EP470: Continuing the ER and Primary Care Through Line Over to Rural Hospitals and Healthcare, With Nikki King, DHA

[00:00:00] Episode 470, Continuing the ER, Emergency Room and Primary Care Through Line Over to Rural Hospitals and Healthcare. A few years ago, I had spoken with Nikki King.

[00:00:23] American Healthcare Entrepreneurs and Executives You Want to Know, Talking, Relentlessly Seeking Value. So the show today, it's sort of an encore, but not really an encore because I recorded this whole new introduction that you are currently listening to. And I also did a few inserts that we popped into the show itself. Inserts from the future, you might say.

[00:00:48] But why did I pull this episode from 2021, you might be wondering, as an immediate follow on to the show from last week about possible Medicaid cuts? Well, for one thing, the show last week about Medicaid cuts were about how the cuts might impact plan sponsors. And it left me feeling a little bit like part of the story was going unsaid.

[00:01:12] So much of what happens in healthcare, we see numbers on a spreadsheet, but can easily lose track of human beings. I was reading something the other day. It reminded me of the people behind these numbers. I don't know if this happened in rural America, but it easily could have. I'll link to it in the show notes. Someone could not get a needed surgery. This surgery had all of the medical necessity boxes checked, except the hospital would not perform the needed surgery without cash up front in prepayment.

[00:01:41] This patient, he did not have enough money to cover the prepayment. So somebody in the hospital finance department gave him a solution. Just wait until the situation becomes life threatening. And then I guess you can go to the ER with your newly life threatening condition and they will have to perform the surgery without the money up front.

[00:02:02] And here we have the theme of people not being able to afford or not being able to access primary care or in this case, I guess something more than that, a surgery. And they wind up in the emergency room. As Dr. John Lee put it, the health care system in this country is like a balloon. And the way we are currently squeezing it, everybody is getting squeezed into the emergency room, which is the very most expensive place to obtain care, of course, especially when that care is non-emergent.

[00:02:31] In rural America, this is particularly true. Now, by no means am I suggesting any kind of magic bullet to this Medicaid situation. As we all know, health and health care are not the same thing as health insurance. And we all know enough about the issues with Medicaid. That is not what the show is about. The episode that follows with Nikki King, who is my guest today, offers some great advice when there's just such a scarcity of clinicians available.

[00:02:59] And she does a great job of it. So I am going to spend my time with you in this intro talking about rural hospitals in rural areas. The place where many patients wind up when they cannot get primary care in their community, just exacerbating all of the issues we have with Medicaid and affording Medicaid. But yeah, even if there is adequate or even great primary care, you still kind of need a hospital.

[00:03:26] The thing is, if an economic situation emerges where, say, for example, and this is the case in a lot of rural places, let's just say a factory or two or a mine or whatever closes down. It might mean the local hospital also closes down. If that local hospital was dependent on commercial lives and cost shifting to those commercial lives. Like this is not higher math or anything. It's easy to see how a doom loop immediately gets triggered.

[00:03:56] Recall that one big reason. And Cynthia Fisher talked about this in an episode from a few months ago. One reason why employers in rural areas are choosing to move facilities somewhere else or overseas is that hospital costs are too high in the USA in these rural areas. So they are closing their factory down because the hospital is charging too much. The lower the volume of commercial lives, the higher the hospital winds up raising their prices for the other employers in the area.

[00:04:25] Now, there's a point that comes up a lot in 2025 in conversations about rural hospital financials or just hospital financials in general, I guess. I had a conversation with Brad Brockbank about this a while back, and I've been mulling over it ever since. There are many who strongly suggest the reason why rural and other hospitals are in trouble is squarely because they don't have enough patients with commercial insurance in their payer mix. As Nathan Kaufman wrote on LinkedIn the other day, he wrote, The tipping point is the percent of commercial gross revenues.

[00:04:54] When most hospitals hit 25 percent, if they don't have commercial rates in the high 300 percent over Medicare range, things begin to unravel. And look, I'm not going to argue any of the points here. How would I know? For any given hospital, it could be a financial imperative to try to get 300 percent over Medicare out of the local employers. I don't doubt it.

[00:05:16] The question I would ask if someone knows that hospital finances are currently dependent on cost shifting, especially in a rural area with unstable industry, what are the choices that are made by hospital boards or leadership? Is this current dependency used as a justification to level up the cost shifting to local employers just as volume diminishes, keep charging more, which is ultimately going to cause even more employers to leave the area, which seems to be kind of a default.

[00:05:44] It's like the safety valve is charge the local employers more. The point I'm making here is not all that profound, actually. It's just to point out that safety valve, taking advantage of it, comes with downstream impact that actually worsen a situation. So what do we do now? And similar to the Medicaid, what I just said about Medicaid, I'm not showing up with any silver bullet here. And running a hospital is ridiculously hard. So I do not want to minimize that.

[00:06:13] And I certainly do not want to minimize Medicare Advantage paying less than Medicare going on and the mental health crisis and the just crippling issues that a lot of rural hospitals face. In the show notes, I will link to a really interesting report by the Center for Healthcare Quality and Payment Reform about the ways hospitals can restructure and rethink how they deliver services.

[00:06:36] But I will take a moment to point out some case studies of success for what happened when people crossed off. Go get more money from the local employers off the list. Then there's also FQHCs doing some amazing things, even in rural areas. Listen to the episode a while back with Dr. Doug Eby about the NUCCA system of care in Alaska, serving areas so rural you need to take a prop plane to get to them. Their patients, their members have some of the best outcomes in the entire country.

[00:07:06] Their secret? Yeah, great primary care teams that include behavioral health, the doctor, the nurse, a whole crew. And look at us. We've come full circle. Primary care, good primary care, I mean, is an investment. Everything else is a cost. Lastly, let me just offer a very large update. Today, you cannot just say rural hospital anymore and automatically mean a hospital in dire financial straits struggling to like make the rent.

[00:07:34] Large consolidated hospital systems have bought up so many rural hospitals for all kinds of reasons that may or maybe not have less to do with mission and more to do with all the things I discussed with Brandon Bilberry in the episode entitled Consolidated Hospital Systems and Cunning Anti-Competitive Contracts. And with that, my name is Stacey Richter. This podcast is sponsored by Aventria Health Group. And here is the original episode with Nikki King.

[00:08:01] Nikki, let me just mention, has gotten a new job since she was on the pod. She is now the CEO of Alliance Health Centers in Indiana. Nikki King, DHA. Welcome to Relentless Health Value. Thanks for having me. How dire is the situation about hospitals in rural America? I want to say that it's roughly 50% of rural hospitals right now are running in the red.

[00:08:25] There's been, I want to say, 200 rural hospitals closed over the last 10 to 15 years. It's very bad. I know that freestanding ERs, emergency rooms, is something that you've mentioned before as a potential solution. Freestanding ERs are a model that has been thrown around as a way to replace rural hospitals who close.

[00:08:47] The general model for that, you have a full service emergency room with a helicopter pad and maybe one or two inpatient beds that could be used if you're waiting for a transfer. If you're in a rural community that has no access to health care after hours, I think that that would be viable. A real big con with that model, though, is it really flies in the face of everything that we've tried to accomplish with value-based care. Right now, one of the major ills of the health care system is how much primary care has taken place in the emergency room.

[00:09:14] When that happens, A, it's much more expensive care than it should have been in the primary care office. It's arguably not as good care. So, for example, I can think of very few emergency room physicians that say that they are very well trained to deal with mental health crises. Yet that's the vast majority of people's first access point into the mental health care system because they don't really have access to a regular therapist or understanding that they should have that.

[00:09:39] When you look at that model, now the ER is probably going to be the biggest provider of health care services. And obviously the impact is that people aren't getting colonoscopies or other regular screenings, etc. You know, like their blood pressure is not getting checked until they have a heart attack. Cutting in from the future, the advice in that CHQPR document report that I mentioned in the intro says that over the past few years,

[00:10:07] they've learned that rural hospitals should not be forced to eliminate inpatient care in order to receive higher payments for other services. That is what is required under the federal rural emergency hospital program. Link to this report in the show notes. It's actually pretty thought-provoking. Okay, back to the original interview. Number two, telehealth has been proposed as a way to help with this lack of access and the lack of providers that are in these rural areas.

[00:10:37] There's a few proposals I know that are on the table relative to telehealth in rural areas. Do you have any insight into, you know, like what are they? Telehealth was almost universally not reimbursed in the state of Indiana prior to COVID. And it's been almost universally reimbursed since COVID. And we've had really improved outcomes from my standpoint. We've been able to really engage a patient population that we wouldn't have been able to keep engaged during COVID, but honestly probably would have never been able to get to in the first place had the telehealth rules not changed.

[00:11:06] I'll be interested to see how that happens. I think one of the things that we've been able to do is we're going to start looking into it and really trying to track outcomes and see if this is worthwhile and if the quality outcomes stack up to telehealth. So I do know that those are some of the things that have been on the table. One of the knocks on telehealth, which is frequently cited, is that it can further exacerbate disparities in care, especially in rural communities because of the lack of access to broadband. Right.

[00:11:35] Is that something that with the patients in your communities or the ones that you see, how many of them have an issue with broadband? Oh, just a lot of them. There's tons of communities that have really, really unreliable internet access. Both in Indiana and Kentucky, there are population centers that exist where the only access are extremely expensive satellite based plans that are just unaffordable, as well as having access even to a computer is not guaranteed.

[00:12:03] What I have seen step into the gap there and help a little bit is disposable cell phones that have data plans. So those have been really helpful for us during the pandemic, you know, burner phones or whatever. The got your Kroger by $30 pre-paid phone with a data plan and they're able to use their data minutes for telehealth. So we've had some success with that. But, you know, we have individuals who are just never going to be able to do that.

[00:12:31] From a technological standpoint, it requires a certain level of savvy. If you've got a 93-year-old lady, her ability to access a cell phone with a data plan and figure out how to download an app and, you know, use it for telehealth is not great. Is it a local health system? It's actually buying the burner phones and handing them out to patients? Like, what do these programs look like? I'm going to be honest with you. I bought them myself. Oh, wow.

[00:12:58] Back at the beginning of the pandemic, we didn't know what the future was going to look like and we didn't really have funding or anything like that to do that. So I just went out and I just bought a huge crate of burner phones and was handing them out to patients. And we had some success with that. They're surprisingly affordable for what you get. So you personally, like you didn't even have a grant. You just went out with burner phones. Yeah, it was kind of five alarm panic, especially in Indiana because COVID went from a rumor to overflowing the hospitals in a week.

[00:13:28] Again, here's me from the future. Listening to this made me remember vividly in a way that I had nearly forgotten just how heroic many clinicians and administrators, just how valiant and how many sacrifices many who worked in health care or work in health care made during the pandemic for their patients. It just brought back a huge sense of appreciation and gratefulness that I really wanted to share. I mean, I had no idea what to do.

[00:13:56] I just panicked the day before we went into quarantine and sent everybody home with a burner phone. Wow. But subsequently, now they have a burner phone and you actually know what their phone number is because you bought it. So then you were able to have reimbursable telehealth calls subsequently for people who would have been just completely alone had you not done that. You know, I especially worry about a lot of our senior patients who live at home. If they get sick, are they going to be able to get to the doctor or what if they need groceries?

[00:14:26] So were you actually setting up telehealth appointments and whatnot with rural patients or was it more like, OK, if you need help, just give me a call? And then basically you were your own 24-7 call center. Yeah, actually, we were we were setting up appointments at the time. Again, pure panic. We had no idea if it was actually going to be paid or not. We just scheduled telehealth appointments the same as, you know, we would normal appointments and just indicated that they were telehealth. And we just hoped and prayed that that worked out. And it actually did.

[00:14:52] So we've come up with two potential solutions for rural health access. One of them is freestanding ERs, which have the financial discipline to not take advantage of the community that they are in. Number one. Number two, telehealth. In particular, telehealth opportunities that recognize the fact that there's broadband issues.

[00:15:14] I'm going to assume, though, unless there's another, you know, Nikki King out there who takes it upon herself to spend her own money on her patients, that it probably would take more of a value-based reimbursement environment, which is something that you also mentioned at the top of this conversation. To inspire the health system to do this instead of a very concerned provider. Would you agree? Absolutely.

[00:15:37] So another possibility that you have talked about besides the freestanding ER and the telehealth is to expand nurse practitioner rights. So expanding NP rights. Do you want to talk about that a little bit? This is a hot potato in the healthcare world. You know, a lot of strong feelings about it on both sides of the aisle.

[00:15:55] But approaching it from purely a database standpoint, what we know is that we've not really seen any significant changes in healthcare outcomes for communities that have nurse practitioners who practice independently. In fact, that model has been widely utilized in the frontier states where they have a very low per mile population and even lower number of doctors serving large areas.

[00:16:19] Utilizing APRNs to the top of their law sends and really empowering them to be independent providers has increased outcomes as you would expect it to for providing an area that didn't have access to service with access to service. And the truth of the matter is, with the landscape being the way it is, the number of residencies for physicians each year is not increasing. But the population of the United States is increasing. And when you look at the places that it's increasing, it's increasing in rural areas.

[00:16:44] And we know that based off research, physicians are most likely to practice within 40 miles where they completed residencies. And the vast majority of residencies are in urban communities. So you have these doctors who might have started out in a rural community with grand ambitions to go back home. But, you know, they get out, they do the residency, they get married, their kids are in school in this urban community. They don't really feel like leaving. So they just stay there. And of course, the demand's there and the pay is there and the quality of life is there.

[00:17:11] There's not a ton to entice them back to their home community other than charitable spirit. This creates an issue where we're going to have a huge bottleneck on the number of available physicians and how far we can stretch them in the future, particularly as the silver tsunami hits with the baby boomers who are aging into a high acuity age range where they're going to need much more intensive services. When you look at how do we fill that gap, disproportionately, that gap has been filled by nurse practitioners who migrate and gravitate to rural communities.

[00:17:40] A, I think it's because of the people who choose to be nurse practitioners and the fact that they can often complete their schooling a lot faster and locally. So it doesn't really make it as hard for them to move after they've completed their training. But also because a lot of them are attracted to the fact that they can practice more independently and practice at the top of their lessons. So, like I said, I know that there's a lot of feelings on both sides about which providers are the best or worst or who's got the strongest skill set in one thing or another.

[00:18:09] But the fact of the matter is, is that a lot of rural communities are going to be in the position where they have a nurse practitioner or no doctor at all. And I don't think anybody out there thinks that no doctor is better than a nurse practitioner. I don't care how hard line you are on doctors' rights and doctors maintaining control. And so in those types of situations, we really need to revisit what the supervision requirements are on nurse practitioners.

[00:18:31] And if that's really the way that we want to go, and do we really see the quality outcomes come out of those supervision programs that would justify their continued existence when, again, you're facing a massive lack of access crosses nationally? It's just another example of what I would consider the sort of like everything becomes this binary. There is middle ground. And it sounds like in some of these, you know, a lot of good arguments are spoiled by some fool who knows what he's talking about. You know what I mean?

[00:19:00] Like, it just sounds like we need to actually look at the data and set our ideologies aside and just figure out what's right for the patients here. Right. Well, you know, I've always wondered, what about something like a policy where if there's no primary care physician practicing within 30 miles, nurse practitioners can practice within that radius independently. Or maybe it could go off the HPSAs. If it's a health provider shortage area designated by HRSA, within those areas, the nurse practitioners can practice independently.

[00:19:27] Things like that, because that would also help entice more nurse practitioners to return to rural communities. One thing that I thought was really interesting is I got the opportunity to tour a hospital called Seven Oaks in Winnipeg, Canada. One of their administrators was nice enough to show me around the facility. He made a comment that was really funny. He's like, we've only got one gerontologist at this hospital. I'm like, you have a gerontologist? I don't think I've ever even seen one.

[00:19:53] But when we started talking about my community that I was working in at the time, population 5,000, obviously much smaller than the city of Winnipeg, which is a very urban area. I was like, yeah, we have five OBGYNs, obstetricians. And he's like, you have five OBGYNs? He's like, what in the world could they possibly be doing? And I'm like, what do you mean? And he's like, we've got one for like the entire greater Winnipeg area. He's like, what do they do? I'm like, deliver babies and stuff, I guess. And he's like, why would you not have a nurse practitioner do that?

[00:20:22] He's like, they do all of them here. He's like, the only people that the obstetricians see here are the highest risk. This reminds me of the NUCCA system of care. And I interviewed Dr. Doug Eby on the show a bit ago. So I definitely, if you haven't listened to that, would recommend going back in and listening to it. But they also serve very rural communities. I mean, ones that you have to take a prop plane to get to. The way that they do it is with primary care teams and a lot of telehealth.

[00:20:50] Because if you have a primary care team and you have the primary care physicians that are interfacing with these specialists and ensuring that they're called in at the right time, then you can do a lot very efficiently. And everyone gets to work at the top of their license. I'm assuming that some of the stuff that we've been talking about relative to nurse practitioners working at the top of their license could be folded into a primary care team like that in some fashion. Oh, yeah, absolutely.

[00:21:20] To me, that's the top standard of care. We did something similar at Margaret Mary with the GROW program. We didn't really have access to child psychiatrists, but we had a need for intensive trauma services for adolescent mental health patients. What we ended up doing was putting the psychiatrist and the pediatrician together and have them work together on a multidisciplinary team and sort of offset one another. And that worked really well. So they were just simply working together and collaborating together? Or was it more official than that?

[00:21:47] Yeah, they would collaborate together and they would have weekly multidisciplinary team meetings with the therapist, the three of them. And they would kind of all three together come up with treatment plans. Got it. And the three are? A pediatrician, a psychiatrist, and a therapist. All right. So let's talk about maternity care in rural America, which is becoming a huge issue. First of all, what's the issue? Let's start there. What's the problem? For many rural hospitals, again, and we said almost half of rural hospitals are in danger of closing.

[00:22:15] Maternity services are a losing prospect. The payer mix is really bad. The cost of malpractice insurance is really high. The cost of just having that service is really high. Most rural hospitals continue to do that service, A, because they have a mission to serve their community. But B, because when you deliver a baby at your hospital, you have a really good opportunity to engage them in the continuum of care for the rest of their lives, which is, A, both good practice and good quality for the patient.

[00:22:42] But again, in an environment where half the rural hospitals are closing, their ability to maintain a losing service line is dramatically decreased, regardless of the community need or if it's the right thing to do or not. And so a lot of rural OBs are closing. So you have women who are hours and hours away from the nearest hospital where they could actually deliver a baby. This is becoming a huge, huge crisis. One of the things that you said that I just want to emphasize is that a lot of hospitals, if you're in an urban setting, it's like a loss leader.

[00:23:10] You want people to deliver their babies in your care setting because then chances are they're going to stay there. It's basically the health facility for the rest of their lives. Right. So if you're in the only game in town anyway, you don't need to be doing that. Obviously, there's some really big downsides to being hours and hours and hours away from the place where you can get maternal care.

[00:23:37] Another huge issue is the lack of obstetricians in rural communities. When you look at back in the day, the vast majority of care was being provided by a general practitioner who just went around with a little black bag and he saw everybody and that made a lot of sense. But the complexity of medical procedures has really changed since then. So back in the day, your little GP was providing oncology, women's services, cardiology, psychiatry, you name it. The general practitioner was doing it.

[00:24:05] But now we know a lot more about each and every one of those services. There's specialists who can do this. But as health care becomes more and more specialized, their ability to treat high risk cases is better. But access gets worse because rural communities are, by definition, low volume and can't really attract and retain that kind of talent. That's a big problem. And obstetrics is really no different. It's becoming an increasingly specialized service. So say you're an OB-GYN who just graduated from residency today.

[00:24:30] For you to go out in rural communities, you're put in this catch-22 where these babies are so rude that they don't come during office hours. And so you have to be on call essentially 24-7. And if you're not, then there's no one to deliver the babies. But say during the day or whatever, you have just enough patients to keep you busy in the office during the day to give you a reason to be there and to keep up your license. But again, it's that call piece. So then you hire two obstetricians who now don't have enough patients between the two of them to keep their day practice full.

[00:25:00] But now at least it's a one and two call. So you can think about having a beer every other week. And you can maybe have a vacation. But that's just a very hard life that a lot of doctors who are just coming out of residencies. Additionally, now you also have the concept of a laborist, which is, you know, an OB-GYN who literally just delivers babies. They're really good at it because it's all they do. They're a master of one trade instead of a jack of all trades. And they have a great quality of life because they work their 12-hour shift and they go home at the end of it and nobody calls them.

[00:25:28] And they go, you know, wake up the next day, work their 12-hour shift. Again, that model is just untenable in rural communities where you might deliver 80 babies a year if you're lucky. They just sit around, twiddle their thumbs most shifts, and they wouldn't see enough action to even keep their license. This is becoming a really heated topic too as family practice physicians who deliver babies and do a great job are unfortunately being forced out of the delivery world by higher malpractice rates.

[00:25:53] A lot of insurance companies want the laborists delivering babies because if you've got a doctor who only delivers babies, then that's the best care for their patients and that they cover or their insured lives that they cover. Unfortunately, they don't realize the implications that that has on access because again, this goes back to the whole nurse practitioner debate. Whatever you think of the quality of a family practice physician delivering versus a laborist delivering,

[00:26:18] whatever your personal opinions on that doesn't super matter because everyone would agree that either of those things is better than neither of those things. And right now, the dichotomy in rural community is neither of those things. This has led to a full-on systemic collapse of obstetric services across the country. And I don't think that it gets enough attention because we've sort of internalized this idea that rural America is dying off and that the rural population is decreasing every year.

[00:26:44] So I don't think they're looking at services that are disproportionately affected by younger generations that are more likely to live in an urban setting, but it exists and it's creating a huge access and health disparities issue. It's like perfect being the enemy of the good. If it's a question of having nobody unless you're driving hours because you've got that sort of lead time. Right. You're kind of left in a bit of a pickle.

[00:27:09] Again, when you don't have family practice delivering babies, they might also just elect to not do OBGYN services or women's health services at all, which means that the folks who live in that community don't have access. Because again, say you're a family practice physician who's going to go practice in a rural community, a family practice being one of the few specialties that does disproportionately pick rural communities to practice in. For you to be trained in women's health, you would need to do additional training to learn how to do deliveries and to be really competent in that.

[00:27:39] And so again, if you think that there's a chance you're not going to be allowed to do deliveries, why would you take all the extra work to train yourself up in women's care when you can use that time to prepare for something else? It's not even just deliveries. It's prenatal care period across the board that unfortunately women's health providers are being shoved out. So just last thing, let's talk about mental health for a moment. If there's not adequate primary care or patients don't realize that PCPs can be their door into effective mental health,

[00:28:08] patients wind up beginning their mental health journey or their care journey in these freestanding ERs, for example. We are seeing a dramatic increase in diseases of despair across the board in rural communities. I saw a huge uptick in this myself after the last election. Without getting too political, I think that rural communities have been on the decline for 60 plus years. Rural communities are trying very hard to hang on to what they have. And for the first time, we saw some attention swing back towards the rural communities.

[00:28:37] And it was this renewed sense of hope and then this sort of hard shift back to normalcy. And normalcy was where rural health was dying. That scares a lot of people who are very culturally attached to their communities. If you live in this little tiny community and you don't see a future there with your job, these things can really exasperate mental health. And there's no access. Obviously, the pandemic dramatically accelerated mental health issues and there's still no access.

[00:29:06] The economy really took a hard hit over the past four years in rural communities and still no access. Also, you're disproportionately more likely to have Medicaid. You can't get providers who can take more than a certain amount, even if they're not for profit. Or you have folks who are farmers or maybe they own an excavating company. They don't have insurance. They can't afford insurance. They make too much to qualify for the ACA plans.

[00:29:33] They don't make enough to buy a commercial plan outright or to go to the marketplace, which again, the marketplace is disproportionately expensive in rural communities because almost all of the insurers pulled out of the rural marketplace because there wasn't a varied enough pool or a large enough risk pool for the insurance company to, you know, make a profit off of it. So when you look at the one market plan that's available in a rural community, you probably can't afford it. And with no insurance, of course, comes no access.

[00:30:00] Obviously, diseases of despair, behavioral health, people are starting to realize how much that actually affects physical health, that they're not two separate things, that it's just kind of like health. Another thing that has been mentioned along these lines is the evil cycle that gets precipitated. Because if you have parents suffering from a disease of despair, you tend to have child abuse,

[00:30:25] which just perpetuates an evil cycle, which I know is something that you have studied and seen. This goes back to the adverse childhood events study, which I think we do not talk enough about in the healthcare administration world. We talk about a lot of it clinically. I feel like a lot of clinical providers are acutely aware of the effects that child abuse has on increasing risk of suicide, substance use disorders, obesity, diseases related to obesity. All these things, providers see that.

[00:30:53] If you've got somebody who's just really lived a rough life, chances are they're overweight. They may or may not have something like two diabetes or hypertension. They probably have depression, anxiety, or both, as well as maybe something like PTSD. Like you're seeing them have issues chronically with employment and their ability to take negative criticism or challenge themselves. That's not everyone. Like that's not stereotyping. I'm just saying that statistically, people who suffer from those things have disproportionately experienced childhood trauma, and that's why they're having trouble coping.

[00:31:22] But from the healthcare administration side, we know that somebody who has an elevated ACE score or adverse childhood events score has a 20-year shorter life expectancy on the whole. Their ability to meet population health value-based markers non-existent. If you have a primary care provider who's just trying to treat depression in an office-based setting, and this is somebody who has complex PTSD, that ain't going to work. This is going to be something that requires intensive treatment.

[00:31:48] And so I think that this is the single biggest challenge to moving to a model that really incentivizes keeping people healthy versus doing procedures in the hospital, because these people are going to have significant and very specific barriers to achieving physical health because of their lack of access to mental health. You had said that population health models, having a reimbursement system that's based on achieving better pop health outcomes is going to be essential.

[00:32:15] And this is probably just another proof point to that being the case. If you had some advice for Medicaid and how that is structured, especially given your experience in rural America and also with mental health and the challenges there, what do you suggest? The easiest low-hanging fruit, first of all, is having national Medicaid and have that put under the same hood as Medicare.

[00:32:39] Having Medicaid vastly different from state to state, both drives providers, administrators, everybody insane. You can implement a program that works really, really great at targeting high-risk people, and therefore Medicaid enrollees in the state of Indiana, and have it completely flop in California just because of the way that the programs are administrated. We can't even talk about best practices in a way that really makes sense beyond the most very basic level. That drives me insane.

[00:33:06] There needs to be one rate all over the country, needs to be one set of rules all over the country, and it also reduces a lot of redundancy within the system. That's just number one. But additionally, looking at value-based models for Medicaid, and some states have done this with great success. I haven't looked into it personally, but I hear rave reviews about the Pennsylvania model and what they did with value-based care in that state. So I know that some states have really, really done this well,

[00:33:33] but the vast majority of states are kind of pretending like Medicaid doesn't exist and hoping it goes away, and especially in light of the really politicized nature of Medicaid in states that did not expand with the Accountable Care Act. The truth is that we're getting to a place where if we don't get behind subsidizing health, we won't be able to pay what happens next. And I can't think of any demographic where that's more important than high-risk Medicaid patients who oftentimes don't have the resources that they need to maintain their personal health.

[00:34:01] We've just got to completely look at the way that we do this Medicaid thing. It's untenable in every way imaginable. The idea of paying for value seems to be definitely at least one leg in the stool that's going to transform healthcare here. Right. And particularly important for rural America that has all of these additional challenges. It's certainly a spider web of complexity. Yep. Nikki, if people are interested in learning more about the work that you're doing,

[00:34:29] where would you direct them for more information? You can look me up on LinkedIn, readily available on most social media platforms. Nikki King, thank you so much for being on Relentless Health Value today. Thank you. Hi, this is Cynthia Fisher, PatientRightsAdvocate.org. We subscribe to Stacey's podcast and we've learned so much from her podcast with all the incredible

[00:34:53] individuals she interviews on healthcare and the opportunities to affect change for the better. I suggest everyone listen to these great podcasts that Stacey provides, so well-informed for all of us engaged in healthcare.