This episode is brought to you by r one RCM, a leading provider of technology driven solutions that transform the financial performance of hospitals, health systems, and medical groups. R one delivers proven, scalable operating models that power sustainable improvements to net patient revenue while reducing operating costs. To learn how you can transform your revenue cycle performance, visit us at www.r1rcm.com/beckers. Hello, and welcome to the Becker's Healthcare podcast. My name is Will Riley with r one RCM. I am joined today by Dave Dunkel. Dave is the president and CEO of Johnson Memorial Health. Welcome to the podcast, Dave. Thanks for having me, Will. Thank you. Dave, if we can start, please, by you just telling us a little bit about yourself, your background, and tell us about Johnson Memorial Health. Yeah. Perfect. Well, again, doctor Dave Dunkel, president and CEO of Johnson Memorial Health. Johnson Memorial Health is a smaller health system in the suburbs of Indianapolis, approximately 900 employees, community based, net revenues, probably a little over a hundred and 20,000,000. So a medium sized hospital by most standards. I've been practicing the community where I serve now CEO as a family physician for about eighteen years before, had different medical staff roles, including chief of staff twice, moved into vice president medical fair role, and then five years ago became CEO of the organization. So pretty excited about that. Excellent. Thank you very much for that background. I'm looking forward to talking to you about some of the big opportunity areas and issues facing providers as we go into 2025. Mhmm. So very keen to get your take on those. Let's start right there, actually. What are you the year is about to turn. What are you looking at for your key priorities for next year? Well, really two things. First is a nonclinical initiative, and that's can we get paid for the care we've already provided. Right? I mean, I'm sure that is a big topic in in health care right now. I mean, everyone knows, I mean, the onerous prior authorizations and clinical documentation requirements. It's really amazing to me, again, especially with the clinician background, how hard it is to get paid for things we've already done. So we've had to invest a lot of resources to try to just get paid. Denial are at an all time high, so we've had to create more denials committees. You know, you try to fight their automation with your own automation, trying to streamline price processes such as insurance verification early on and really just try and do everything we can. The disappointing thing is I've had to add, you know, percentage wise more employees in the revenue cycle than I have at the bedside. And that that's a real problem with medicine. And I really feel, you know, it's a struggle. It would not be this hard if we just got paid for what we did. And, you know, for companies to be able to look back and deny even after you've been approved for things, is really a struggle. I feel that it's it's just unfortunate that the way things things are going right now. And we gotta we gotta have things change. It's really one of the things people don't aren't as aware of is just the request for documentation. I literally literally reviewed a case recently where the insurance company asked for materials eight different times. The same thing was sent to them. They kept requesting the same materials. We said, you know, you've got this. What that does is it just extends the time, you know, for timely filing. And it's just one of the many tricks that we have to fight hard to overcome. Yeah. Yeah. What do you think I mean, so you've talked about a couple of things with that. You talked a bit about about using technology to help with that. Yeah. I'd love it if you could talk to us a little bit about how you're doing that and also talk about perhaps what you think the long term solution is to that, or at least a medium term one beyond massive structural change. Yeah. Well, the unfortunate thing is, again, I'm in a small health care system. Yeah. And we're you know, every it seems every every month, my CFO, a revenue cycle director, talking about new technology that we can invest in. Again, you know, AI that works twenty four seven, works on the weekends, and basically to combat the payer's AI. And, you know, it it's like a science fiction movie. Right? All the AI is working in the background trying to be sure we get paid. So that that that's, you know, again, a struggle. I really feel if we wanna improve the system, I look at you hate to think that it's gotta be litiginous, but you look what happened in California when at that when a large payer was, you know, denying a claim every three seconds. Right? And so the states that, you know, you weren't meet you know, they weren't meeting the requirements of reviewing those claims. Unfortunately, I think, you know, especially myself as a physician, we just have taken so much lying down Mhmm. Throughout the years. It's time to go on the offensive. And I really don't feel that the general public understands how hard it is to get paid. And, you know, the and we talk about things like hospital prices. You hear, oh, hospitals are charging so much. You know, it's it's outrageous. We're not getting reimbursed that. I mean, you know, you get you get paid on a percentage. And so I really feel, again, as a family doctor, one thing I try I always try to do with my patients was be totally transparent and explain everything that we're doing. I didn't want it to be, oh, we just do this because I say so. I was never that type of person. And I really feel we have to do the same thing with with the respect of payer, and hospital relations. We really have to stay on the forefront and keep it out there in the public. And, also, I feel like we we really need legislative help. I I have really since the last two years of this job, I've really made it a great effort in Indiana to meet with my representatives at the state level and also federal level to really and they it's amazing me that when you really sit down and say, okay. Here's an example. We sent we sent, you know, x documents to the payer eight separate times, and they just sit there dumbfounded. And they said, oh, you have no recourse? No. I have no recourse. Mhmm. And especially as a smaller organization, we can get bullied. We I don't have the option to say, oh, I'm gonna go out of network. Mhmm. It's really not an option for me because we're close to a couple larger tertiary systems, and the big payers can say, hey. You just go up the road. Mhmm. And, you know, I actually had a the monopoly talk with, one of our legislators who was talking about the big systems in Indiana. And in fact, it was a Becker's article that pointed out recently, you know, that in Indiana, for example, the four big systems, I think, control 49% of all hospital beds, commercial beds in the state. But the four big payers have 92% of the commercial lives in the state. So that's what monopoly is. It's not with the hospitals. Right. So, again, it's education. So are things like, you know, we see health systems opting out of Medicare Advantage Plans, for example. Is that is that kind of a recourse that's available to you? Is it something you would do? Yes and no. Because, obviously, we're still competing for business. Yeah. Right. So, you know, sometimes you have to take lesser pay to get people inside in the door. Yeah. Yeah. But again, I just feel it shouldn't be so hard to get paid for delivering care. You know, you look at a simple system like you build a house and it's cost plus x percentage. Yep. And I think people would be surprised, especially people in the business world. We talk about, you know, if I could count on a 3% margin every year, I mean, I would be giddy. I mean, just, you know, because for budgeting and those type of things. So it it is a constant struggle. I want to ask you a bit about artificial intelligence and any automations or innovations that are exciting you about 2025. And I wonder if there's anything there where you think that, like, many people are talking, for example, about producing, really accurate notes of patient accounts, for for example. And and and maybe that's where you wanna go, and and maybe that has some downstream benefits in terms of then presenting cleaner claims and things like that. I'd love your perspective on those. Yeah. In fact, that's the thing I'm most excited about. Is that right? '25. We're an Oracle shop. We're gonna roll out the Oracle Clinical Digital Assistant. Again, AI empowered technology that, you know, basically takes elements of the patient physician, or clinician encounter, puts that into a health record, allows the the clinician to quickly review that record. So, again, improves documentation. But the big thing is too, you know, it's supposed to cut down on that pajama time, that documentation time, because that's one of the things we really have seen in the profession. And myself, again, as a former practicing family physician, it really bothers me when I see my peers struggling so much with work life balance. And but also, you know, sometimes I think you have to take a step back. And, like, I was a family doctor who would get to the hospital in the morning, run up to the floor, see a couple patients, run by the nursery, see a baby, maybe do office, see thirty, thirty five people every day because I had a little, you know, $5 Dicaphone with, you know, a little tape. And, you know, I'd all my patient encounters were you know, I paid somebody $9 an hour, and, magically, I'd come in the next day, and all my notes were ready. And, you know, so there's part of me that looks at some of these investments, though needed. And you sit and think, you know, we're not being any more efficient than we were ten years ago. Right. And I think sometimes we have to take a step back in health care and say, you know, automation is supposed to improve things, and we're just trying to get back to where we were ten years ago. But, again, I am excited about the Oracle Digital Assistant. I think my clinicians will be very happy. I think it will approve access to care, obviously, because we all know that access is difficult. There's a primary care shortage Yeah. In The United States. We wanna be able to get people to get to be seen. And, again, I'm a family doctor. Having a family doctor is important. You know, studies show that a primary care having an established primary care provider decreases health care costs. And one of the big things we've tried to do in in our organization last couple years is direct to employer contract. And that's one of the things I point out to employers. You know, if you're if you're if you have an employee who has a primary care doc and they get in, you know, an average visit to primary care doc is under a hundred dollars, you know, around about an average ER visit is about $2,000. So, again, really establish the importance of primary care. Yeah. Perfect. Are there any areas of the new technologies that make you concerned? Are you, cautious about anything? I wanna say cautious, but some of the algorithms, you know, picking out, unhealthy populations, I think it's good, but you worry about people being missed. You know, there's something to be said about laying eyes Mhmm. On patients and charts. And, again, as a clinician, I always think the best thing to do is for me to decide. Mhmm. But I feel that to be able to screen numbers of peep numbers of population in a quick efficient manner, I'm overall excited, but still a little wary. Yeah. Okay. Okay. Let's talk about another leadership dilemma, cybersecurity. So it's a big topic, obviously, come to the fore in 2024, for all sorts of reasons. As a leader, how do you prioritize investment and focus in that space given all of the other things that are on your plate? Well, as a leader who three years ago spent a Saturday morning talking to the FBI about his cyber attack Uh-huh. This is this is at the forefront of pretty much our thoughts every single day. And I can tell people you can't spend enough on cybersecurity. It's it obviously has to be a huge, huge strategic initiative for organization because I don't wish, you know, a cyber attack on anyone. So we we the unfortunate thing is, again, is how much it costs. Right? I mean, it's Mhmm. To think how much more we're spending now than we used to. And even when we had our cyber attack, we still we had done all the tabletop exercises. We had been certified that we've done everything we needed to do. And still what's scary is all it takes is one employee. You know? Again, we have, you know, just under a thousand employees. But these organizations with 40,000 employees, all it takes is one thumb drive, you know, one one one one click. So so we've done a lot for education. Every two weeks, we have modules that go out to our employees that they need to complete. If they don't complete them, their leader gets an email. And so we have lists. Obviously, we do internal, you know, fake email phishing and, you know, I get those reports. It was kinda scary. We sent one that was so good. 40% of our employees clicked on it. I was like, okay. That that was you talk about stuff that keeps you up at night? Yeah. Yeah. It's okay. Yeah. That keeps you up at night. But, again, so it's it's we try to keep it at the forefront. And, you know, when we talk about, we don't ever want that to happen again. But, you know, the thing that's crazy is when you talk about again, we have security that detects these threats. Just the the phishing that occurs every single day. I mean, we're hit every hour, every couple hours. I mean, it's it's that often. And I don't think people realize that. Yeah. You know? And, obviously but, you know, I don't know what the solution is there. I mean, I've said it before. I think in some ways, it's kinda like you look at I equate it somewhat to marijuana and some you know, decriminalizing might be best. I mean, you know, we laugh sometimes, not laugh, but at the hospital, you know, you walk in the hospital. Once you walk in a hospital, anything that happens, we're responsible for. Right? I mean, you trip and fall, it's my fault. If you refuse to wear your, you know, yellow non slip socks, don't have a bed alarm, you fall, and sometimes you it's my fault. It's the you know, it's it's our organization's fault. And sometimes with cybersecurity, it's especially with protected medical information, it's like, if I've spent, you know, million dollars in cybersecurity, I've done everything I'm supposed to do. You know, how much should a health care organization have to pay? Yeah. You know, I mean, obviously, there's things like the change health care, which disrupted, the health system. But, you know, there has to be limits when when you do everything you're supposed to do. And and, honestly, it's become such a big cost for community hospitals like us. I would love to get some, you know, some support. Yeah. I mean, when you look at all the other things we do with charity care and, you know, here's another expense. It really there's no ROI on it. It's just you're it's you're paying to prevent, like, lots of insurance. So, but, again, you can never invest enough in cybersecurity. Well, let's end perhaps with a thought on, like, what what is the future then for health systems like like yours? Like, what does it what does it look like? Right? We've talked about all sorts of challenges, yet you're in this community doing good work, serving your patients. How do you how do you square the circle? It's tough because, you know, I tell my I tell my leadership team, we are so blessed every day to have this ability to take care of patients and make such a difference in people's lives. The unfortunate thing is you gotta get paid for it. Right? And and, but I really feel that for organizations like us, it's it's partnerships, it's collaborations. But, you know, we try to stay, independent. So we actually have a consortium of hospitals. We call ourselves suburban health organization where we're we're interdependent independent hospitals. So we can take care of you know, we can take advantage of economies of scale like a larger systems Mhmm. And, you know, utilize savings there, share ideas without really trying to run anyone else. I think that that is, you know, collaboration and then collaborating with the big systems when when possible. We're part of the Mayo Clinic Care Network, which has been which has just been an absolutely fantastic way for our clinicians to, you know, raise their game and, you know, and for our patients to have access to that Mayo Clinic Care network at no added cost to them. It's it's that's great. We have we have relationships with the big academic medical center and couple of the other tertiary systems. Kind of I've I've said I like to be friend to all, foe to none. Mhmm. I think that's really important for systems our size. Yeah. Got it. Okay. David, it's been a real pleasure talking to you. Thank you so much for sharing your perspectives. Thank you. Hey. Thanks for having me. Thank you.