This is Alan Condon with the Becker's Healthcare Podcast. And I'm thrilled to be joined today by Nicole Stallings, President and CEO of the Hospital and Health System Association of Pennsylvania, which I believe represents 235 hospitals as well as the patients and communities that they serve in Pennsylvania. Nicole, a real pleasure to have you make your debut appearance on the Beckers podcast with us today. For those of our listeners who mightn't be as well acquainted with you, the work that you do at HAP, do you mind giving us a little bit more insight into your role and your background? Sure. And thanks for having me. At HAP, we are the trade association for Pennsylvania's hospitals, which means we're their advocate in Harrisburg and in Washington, DC. We partner with other community partners, business groups to advance the key areas impacting our hospitals, their patients, and the communities they serve. Fantastic. Nicole, I was excited to dive right in here. There's a ton to cover a lot going on. Let's see how much ground we can cover in fifteen, twenty minutes. But I wanted to kick things off. I think the latest we've seen, Becker's COVID report last week from Kaufmann Hall, which said that I believe thirty seven percent of hospitals in The US are still losing money. Many of those hospitals are rural hospitals, which still face a lot of financial distress and closures. Can you begin by giving me a little bit of insight into the policies or maybe funding mechanisms that you believe are most critical to keeping these hospitals open? Sure. I think to start, it is really taking that step back and realizing that many hospitals, not just rural hospitals, are facing financial distress. And now as we look back to about five years ago from when we, first admitted that, that very first COVID patient, our hospitals have certainly seen recovery. It's variable, but the health care delivery system still in many ways is fragile, and that's especially acute with our rural hospitals. In Pennsylvania, we have six hospitals, rural hospitals who have closed in the past five years, and I saw, a Becker's report that showed that 18 rural hospitals are at risk of closing and I think 10 were deemed to be an imminent threat of closure. And that's because we're seeing in rural communities, not just in Pennsylvania, but across the country, you know, the constant population, so that's impacting your volume. Certainly, it's difficult to recruit a workforce into those communities, and when you're able to do it, it's at a significantly higher rate than in other parts of our state. And reimbursement. The majority of the patients that come to our rural hospitals have either Medicaid or Medicare as, their insurer, and we have chronic underfunding from those government payers. So, in Pennsylvania, Medicaid reimburses our rural hospitals at about 74¢ on the dollar. So what do we do about that? In Pennsylvania, last year, we were able, as a result of, our association's advocacy, to get funding in the governor's budget, that supported rural hospitals. But I'm pleased to say that last month when the governor released the budget, that funding was again in there. So we're certainly appreciative of that, but it's necessary but not sufficient. So we need to look at a couple of areas, the things that are fundamentally flawed or outdated, in our in our system. Regulations in Pennsylvania that impact hospital licensure haven't so we certainly have opportunity to make sure that they reflect the reality of care that's provided in rural hospitals. Air practices are another opportunity when you look at the high prevalence of Medicare Advantage, in those rural communities and looking at prior auths and denials. What are the opportunities there? And then finally, I would say we just have to fundamentally look at the reimbursement models, understanding that rural hospitals have very high fixed costs with that low volume. So, in Pennsylvania, eighteen of our hospitals participated in a rural hospital demonstration through CMS, and it's set to expire sense funding. It also allowed hospitals, because they had a little bit of that cushion and weren't so volume dependent, to invest in their communities and and try to keep people healthier and not needing to seek care in the hospitals, which is counter to what you would do at a strictly fee for service environment. That model is ending at the end of the year, but we need to see what's next, be it some form of global budget or perhaps some other sort of funding that, accounts for those high fixed costs, maybe has an additional payment, for essential services like maternal health or behavioral health so that we don't have those care deserts. All of these things together, I think, are going to be critical to examine. There's really not a silver bullet. It's gonna have to be multifaceted. It's gonna have to be sustained. Absolutely. For sure. There's not one silver bullet. It's really a multi pronged approach, it seems like. And and to your point, there is such a chronic underfunding problem. That coupled with the fact that reimbursement increases has certainly not kept up with the rate of inflation in recent years as well. We're certainly adding further pressure on on hospital balance sheets. I guess, Nicole, the the million dollar question, I guess, the challenge that the hospital seem to be struggling with, particularly in some of these, rural, maybe underserved communities, is how they balance that financial sustainability in the current environment with the need to also provide essential services even when patient volumes are low, for example, in maternity care, which we so often hear as such a challenge? Pennsylvania has the, unfortunate distinction of having one of the highest percentages of our rural hospitals that have stopped offering OB. And we now have an area in the Northwest part of the state that's the size of Connecticut without a birthing hospital. And and when you look at the reasons why they are really multi, factorial, it's certainly you can't recruit the specialists that you need, the that highly specialized workforce that you need to maintain twenty four seven access to, a labor and delivery unit. Again, volume dropping makes it to where it's difficult to maintain that knowledge base and the skills that that obstetric team really need to have to provide high quality and safe care. And, you know, I'd be remiss if I didn't mention Pennsylvania's medical liability climate. It's one of the worst nationally, and the venue shopping that is now permissible in Pennsylvania makes it even more challenging. And recruit health care providers to rural Pennsylvania because that looming threat of an alley county lawsuit and those higher insurance costs really are impacting, care. So we, in January, released a report, a bit of an action plan, that included some recommendations on expanding access to care in maternal areas, looking, at everything from from emergency department readiness to training, and EMS to expanding home visiting programs and really meeting patients where they are. We know that if you live in a maternal care desert, you're likely receiving care from a family medicine physician or a nurse practitioner rather than an obstetrician. And so, we in the state are really thinking through what are those connections to the regional specialists, thinking about hub and spoke, but then the ability to leverage remote patient monitoring and keep that closer eye on individuals who might be high risk. It really requires a lot of partnerships between our hospitals and, rural, suburban, and urban areas, but also also some policy changes, to allow the use of that technology. Yeah. And that that's something that just to go back on something that you've mentioned, I I recently spoken with, Brian Devine. He's the CFO of Allegheny Health Network, And that was something that he brought up in terms of Pennsylvania seems to be more acutely challenged with the medical liability climate there, more so than other states, it seems like, which really kind of adds another layer of complexity, another layer of pressure to some some of these hostels as well, it seems. I guess, anything to add there before we run into onto our next question, Nicole? I I just I guess my big question here is why Pennsylvania seems to have a bit more challenging in this climate rather than other states? About two years ago, a rule changed that allows for venue shopping. And so now you could be providing care in a rural community if there's an adverse outcome and perhaps one of the care providers was, you could then pull that that complaint that lawsuit into other jurisdictions like a Philadelphia County, which is notoriously very plaintiff friendly. We see a high degree of nuclear verdict. And so just within those two years, we are seeing a massive number of cases that are being brought into jurisdictions like Philadelphia, which are incredibly challenging, for, our work. That's certainly a component of why we are seeing access to maternal healthcare continue to decline in Pennsylvania. Mhmm. And and I wanted to to jump right to maternal health, but you just ended on there. So I know HAP does a lot of work in this area in terms of engaging stakeholders or working with providers. I'm curious, can you talk about the kind of innovative models, whether it might be midwifery programs, mobile clinics, telehealth, anything else, some of these programs that are being explored to improve maternal health care access in some of these underserved regions in Pennsylvania. Sure. There there's quite a few ways in which we are looking to fill the gaps and to meet the needs, within our communities. One that I would highlight is partnerships between birthing and non birthing hospitals. So we would have a Titusville area hospital, small, hospital that does not currently deliver babies. They partner with an affiliate hospital, Meadville Medical Center, and they offer prenatal and OB GYN services. And they also conduct regular training and drills so that the emergency department is prepared to safely deliver babies and emergencies. But then we also have systems like, WellSpan Health that is focusing on blood pressure monitoring across all of their birthing hospitals so that if you are a high risk patient, you get that automatic blood pressure cuff that will continuously provide those readings, and that will allow warning signs to come back to the hospital and we can improve maternal health outcomes and really avoid a lot of those complications. There's a lot of innovation that's happening. We need to pair that innovation with some policy change and additional supports to support, Pennsylvania's, birthing birthing moms and families. Mhmm. Apparent that innovation with policy change. And speaking of policy changes and shifts, Nicole, the next question, no doubt on top of mind for you, on top of mind for hospital leaders across the country, really. With with the new administration in Washington, what are the biggest health care policies you just Pennsylvania hospitals should be preparing for? With so many moving parts at the moment, how are you kinda recommending that hospital leaders keep up to date and stay on top of these potential policy shifts? Sure. We're very focused on protecting and preserving Medicaid. Pennsylvania is an expansion state. We have 3,200,000, residents that are currently covered by Medicaid. And so, for example, if we were to roll back expansion, it's projected that we would have the fifth highest impact in the nation in terms of an increase in the number of uninsured. So, in addition to a significant rise in the uninsured, which we know results in delayed care and overall uncompensated care, which would impact health care costs for all. And these Medicaid proposals could also have a really devastating impact on health care delivery. We don't have, public hospitals in Pennsylvania, but we do have hospitals where Medicaid makes up half of their net patient revenue. And for some hospitals, it's as high as 69%. So not only are we talking about devastating access to care, we're talking about decimating hospitals financially. That means stopping services, even potentially closing doors. And then that vicious cycle would continue when you think about all of the jobs and delegation is that, protecting Medicaid isn't just about coverage for 3,000,000 Pennsylvanians who rely on it. It's about protecting access to care for everyone in the community. But Medicaid is not the only thing that's currently on the table right now in in, Washington, DC. And so it's our job, really, as a hospital association, hospital association to help our members distinguish between things that are true signals and the noise and to make sure that we are providing avenues for, them to tell their story locally to members of their delegation about what these cuts truly mean. We know that, keeping access to care in communities is a bipartisan area where we can see some agreement, and so that's where we are focused right now. Yeah. I mean, if it's such a it's such a challenge, I imagine, kind of, hospital leaders would be pulling their hairs out trying to get to the bottom of this. I think I don't wanna make it political. Maybe it's hard not to, but Republicans have consistently said that they won't cut Medicaid. The CBO congressional budget office yesterday said it's impossible for them to reach their I believe it's $880,000,000,000 in savings over the next ten years without cutting Medicaid. To your point, there is so much noise at the moment that I've seen a lot of, people up in in in congress kind of giving their stories about Medicaid and and trying to save the program. But I guess, are you hearing anything, maybe behind closed doors or from folks in Washington, about what those potential Medicaid cuts might actually look like? Any specifics at all? Or to your point, is it still all up in the air still waiting to hear what's gonna happen? I think, you know, any of those potential Medicaid proposals are all very difficult decisions. I agree with you. It's hard to imagine how you get to 880,000,000,000 in savings without looking to Medicaid and and from a health care bone, if you will, and what does that really mean? And so, our job right now, I believe, is to very clearly explain to lawmakers what this means, what the implications are. And it's not, again, just talking about coverage for Medicare beneficiaries. There are community impacts. There are economy impacts locally and in, here in the Commonwealth and nationally. I remain optimistic that we are still early enough in the game that we can, continue to tell those stories and and change some hearts and minds because the alternative is decimating access. It's devastating economies. Absolutely. And certainly no easy feat. What a challenge. But I certainly appreciate the work that you and all your team will have to. Nicole, the last question for you kind of ties right into our discussion before I let you go. But, what role should hospital leaders and associations play? You've talked about this a little bit already, but maybe any expand expansion on some of your insights there. What role should hospital leaders and associations play in shaping the conversation around health care funding and reimbursement at the state and federal levels? Anything to add there before we wrap up? Yeah. I would just say we have to tell our story. Very few people outside of our industry understand the complexities, understand those financial pressures that are on hospitals? And so we need to be able to connect those dots between adequate reimbursement, for example, and sustaining care that communities rely on. So communicating that is really critical and it has to be framed as a shared issue. This is not hospital stability is not a hospital issue. It's a community issue. You cannot have a healthy and vibrant community without a healthy and financially viable hospital. And so we have some natural allies here, I believe, with business community and local government to understand how critically important, that is. But politics are local. And so that's where hospital leaders, from an advocacy association perspective, hospital leaders are our greatest advocacy act asset. They are engaged in local businesses and community organizations. They serve on local boards and and and really can find those natural allies. So my advice to hospital leaders is tell the story that only you are able to tell about how you support your community, about how adequate funding and reimbursement are critical to that mission, bring those strong allies to the discussion, and make sure that everyone understands that access to care isn't a hospital issue, it's a community issue, then they're all in. Nicole, so so well said and a great point to wrap up here. So greatly appreciate and respect the work that you and your team at HAP are doing at such a a pivotal and crucial time in in the hospitals, not just in Pennsylvania, but really across the country. Thank you so much for taking the time out of your busy schedule to to have a talk with us today on the Beckers podcast. Thanks, Alan.