a lot of staff jumped on that traveler bandwagon because they could make more money.
 
 And so that's a big challenge.
 
 If you're an independent critical access hospital versus a hospital that's part of a system, you know, there's also some differences and some pros and cons.
 
 You know, we're part of a system that's nice.
 
 We have great, we have depth on the bench in some areas and we have the ability to have like back office functions handled at the corporate level, coding, billing, HR, payroll.
 
 Typically, if you're part of a system, you can get a better electronic medical record.
 
 We have Epic, but there's Epic, there's Cerner.
 
 But, you know, if you're a smaller hospital, you may be more nimble and if you're doing well financially, you probably have better access to capital to do things because you only have to deal with your board and your one hospital versus a system that has 20 hospitals and they're all asking for capital and they only want to do so much to keep a good bond rating.
 
 So, you know, there's pros and cons to both.
 
 But I think St.
 
 Joe's has done phenomenally well since it's become part of the system and part of that was our conversion because we became critical access and part of that was being part of the system.
 
 And I guess I forgot to mention, when you're critical access, you can only have no more than 25 acute care patients on any given day.
 
 I forgot to mention that.
 
 That's the significant thing.
 
 So, hospitals that converted had to reduce, a lot of them had to reduce their bed count.
 
 So no more than 25 acute.
 
 You can have more patients in the hospital, but they'll be observation patients.
 
 Your average length of stay cannot exceed 96 hours.
 
 So that's four days.
 
 So I can have somebody here for two weeks, but I have to have some other people here for two days, three days to balance that out.
 
 And then there's a distance requirement.
 
 You cannot be any closer to the next hospital, has to be 35 miles away in most of the terrain in the United States.
 
 In mountainous terrain, you can get an exemption and have that down to 15 miles, which is what we have.
 
 And I believe there's around 23, 25 hospitals in the US that have that mountainous terrain exemption.
 
 Well, that makes sense for West Virginia.
 
 So those are the other things.
 
 I should have mentioned that that's the other differences between us and PPS.
 
 Sure.
 
 So you talked a little bit about staffing stability and I mean, everyone's talking about difficulties in staffing, nursing homes, hospitals.
 
 Is it easier to obtain staffing in a critical access hospital or you think it's more difficult compared to a non?
 
 You know, I mean, there are those, I mean, young people typically, if they grew up here and let's say they went to Wesley into the nursing program or D&E and Elkins or whatever, you know, they're like, oh, you know what, I want to get out.
 
 I want to go to the big city and get out.
 
 But then we find they come back.
 
 But it may not be for a while.
 
 But then they get married, they start having kids and like, you know what, I want to come back to where it was.
 
 I didn't spend time in traffic.
 
 It's easy to get across town to the store.
 
 So I think it is harder.
 
 I think you just have more of a labor pool in a bigger city.
 
 And you have more opportunity for people to pick up like PRN hours.
 
 So kind of filling in those gaps for you.
 
 And you just don't have that labor pool in a smaller community.
 
 So I think it is more difficult if you're in a smaller, more rural community.
 
 Yes.
 
 So I just have to highlight.
 
 So WVU St.
 
 Joseph's Hospital, you received the National Patient Safety Excellence Award, which is huge.
 
 There's a really big push with patient safety these days.
 
 So what's the secret to this success in patient safety?
 
 Well, I think there's a number of things.
 
 We have a really good team here.
 
 It's sort of a quality department that really focuses on patient safety.
 
 And they're constantly looking at records.
 
 They're constantly looking at any incidences for common themes and threads.
 
 And they're really good at ferreting out issues and then working on ways to correct them.
 
 And we have really good staff educators that if they see a problem, they can get the staff educated on how not to repeat that problem.
 
 I also think we've done a really good job.
 
 And this is kind of a nationwide push in getting people to share when they have a near miss or even when they have a mistake.
 
 In the old days, you didn't want anybody to know you made a mistake.
 
 And then those mistakes got under counted and they could repeat themselves.
 
 And now there's much more of a push to get that information out.
 
 So, corrective actions can be put into place.
 
 We round on our staff.
 
 It's actually a formalized process where we round and we talk to our staff about, you know, and one of the questions is, do you have any quality or safety concerns?
 
 And do you have any ideas on how we can improve that or how we can improve processes in general?
 
 And we use a web-based tool to database all that.
 
 So it's very easy for us to to look at suggestions and to act on suggestions.
 
 And sometimes we can't, you know, it's not going to work here, but we can close the loop with the staff member too.
 
 So they feel like, you know, hey, they listened to me.
 
 So and they said yes to it or they said no, but they felt they felt that they were engaged and listened to.
 
 And then we also work really hard to make sure that the staff had the tools they need and that they're trained to use those tools.
 
 So, you know, there's nothing worse than than a nurse trying to find a blood pressure machine and spending 15 minutes running around every room because, you know, one's broken and one's stuck in a corner, you know, and then that's that's patient care time they don't that they've lost.
 
 So giving them the tools.
 
 Yeah, you've created a culture of patient safety.
 
 I think that's the key.
 
 And we and, you know, we we talked to the staff to it was one of our questions, our employee engagement survey, you know, the staff feel safe.
 
 And what is safety to a staff member, too?
 
 You know, and it's is it is it the parking lots well lit and I feel safe going to my car?
 
 Is it, you know, we put salt out for ice is that I have a patient lifting machine to move this patient so I don't hurt my back or, you know, it's a myriad of things.
 
 But again, you know, we're constantly asking them so that we can we can operationalize their suggestions.
 
 So shifting gears a little bit, you appointed the 2024 board chair for the West Virginia Hospital Association.
 
 Twenty twenty four is going to be a big, big year for you.
 
 Yeah, yeah, yeah, go ahead.
 
 Sorry, I was just going to ask you the main priorities of the Hospital Association this year.
 
 Well, you know, our big focus these last few few weeks has been what's going on down in Charleston and all the legislative activity.
 
 And we had kind of some priority bills that we've had some pretty good success with.
 
 One is the what's called the Directed Payment Program.
 
 And that is a way that we collect funds in West Virginia and we send them to the federal government and we get matching funds that come back to us.
 
 And with some changes recently, that return on investment is a three to one.
 
 So we give a dollar and we get three dollars back.
 
 We also expanded that through legislation to include not only not it only included the PPS hospitals up until this year.
 
 The legislation that is we've gotten through the House and the Senate and it is on the governor's desk and that will also add critical access hospitals.
 
 So we'll we'll pay an assessment.
 
 But for every dollar, again, we pay, we get three dollars back.
 
 So that's a real that's a real win for us in pulling in additional federal dollars to help support our services.
 
 The other one is 340B.
 
 I'm sure you're probably familiar with the 340B program.
 
 It's a program that is funded by the pharmaceutical companies.
 
 And it allows us to get drugs at a cheaper rate.
 
 And we can use that cost savings to help fund things that we do here that are not normally reimbursed.
 
 So community services and things like that.
 
 People that don't have insurance or are underinsured.
 
 And we wanted to improve the 340B protections because the pharmaceutical company is constantly trying to whittle that down.
 
 And we we don't want to whittle down.
 
 So we worked on what we call the contract pharmacies and how many we can work with.
 
 They wanted it to just be one.
 
 We wanted it to be whoever wants to work with us.
 
 And so that legislation is also passing through the House and Senate.
 
 I think we're going to get that across, too.
 
 And then the last one was the anti-doxing, which is basically protecting our workers.
 
 So if you irritate a patient for whatever reason, we don't want your name and address put out on Facebook or Instagram or X, you know, to come and get harassed because something happened that a patient or family member didn't like.
 
 So that's this anti-doxing legislation.
 
 And then we're always pushing, we're always working on keeping CON.
 
 So CON is certificate of need.
 
 And West Virginia is a certificate of need state, which I think is a great thing because it helps prevent overbuilding and cherry picking.
 
 So cherry picking is like a for-profit physician group wants to build just an orthopedic surgery hospital in Morgantown.
 
 And they're only going to take paying good insurances, and they're not going to take Medicare, Medicaid, and they can kind of cherry pick.
 
 And that reduces the community hospitals, their revenue streams to help shore up things that they get underpaid or no pay for.
 
 And so, COM protects that, it protects overgrowth.
 
 I mentioned I was in Wisconsin, and I was in a city there, Eau Claire.
 
 We had our large Catholic hospital, we had the Mayo Hospital.
 
 A couple years later, the physicians decided they were going to build a hospital.
 
 Then a physician group that we worked with at our hospital, that was our primary referral source, because we did not employ a lot of physicians, decided that they wanted their own hospital too.
 
 Just a couple of weeks ago, I got an email that that large hospital that had been there for over 125 years is closing, because the environment is too rancorous and too competitive, so they're closing.
 
 Super nice hospital.
 
 They just recently spent millions in renovations, and now they're going to close it.
 
 I don't know what's going to happen to it.
 
 So, CLN is, I think, a good thing.
 
 There are people that think that it reduces competition, but we try to tell people that about 75 to 80 percent of my payers are Medicare, Medicaid, PEIA, and those are payers that I cannot negotiate with.
 
 They say, Skip, here's our prices.
 
 If you don't like it, then don't take care of our people, but this is all we're going to pay you.
 
 This is really more so on the prospective payment system side because we do have the advantage of cost-based reimburse.
 
 But you cannot negotiate, so you can really only negotiate with your private payers like BlueCost, BlueShield, and Humana, and Travelers, and those guys.
 
 This whole idea that it opens up a competitive market, it's not competitive when 80 percent of your payers don't negotiate.
 
 Yeah, makes sense.
 
 With your diverse background and experiences in healthcare in West Virginia, how do you see the healthcare environment changing in the next five years?
 
 I think in West Virginia, we might continue to see some consolidations of hospitals.
 
 They might align themselves with WVU, with Vandalia, with Mountain Health.
 
 Just to get a little more depth on their bench, a little more back office support.
 
 Sometimes when times are tough, you might be able to get some loans from your parent group to keep you going.
 
 So I think we might see some more of that.
 
 And then I hope we see more technologies coming into West Virginia.
 
 There's CRISPR, which I think is going to be a revolutionary technology once it gets perfected.
 
 I'm sure you're familiar with it, where you can basically edit gene defects to cure diseases.
 
 I think using AI to aid providers when you've got a myriad of symptoms with somebody, they can help AI can help minimize or eliminate possibilities down to a more narrow few, and can look at what kind of treatment regimens were done for patients like that by other providers across the data access that AI tool has to give you as a physician or an advanced practice provider better tools to take care of people.
 
 And then I think genetic testing is gonna be very helpful because we can kind of get a better look under the hood of people to help maybe start treating something that they may develop sooner, or maybe go back to CRISPR and fix it.
 
 So.
 
 Yeah, hopefully making things better.
 
 Yeah, you know, and my understanding about, from my limited reading on CRISPR is it's not a super expensive technology.
 
 It's just gotta get perfected better.
 
 And so, you know, and I failed to kind of complete my answers back to the other question about as the chair for the hospital association.
 
 So legislating, I talked about legislation.
 
 You know, I'm also, I think, working on, it's great to have synergies, like when I was in Wisconsin, a lot of the independent hospitals shared common back office functions through a centralized office, like the hospital association.
 
 And we do that now, but if we can expand those services to help those hospitals that need those things to have access to them, to reduce their cost and give them a little more depth.
 
 And then we're working to try to improve licensure and expedite licensure in the state of West Virginia.
 
 Because if I bring in a doctor from another state, it can take sometimes quite a while, because first you have to get a license from the board in that state, and those boards may meet every other month.
 
 So it could be 60 days I'm waiting.
 
 And then once they get the license, then they have to do the payer credentialing to get approved by the payers that you work with.
 
 And that can take another 90 days.
 
 So you could be looking at five months to you hire somebody.
 
 So trying to expedite processes like that.
 
 We're actually trying to work with the Respiratory Therapy Board because they just changed the criteria to be able to work in the state of West Virginia.
 
 And they kind of raised the bar.
 
 And I think unnecessarily.
 
 There's the certified respiratory therapist and the registered respiratory therapist.
 
 And 47 states, and we were one of them, only required you to be certified.
 
 Alaska doesn't require anything.
 
 And then there were seven states, if I'm doing my math right, that required to be a registered respiratory therapist, which is basically achieving a higher score in the test.
 
 And we've been running under certified for years, but for some reason, and we're just trying to work with the board to figure out exactly why did you make this change?
 
 Because we can't get enough of these folks.
 
 And they're retiring and I can't get them.
 
 And to raise the bar, to make it even harder when 47 other states don't have it that way, why do I have to have it?
 
 And it's been working fine all these years.
 
 So things like that, that the association can help us do.
 
 Yeah, super important to get providers into West Virginia.
 
 I practice in West Virginia, so I get it.
 
 And it's a wonderful place to practice, but I know they have a little bit of a provider deficit.
 
 So, yeah, super important.
 
 So last question, I'm really curious about what your response will be.
 
 If you're in charge of health care in the United States, what is the first thing you would do?
 
 Oh, man.
 
 I guess we as a nation have to figure out how are we going to shore up Medicare and Medicaid?
 
 Because, as I mentioned earlier, it is on a trajectory to run out of money, much like Social Security is.
 
 They got to figure that out too.
 
 And I don't know what that is.
 
 It seems like improving technologies typically increases costs.
 
 But I think there's some technologies that I was mentioning, the CRISPR and the genetic testing, those are not super expensive and they can help you see things and fix things that may be lower cost.
 
 So maybe that'll help us there.
 
 People talk about the single payer model.
 
 I know that countries that have that, some of them anyway are not happy with that because the wait times can be crazy.
 
 My father's family is from Norway.
 
 My grandmother needed a hip replacement.
 
 Dr.
 
 Sarr said, yeah, you need a hip replacement.
 
 We'll get you on the list.
 
 It'll be two years.
 
 She was like, wow.
 
 But then she fell and broke her hip.
 
 Of course, they had to fix that and that got it done quicker, but a two-year wait.
 
 I took some physical therapy classes from a guy from Oslo, Norway, and he said the wait times for people to get in to see him were huge.
 
 He said, by the time they got to me, they were really, really bad or they had gotten better and didn't need him anymore.
 
 With the advantage of having a single-payer system, you don't have to deal with all these different insurance companies, all these different rules and regs and stuff.
 
 You just focus on one entity, one set of rules.
 
 That would make it easier because there's so much that we have to put up with.
 
 Then we're constantly fighting with the Medicare managed care organizations.
 
 They deny and we have to resend and get additional information.
 
 They make it very onerous and probably one of the largest gross in health care spending has been this administrative staff that do all the work, so you can just get paid for the work you do.
 
 That's just crazy.
 
 I would somehow figure out how to reduce all of that requirements for proving what you do is needed, so you can streamline that and reduce that expense.
 
 On a more local level, I think getting a waiver from CMS to be able to provide transportation to your patients in rural communities to come into their appointments to get home would be great.
 
 Right now, we can provide that, but only to established patients, which means they have to have an appointment or they have to already be in our system as seeing one of our providers.
 
 We can give them vouchers to help because health and equities are a big thing in West Virginia, and a lot of it is tied to people can't get in or they can't get home, so they don't even bother.
 
 It's the ones that don't even bother, then they're not established, but I'm prohibited from advertising through the church or in the paper or wherever to let you know, hey, if you want to get in here to get seen because you've got hypertension or you've got diabetes, we have a voucher system, but CMS says that's an inducement and I can't do it, but they also want me to fix health and equity.
 
 I've actually been working now actively to try to get a waiver.
 
 It's like if you want us to fix health and equities, let us get people to their appointments.
 
 I am not making a killing on Medicare and Medicare patients.
 
 It's not like I'm going to make a windfall on this by doing it, but it's going to help people get in and get the care they need.
 
 Yeah, I agree.
 
 Transportation is huge.
 
 I think that's maybe doable, but the single-payer system, maybe not.
 
 I know.
 
 I don't like it.
 
 If there's some way we could just streamline the payment models and make them less onerous, that would help save a lot of cost and expedite things.
 
 Yeah.
 
 I agree.
 
 We could talk for a long time about this.
 
 But Skips, thank you so much for joining us.
 
 It was amazing information.
 
 I'm sure the viewer is going to have a lot of questions, so maybe we'll do a follow-up.
 
 Critical access hospitals, they can do a lot.
 
 I have friends that run them that have interventional cath labs.
 
 They have linear accelerators doing great cancer care.
 
 They do dialysis.
 
 They don't necessarily have to be a small place.
 
 They can be a pretty robust place that offer quite a bit to their communities.
 
 Yeah.
 
 Let's talk about it more.
 
 Thank you so much for joining us.
 
 Thanks for having me.
 
 I really appreciate it.
 
 Take care.
 
 Thank you for tuning in to Taking Healthcare by Storm, Industry Insights with Quality Insights Medical Director, Dr.
 
 Jean Storm.
 
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