Forum/Town Hall: A Roundtable to Examine the State of New York'S Rural Hospitals

1 ROUNDTABLE DISCUSSION JOINTLY HELD BY

THE NEW YORK STATE SENATE STANDING COMMITTEE 2 ON HEALTH AND THE NEW YORK STATE SENATE

LEGISLATIVE COMMISSION ON RURAL RESOURCES 3 -------------------------------------------------- 4 FORUM/TOWN HALL: 5 A ROUNDTABLE TO EXAMINE THE STATE OF

NEW YORK'S RURAL HOSPITALS 6

-------------------------------------------------- 7 8 Van Buren Hearing Room A

Legislative Office Building, 2nd Floor 9 Albany, New York 10 June 3, 2013

11:30 a.m. to 1:30 p.m. 11 12

PRESIDING:13

Senator Catharine Young 14 Chair, Legislative Commission on Rural Resources

Member, Standing Committee on Health 15 16 SENATE MEMBERS PRESENT: 17 Senator Terry Gipson 18 Senator Elizabeth Little 19 Senator Patricia Ritchie 20 Senator David Valesky 21 22 ASSEMBLY MEMBERS PRESENT: 23 Assemblyman Dennis Gabryszak 24 Assemblyman Phil Palmesano 25 1 ROUNDTABLE PARTICIPANTS: 2 Ann Abdella

Executive Director 3 Chautauqua County Health Network 4 Jim Clancy

Assistant Commissioner, Office of Governmental and 5 External Affairs

New York State Health Department 6

Gary Fitzgerald 7 President

Iroquois Healthcare Alliance 8

Fred Heigel 9 Vice President, Regulatory Affairs

Healthcare Association of New York State 10

Jarrod Johnson, FACHE 11 Chief Operating Officer

Brooks Memorial Hospital 12

Steven Kelley 13 President/CEO

Ellenville Regional Hospital 14

Karen Madden 15 Director, Charles D. Cook Office of Rural Health

New York State Health Department 16

Joan Cleary Miron 17 Director, Division of Primary Care Development,

Office of Primary Care 18 New York State Health Department 19 Amy Nickson

Deputy Director, Division of Governmental Affairs 20 New York State Health Department 21 Chandler Ralph

CEO 22 Adirondack Health 23 Dr. Don Rowe

Chairman 24 New York State Rural Health Council 25 1 ROUNDTABLE PARTICIPANTS (Continued): 2 Gail Speedy (via teleconference)

Executive Director 3 Universal Primary Care 4 Art Streeter

Senior Planner 5 Finger Lakes Health Systems Agency 6 Rae Ann Vitali

Assistant Director, Division of Primary Care 7 Development, Office of Primary Care

New York State Health Department 8

Mark Webster, FACHE 9 President and Chief Executive Officer

Claxton-Hepburn Medical Center 10

Fran Weisberg 11 Executive Director

Finger Lakes Health Systems Agency 12

Caleb Wistar 13 Associate Director, Division of Workforce Development,

Office of Primary Care 14 New York State Health Department 15

---oOo--- 16 17 18 19 20 21 22 23 24 25 1 SENATOR YOUNG: Well, thank you, and good 2 morning. 3 I'm Senator Cathy Young, and I'm chair of the 4 Rural Resources Commission. 5 And, I'd like to welcome my Chair in the 6 Assembly, and that's Assemblyman Dennis Gabryszak. 7 We have several members here who are on the 8 Commission also, and I want to welcome them. 9 So we have Senator Gipson, Senator Valesky, 10 Senator Ritchie, and we are so glad you're here 11 today. 12 And I do want to point out that I'm on the 13 Health Committee too. 14 And, Senator Kemp Hannon, who does a 15 marvelous job in chairing the Senate Health 16 Committee, regrettably, could not be here today. 17 He's at the funeral of our former colleague, our 18 dear friend, Caesar Trunzo, who recently passed 19 away. 20 And, so, he's on Long Island right now, and 21 will be here later in the day. 22 So, he sends his regards; he sends his 23 regrets. He truly was looking forward to the 24 conversation today. 25 He and I had a very long discussion on Friday 1 afternoon about his viewpoint on rural health care, 2 which was very beneficial, I believe. 3 So, I do want to thank everyone for taking 4 the time to be here. 5 Tomorrow there is a session on urban 6 hospitals, and so I thought it would be very timely 7 to have this discussion today about our rural areas, 8 because, as we all know, there are fewer resources 9 than there used to be. 10 In many cases, our rural hospitals are 11 struggling, and we're not a one-size-fits-all state. 12 And, so, I thought it would be beneficial for 13 us to get together and discuss some of the trends 14 that are occurring, and some of the possible 15 solutions that the State could undertake, moving 16 ahead. 17 So, this is a very serious policy discussion. 18 Your expertise, your input, is greatly 19 appreciated and valued. 20 And, again, I want to thank you for being 21 here today. 22 Assemblyman Gabryszak, did you want to say 23 anything? 24 ASSEMBLYMAN GABRYSZAK: I just want to thank 25 the Senator for bringing this together. 1 I'm very interested in sitting down, being 2 new to the Rural Resources Commission. I'm very 3 interested in what you have to say. 4 So, I just want to thank you for the 5 opportunity, and, get your input. 6 SENATOR YOUNG: Thank you, Assemblyman. 7 Any of the members want to say anything? 8 Okay. 9 SENATOR RITCHIE: Actually, I would. 10 Thank you. 11 Because of the district that I represent, in 12 the last two years, I've had two hospitals that have 13 been very close to being closed down, and, a real 14 issue, making sure that we have quality health care 15 in the North Country. 16 And, I know Jim Clancy is here today. 17 In the past year, he's spent, pretty much, 18 if not a daily basis, a weekly phone call, making 19 the trip up. 20 And I just want to say publicly, Jim, how 21 much I appreciate you focusing on the hospitals in 22 my area; making sure that the people I represent 23 have access to quality health care, even though we 24 are in such a rural area. 25 So, thank you. 1 SENATOR YOUNG: Thank you. 2 I thought that we could go around the table 3 and everyone could introduce themselves. 4 There are bios on everyone, that -- if 5 anybody has any questions, but, I'd like to start 6 with my friend Ann Abdella, who has traveled here 7 all the way from Chautauqua County, the furthest 8 point west in the state. 9 And, so we welcome you, Ann, and thank you 10 for being here. 11 ANN ABDELLA: Thanks so much. 12 Is this on? I can't tell. 13 SENATOR YOUNG: Yes. 14 If the red light is on, that means it's on. 15 ANN ABDELLA: Thank you, because, I'm from 16 the country, and we don't do this this way. We just 17 shout. 18 [Laughter.] 19 ANN ABDELLA: Good morning, everybody, and, 20 thanks for doing this. I think this is a very 21 timely conversation. 22 But, I'm Ann Abdella, and I'm the executive 23 director, in the typical rural fashion of, not one, 24 not two, but three organizations. 25 One is a rural health network of the three 1 hospital organizations in our community; 2 A small independent practice association of 3 about 100 physicians, the three hospital 4 organizations, working in Medicare Advantage; 5 And then, recently, in the last year, we 6 formed one of the Medicare shared-savings program, 7 accountable-care organizations. And, I gather, are 8 one of the very few rural examples of that in the 9 country. 10 SENATOR YOUNG: Thank you, Ann. 11 Mark? 12 MARK WEBSTER: Thank you. 13 I'm Mark Webster. I'm with Claxton-Hepburn 14 Medical Center up in Ogdensburg. 15 So, people tell me it's a suburb of Ottawa, 16 and from Senator Ritchie's district as well. 17 So, St. Lawrence County, I'm told, is larger 18 than the state of Rhode Island, so it is a very 19 rural and demographically challenged area. 20 So, we're with -- and, by the way, I see my 21 name tag says I'm president of the hospital, and I'm 22 with HANYS. 23 And, so, I'm not sure if that means I did 24 something right or wrong with the HANYS, so -- 25 [Laughter.] 1 MARK WEBSTER: But, we are a 130-bed 2 hospital. It's a medical-surgical community 3 hospital, and we're a sole community. 4 And, so, we've been profitable eight of the 5 last nine years, and, so, kind of have a -- you 6 know, some successes that we've done, but it gets 7 harder and harder every year. 8 And as Senator Ritchie has indicated, I see a 9 lot of my neighbors beginning to collapse. And it's 10 not a sudden demise, it's a gradual demise. 11 And, so, the patients that have been moved 12 from med-surg to ICU. And unless something is done, 13 you can kind of see the inevitable demise of them. 14 So, I'm encouraged to be here. I appreciate 15 the opportunity. 16 We're with the Fort Drum Regional Health 17 Planning Organization. We're in that network, doing 18 some exciting things there. 19 And, so, maybe we can get a chance to talk 20 about that later on. 21 SENATOR YOUNG: Excellent. Thank you. 22 Fred? 23 FRED HEIGEL: Good morning, thank you. 24 My name is Fred Heigel. I'm vice president 25 for regulatory affairs at HANYS; the Healthcare 1 Association of New York State. 2 One of my responsibilities there is to assist 3 our rural constituency, which makes up, roughly, 4 50 of the 200-and-some hospitals in the state; 5 roughly, a quarter of the state. 6 I know Mark very well. Spent time in the 7 North Country, the Southern Tier, et cetera. 8 And, I appreciate the opportunity to be here 9 today. 10 Thank you. 11 SENATOR YOUNG: Thank you, Fred. 12 GARY FITZGERALD: Senator, I'm 13 Gary Fitzgerald, the president of the 14 Iroquois Healthcare Alliance. 15 We have 53 hospitals in 31 upstate counties, 16 and 32 of those are rural hospitals. 17 So, we work with HANYS and our hospital 18 members here to make sure that fair funding for 19 those hospitals and access to services continues in 20 the rural areas. 21 Thank you. 22 SENATOR YOUNG: Thank you, Gary. 23 KAREN MADDEN: Hi, I'm Karen Madden, with the 24 New York State Department of Health, in the Office 25 of Rural Health, and the Bureau of Health Facility 1 Planning. 2 SENATOR YOUNG: And Karen's always been very 3 helpful, and I appreciate that. 4 Next, Jim? 5 JIM CLANCY: Hi, Senator. 6 And, thank you, Senator, and 7 Assemblyman Gabryszak, and Senators Ritchie, 8 Valesky, and Gipson, for having us here today. 9 This is very timely, very important, as 10 you've already mentioned. 11 I'm going to be sitting at this table 12 tomorrow, talking about downstate and Brooklyn 13 hospitals. 14 I think the proof is, that we have a 15 statewide issue here. There's not a "one size fits 16 all." 17 And hearings like this, and around here, will 18 just help us to better understand everyone's 19 community. 20 As Senator Ritchie said, I understand her 21 community very well, unfortunately, because of the 22 issues that we're having there. 23 And because of that, and because there -- 24 this issue kind of transcends and goes in between 25 programs, we brought several staff with -- 1 SENATOR YOUNG: You have an all-star lineup. 2 JIM CLANCY: We have an all-star lineup here, 3 to make sure that at least the conversations are 4 being heard by the right people, and you're hearing 5 from the right program folk. 6 And I don't know if you want me to take a 7 minute to introduce them? 8 SENATOR YOUNG: Yes, please. 9 JIM CLANCY: Great. 10 So sitting behind me, and this is in no 11 particular order: 12 Amy Nickson, the director of our legislative 13 affairs and government affairs; 14 Over behind you is Caleb Wistar -- and I 15 wrote their titles down so I make sure I get it 16 right -- assistant chief of health planning for the 17 office of primary care; 18 Joan Cleary Miron, director of the division 19 of primary-care development; 20 And Rae Ann Vitali, assistant director of the 21 division of primary-care development. 22 Thank you for having us. 23 SENATOR YOUNG: Thank you very much. 24 Don? 25 DR. DON ROWE: Good morning. 1 I'm Dr. Don Rowe. I'm the chair of the 2 New York State Rural Health Council; the director of 3 the Office of Public Health Practice at the 4 University of Buffalo School of Public Health and 5 Health Professions; and, a former public-health 6 director for 17 years in a rural county of New York 7 State. 8 SENATOR YOUNG: Thank you so much, Dr. Don. 9 We really appreciate you being here. 10 Yes, Steve? 11 STEVEN KELLEY: Good morning. 12 I'm Steve Kelley. I'm the CEO at 13 Ellenville Regional Hospital, which is in -- sort of 14 straddles the Hudson Valley and the Catskills in 15 Ulster County. 16 And I agree with Mark, I think that there is 17 quite an erosion in our industry of hospitals that 18 are failing. 19 I think, in the rural areas, the hospital is 20 the safety net that really is the only organization 21 that has the wherewithal for recruiting physicians. 22 And I think if our hospitals close, we will 23 have vast parts of the state with no health care at 24 all, because physicians are not rushing out to rural 25 areas to practice upon finishing their residencies. 1 We are seeing more -- more focus on primary 2 health care. 3 We have a residency program in our small 4 hospital, with the Institute for Family Health, 5 which has a lot of training programs for family 6 physicians. 7 But, I think without having -- having sort of 8 anchor tenants in this mall, so to speak, we will 9 not be seeing physicians attracted to rural areas, 10 and I think we will see vast areas where they're 11 just -- excuse me -- where there will not be primary 12 care or secondary care. 13 And then I think we will see a very large 14 depopulation, because we need to have health care, 15 and that's such an essential part of the fabric of 16 the community. 17 SENATOR YOUNG: Thank you. 18 CHANDLER RALPH: I'm Chandler Ralph, and I'm 19 CEO of Adirondack Health, and we have facilities in 20 Tupper Lake, Lake Placid, and Saranac Lake. 21 We're the largest private employer in the 22 6-million-acre park. 23 We are the only full-service community 24 hospital situated in the middle of the mountains, 25 so, our nearest full-service hospital is 55 miles 1 away. 2 I think there are a number of huge issues 3 that are facing smaller rural hospitals. 4 I served on the board of the 5 American Hospital Association for three years, and I 6 will tell you it's not unusual, rural hospitals are 7 challenged throughout the nation. 8 I think there are ways that we can help, but 9 the bottom line is, is that the erosion of the 10 reimbursement. 11 And I also speak for long-term care. 12 We have two nursing homes. 13 We've lost $11.7 million from those nursing 14 homes over the past 7 years. 15 And the board, this past Friday, said: You 16 either close it or you sell it, but we can't 17 continue to serve our communities as we have in the 18 past. 19 And I think that's what we've really threaten 20 here, is, we've done many things to serve our 21 communities in many different ways. 22 Without the funds, we're going to have to cut 23 back on those. 24 And there's some really vital services that 25 we provide. 1 So thank you for having me here today. 2 SENATOR YOUNG: Thank you so much for being 3 here. 4 Fran? 5 FRAN WEISBERG: Thank you so much, Senator. 6 My name is Fran Weisberg. I'm the executive 7 director of the Finger Lakes Health Systems Agency. 8 And, Art Streeter is our senior planner. 9 And we are the oldest health-planning 10 organization, actually, in the nation. 11 But for those of you who might have thought, 12 Thank God, that all the HSAs went away, we truly are 13 not the HSAs of yesteryear at all. 14 We really do try to bring all of the 15 stakeholders together, to say: 16 What can -- where can we find a consensus? 17 What are the priorities, what are the needs, 18 what are the gaps, in the communities that we have? 19 And that's, bringing the hospitals, the 20 insurers, the doctors, community, all together. 21 And we did that with, How many beds were 22 really needed in our region, and so you don't have 23 an excess of beds in an urban area and struggling 24 hospitals in the rural area? 25 What we really called for is a true regional 1 system of care. 2 And I'm very honored that we were invited 3 here today, because we did do a regional planning 4 process that did get a consensus of many, many 5 different people, that I would like to talk about 6 today. 7 So, thank you. 8 SENATOR YOUNG: Thank you. 9 ART STREETER: Art Streeter. I'm with the 10 Health Systems Agency in Rochester, and have done 11 acute-care planning for 30-odd years at this point. 12 I actually wrote a piece, just about 30 years 13 ago, in Maine, that pointed out that the rural 14 hospital is really the keystone of the local 15 delivery system. 16 And it's still true, if you don't protect the 17 rural facilities, we're going to have to duplicate 18 their services in the urban, but it won't be the 19 right place and it won't be the right time and it 20 won't be the right cost. 21 SENATOR YOUNG: Thank you. 22 Jarrod? 23 JARROD JOHNSON, FACHE: Hi, how are you? 24 I'm Jarrod Johnson, chief operating officer 25 at Brooks Memorial Hospital -- 1 ASSEMBLYMAN GABRYSZAK: No, it was on. 2 JARROD JOHNSON, FACHE: It was on? I'm 3 sorry. 4 -- in Dunkirk, New York. 5 We're part of a two-hospital system: 6 Lake Erie Regional Health System of New York, which 7 also has a hospital, Lake Shore Health Center in 8 Irving. 9 And I share many of the issues that my 10 colleagues sitting around the table share. 11 And, you know, we're strategically located 12 between Erie, Pennsylvania, and, Buffalo, New York, 13 so the nearest tertiary care is at least an hour 14 away. 15 And, so, you know, one of the things that, in 16 addition to everything else that everyone else has 17 articulated today, is, if you look at keeping care 18 local, is what we want to do, and, you know, 19 actually being able to, you know, refer to tertiary 20 centers when we have to. 21 So, you know, we struggle, just like everyone 22 else. And we're looking for an opportunity to keep 23 our services local so that our community can be 24 served well. 25 SENATOR YOUNG: Thank you. 1 And thank you so much for being here today. 2 Sometimes people say: Why don't you have a 3 hearing, because you can get expert testimony? 4 And it is very valuable to have hearings, but 5 I often find, that when we're trying to develop 6 policy, it's much better to have a roundtable 7 discussion, where you can have an exchange of ideas, 8 a disc- -- you know, a dialogue, and that creates a 9 synergy where you can get some really wonderful 10 initiatives started. 11 And that's why we're having the roundtable 12 today. 13 So many excellent points have been brought up 14 already, through the introductions, and I really 15 appreciate that. 16 As President Steve Kelly said in his remarks, 17 this is really a matter of access. It's a 18 life-and-death issue, not to be dramatic, but it 19 really is. 20 And as we look at Upstate New York and the 21 decline in population, and all the initiatives that 22 are underway to try to reverse that trend, if we 23 don't have access to hospitals and health care, then 24 I believe it's all for naught. 25 So that's why it's so critically important 1 that you're here today, so that we can work on those 2 issues. 3 One of the things that I wanted to discuss 4 today is that, under public health law, "rural" 5 means: A county with a population of 200,000 6 persons or less, or a town with a population density 7 of 150 persons or less per square mile, and other 8 rural areas pursuant to standards promulgated in 9 regulation by the commissioner. 10 So during this fiscal year, we did reinstate 11 the 2 percent across-the-board cuts to facilities, 12 to begin in 2014. 13 And, so, there's the DANY program from the 14 full funding, at 5.5 percent reduction from last 15 year. 16 And, so, we were at -- there was an 17 additional $400,000 added for the program. 18 So the total will be $6.65 million, roughly. 19 But one of the questions is: Are we defining 20 "rural" appropriately? 21 You know, what is "rural" in 22 Upstate New York? 23 And we all have our own vision of what that 24 may be with populations, but, related to that is: 25 How far away is too far away? 1 So, we're talking about, the Lake Shore 2 System, and the fact that that's right in between 3 Buffalo, and, Erie, Pennsylvania, but, how far away 4 is too far away for someone to have access to 5 hospital care? 6 And I think we should have a discussion about 7 that. 8 Is it defined by population? 9 Or, is it defined by distance? 10 Or, is it both? 11 So that's a question that I wanted to throw 12 out right away. 13 Anybody have any input on that? 14 Ann? 15 ANN ABDELLA: Well, I might suggest weather, 16 since we get 300 inches of snow where we are up at 17 the lakes. 18 And I'm sure our friends in Tug Hill would 19 have an even bigger story to say about that. 20 We just had a --WCA just had their annual 21 meeting the other day, and we were talking about 22 Starflight, and the fact that, because of weather, 23 they can only respond to about a third of the calls 24 to helicopter people even out of the area, because 25 of weather. 1 So, I think that's just got to be another 2 factor we can consider. 3 SENATOR YOUNG: Weather is a very important 4 point. 5 GAIL SPEEDY (teleconference): This is -- 6 excuse me. 7 SENATOR YOUNG: And as you know, a few years 8 ago, we worked very hard to keep Westfield Memorial 9 Hospital open. 10 And part of the case -- well, the case behind 11 that was the fact that, in January, it's very 12 difficult to get to the hospital in those regions of 13 Chautauqua County. 14 Anyone else want to answer that? 15 Yes. 16 DR. DON ROWE: If I could, I apparently 17 neglected to do the things that I didn't know I was 18 supposed to do. 19 So, if I could take the opportunity to just 20 jump in here to talk about -- a little bit, about 21 the Rural Health Council, and its responsibilities, 22 and then specifically address that question that you 23 asked? 24 Is that appropriate? 25 SENATOR YOUNG: Yes. 1 But before you do that, I do want to 2 welcome -- I just noticed that 3 Assemblyman Phil Palmesano just joined us. 4 So, we welcome you, Assemblyman. We 5 appreciate you being here today. 6 And, also, I want to announce that, 7 Gail Speedy, from my district, is on a conference 8 call. 9 So she's here, somehow. 10 GAIL SPEEDY (teleconference): Thank you, 11 Senator Young. 12 And I also want to thank you for 13 accommodating me. 14 I am on my way west, as we speak, so 15 I appreciate you accommodating me. 16 SENATOR YOUNG: Hi, Gail. I'm so glad you 17 can be here with us, kind of. 18 Thank you. 19 So, Dr. Don Rowe would like to talk about the 20 New York State Rural Health Council. 21 DR. DON ROWE: Certainly, briefly. 22 The Rural Health Council is charged with the 23 responsibility of assessing the myriad of factors 24 that impact the health of our rural residents, and, 25 to advise policymakers of the challenges that they 1 face, and, where possible, offer suggestions for 2 solutions. 3 I would like to also put a very personal spin 4 on the importance of rural communities and 5 hospitals. 6 Rural hospitals are central to the health and 7 well-being of our rural residents. 8 They are the economic engines of the 9 communities they serve, and so much more. 10 They are our neighbors and friends, and a 11 magnet for business and commerce. 12 How will we serve those who till the land and 13 grow our food if they are unable to get the quality 14 health care they need without traveling inordinate 15 distances to urban centers who don't understand and 16 appreciate what they do? 17 It is essential that we find solutions to 18 assure the continued viability of our rural 19 hospitals. 20 I have more to say, I hope, during the course 21 of this discussion. 22 There are some key points that I hope we'll 23 have an opportunity to speak about, one of which is, 24 the central role of prevention, not just curing; 25 Graduating more primary-care practitioners in 1 this new environment, instead of specialists; 2 Incentivizing collaborations and 3 partnerships; 4 And CON reform. 5 And I would like to also mention the 6 importance in what the rural health networks in 7 New York State do, as safety-net providers, and 8 expanders of services associated with hospitals, the 9 wonderful work that they do. 10 And, also, I would like to talk about, 11 perhaps, a reference, some interesting opportunity, 12 to look at a successful health-care initiative 13 that's occurred in Colorado, that focuses on 14 patient-centered care, that focuses on quality 15 improvement with cost reduction. 16 And, thank you for the opportunity to 17 introduce those ideas. 18 SENATOR YOUNG: Do you have background 19 information, Doctor, on the Colorado model? 20 DR. DON ROWE: Yes. 21 I don't have it with me. 22 It was broadcast on March 7, 2011. 23 Its focus was through Dartmouth College that 24 does the CMS data analysis. 25 And it focused on the specific buy-in between 1 the provider and the practice community, and 2 engaging multiple different practices in this 3 process. 4 The end result of this was a dramatic 5 increase in the quality of care, and an equally 6 dramatic drop in the cost of care. 7 I will be able to give you a link later on. 8 I don't have the link with me right now, but 9 you can still access it. 10 It's one hour, and it's extremely valuable 11 and informative as a potential model, or a tool, 12 that we can look at as we reshape New York State's 13 system. 14 SENATOR YOUNG: Thank you. 15 Do any other members have any questions so 16 far? 17 Does anyone want to -- 18 GAIL SPEEDY (teleconference): Senator Young? 19 SENATOR YOUNG: Yes, Gail? 20 GAIL SPEEDY (teleconference): I wanted to 21 respond, if I may, if it's appropriate, to your 22 original question. 23 SENATOR YOUNG: Sure, we'd like to hear from 24 you. 25 GAIL SPEEDY (teleconference): I think one 1 thing we've got to consider, when we look at rural 2 health care, are the social determinants of health, 3 particularly poverty, because when we look at 4 traveling, and I [unintelligible], because I live a 5 snowbelt, and so you can also have those issues of 6 trying to access care simply by trying to drive 7 through bad weather. 8 But a lot of the folks we serve, and I am the 9 primary-care provider of -- sort of, the largest 10 primary-care provider in Cattaraugus and 11 Allegany Counties, and what we often see, 12 particularly when we have to access specialty care 13 for high-risk OB patients or ill children, is the 14 barrier of care isn't so much a factor up to 15 Buffalo, but, it's that trip to Buffalo, and the 16 cost of gas, and the cost of the lunch, and time off 17 of work when someone doesn't really, actually, get 18 vacation time, so those are lost wages. 19 So when we look at issues related to access 20 and to rural health care, I think we really have to 21 understand poverty. 22 And I don't know how we would redefine or 23 make it -- make poverty sort of an element that we 24 predict on, as far as access, and ability to access, 25 a farther distance. 1 But I do think that that's an element we 2 should at least consider. 3 SENATOR YOUNG: Thank you, Gail. That's 4 really an excellent point, and I'm not sure we've 5 really thought about that in the past. 6 The other issue that emerges, at least in my 7 district, and I imagine that it's across the state, 8 is that we have specialty populations. 9 So, for example, we have Amish in my 10 district. And as you know, most of the Amish still 11 use horse and buggy, literally, to get around. And 12 they also, sometimes, don't seek health care when 13 they need it. 14 And, so, when they establish a trust 15 relationship with a hospital, then that really makes 16 a difference whether they get the care that they 17 need, or not. 18 And I don't know, Ann, if you could speak to 19 that, the experiences we've had; for example, in 20 Chautauqua County. 21 But -- but the fact is, is that, if there's 22 not some kind of fairly close access, then the 23 outcomes probably aren't very good. 24 ANN ABDELLA: I would say that's absolutely 25 true. 1 In fact, I might even defer to Jarrod, 2 because y'all have the Canawango clinic, complete 3 with its horse hitch out front. 4 JARROD JOHNSON, FACHE: I think it's a very 5 good point. I think the special population, the 6 Amish, are a big constituent of our health system, 7 and big, heavy users. 8 And -- you know, so when you asked the first 9 question about population, "Is it population? Is it 10 distance?" I think it's both. You know, I think, 11 especially for that population. 12 There's no way you can get to Buffalo or 13 Erie, you know, on a horse-drawn buggy. 14 So, you know, we provide that service. 15 And, so, you know, the definition is, I think 16 it's "both." 17 GARY FITZGERALD: They also don't -- most of 18 the ones that we have in our region don't believe in 19 or accept health insurance. 20 SENATOR YOUNG: Right. 21 GARY FITZGERALD: So there's no Medicaid, 22 there's no private insurance. 23 So, I'm sure the CEOs can explain. 24 I've been to hospitals where the bartering 25 system goes on between: We'll makes some furniture 1 for the hospital, we'll do some handrails for the 2 new unit, in exchange for health-care delivery. 3 And, so, try to figure that into your 4 bad-debt and charity-care calculation, and trying to 5 figure out reimbursement. 6 [Laughter.] 7 GARY FITZGERALD: It really is an important 8 piece, and it's a growing population in upstate, as 9 you know, Senator. 10 SENATOR YOUNG: Yes. 11 Thank you, Gary. 12 ART STREETER: Actually, Senator, I'm not 13 sure that any single definition is going to work. 14 We've always said, for instance, that primary 15 kinds of services, like, ED and OB, ought to be a 16 half hour, or something of that nature. But there 17 are a lot of other services that you can't support 18 in a rural area. Or, you can support it if you're 19 connected with a tertiary center that can have folks 20 come out and visit. 21 And the problem is volume. 22 We have a low population. We just don't have 23 the volume for some of the fancy stuff. 24 So you really need to think of all of those 25 things as you think about a definition. 1 SENATOR YOUNG: Yes? 2 CHANDLER RALPH: And I know this isn't a very 3 definitive answer, but a lot depends upon what the 4 community's expectations are. 5 I'll give you an example. 6 We have two emergency rooms ten miles apart, 7 between Lake Placid and Saranac Lake. 8 We lose a half a million dollars on the one 9 in Lake Placid. It has 4,000 visits. It 10 has .1 visits per hour between 9 p.m. and 7 a.m. 11 We are trying to close that emergency room. 12 That 10 miles might as well be 1,000 miles 13 for the members of that community. 14 So I think that's one of the struggles we 15 have out in the field, is it's not a definition 16 that's easily defined. 17 SENATOR YOUNG: Jim? 18 JIM CLANCY: I think that's an excellent 19 point, and I'm glad it was raised, because there is 20 community expectations. And we are now working in 21 this world, whether it's rural, whether it's urban, 22 of: What is the community need? And what are the 23 needs, and what are the services, that the community 24 is going to use? 25 Because, hospitals close, facilities close, 1 because people stop using them. 2 So we need to make sure, and that's really 3 the charge of the department here, and it is a 4 challenge that we have, to figure out: What is the 5 proper service model for that community that people 6 are going to utilize? 7 So I think that's an excellent point because, 8 anytime the word "closure" is mentioned of any 9 facility, it raises, obviously, the concern of the 10 community, but the concern of the folks that really 11 aren't using the facilities. 12 SENATOR YOUNG: Does the Department of Health 13 have any kind of formalized process that you go 14 through in evaluating these situations? 15 Or, how does that work? 16 Is it just case by case? 17 Or -- how are you approaching those issues? 18 JIM CLANCY: I would say, generally, we are 19 looking at it in a statewide viewpoint. 20 I don't know if anybody wants to jump in, but 21 can somebody talk about the rural? 22 If Caleb or Joan want to jump in, please 23 don't hesitate. Or Amy. 24 But, we -- they're -- we're not going -- it's 25 not crisis management. I mean, we're not trying to 1 get through one catastrophe to get to another 2 catastrophe to figure it out. 3 So, OHSM is working, the staff at OHSM, to 4 put a plan together, to figure out where -- what the 5 state looks like. What are the needs of the 6 communities? 7 And, unfortunately, we do have to also go 8 from crisis to crisis at the same time. 9 SENATOR YOUNG: But are you looking at all 10 those elements that were identified earlier, such 11 as, poverty, special population -- 12 JIM CLANCY: Absolutely. 13 SENATOR YOUNG: -- distance, uhm -- 14 What was the other one? 15 JIM CLANCY: Weather. 16 SENATOR YOUNG: -- weather, right. 17 JIM CLANCY: Wintertime, trying to get over 18 the mountain. 19 SENATOR YOUNG: Right. 20 JIM CLANCY: Yes, we're all very sensitive 21 and appreciative of the travel and the distances 22 that folks have to, you know, navigate to get to 23 their health care. 24 FRAN WEISBERG: If I could just say, I think, 25 uhm -- it's not just because we are a regional 1 planning organization, but I do think that, like all 2 politics is local, all health care is local. And I 3 think it really does cry out for a local and a 4 regional approach. 5 But I am glad that many you of said: What 6 are the services that the -- a population approach 7 to this; what does the population need and want? 8 From prevention, to coaches, to care 9 managers, to transportation; it's not just about the 10 hospital of the past, but what do the residents that 11 live in that community, in that region, to keep them 12 healthy, as healthy as they can be? 13 And that is a process that is -- takes all of 14 the stakeholders coming together. And I think some 15 areas in the state have been doing this. 16 I think rural health networks has been doing 17 a beautiful job. 18 I think, you know, some of the 19 health-planning organizations. 20 The prevention agenda is really looking to 21 get at that. 22 I think, to look, but to marry, what the 23 county health departments are doing, what the health 24 systems' folks, and I think the State Health 25 Department has been very -- has been very responsive 1 to looking at what the regions, how to build the 2 services of the future, and what makes the most 3 sense. 4 And when we did do our regional-planning 5 process, we had four hospitals within 18 miles of 6 each other. 7 You can either decide they're going to close 8 dramatically, or we can do it more planfully. 9 And I think you -- it's amazing how much 10 community leaders do want to do it right. 11 If you just set up something, they are smart 12 and good, and know there is some gain. 13 SENATOR YOUNG: Doctor? 14 DR. DON ROWE: Yeah, I would also like to say 15 that, health departments, in conjunction with 16 hospitals and community-based organizations, are 17 currently conducting community health assessments, 18 to get a sense of what the needs are of the specific 19 community in the very broadest of sense, using the 20 social determinants of health as the baseline. 21 And, in addition to conducting the 22 assessment, relatively new to this process is, not 23 just doing the assessment, but to develop a 24 community health-improvement plan, with hospitals, 25 CBOs, and health departments working together to 1 strategize, identify particular priorities, and then 2 take action based on those. 3 And that's relatively new, and it's extremely 4 valuable. 5 And regional planning does, of course, become 6 very much a part it. 7 In our region, P2 is an example of an 8 activity that is going on. 9 FRAN WEISBERG: And Syracuse has it, Albany, 10 and the North Country, and it came right out of the 11 last PHHPC CON redesign to move that. 12 SENATOR YOUNG: So it does seem to be working 13 right now? 14 FRAN WEISBERG: No. 15 DR. DON ROWE: Well, we don't know. 16 FRAN WEISBERG: Well, it hasn't started yet. 17 It was -- 18 DR. DON ROWE: What we don't know -- 19 FRAN WEISBERG: We're the only area of the 20 state that has very formal planning. 21 DR. DON ROWE: The community health 22 assessments, the community health-improvement plans, 23 are, technically, due November 15th of this year, 24 and so we'll have a sense. 25 Some are well along in the process, some a 1 little bit behind; but, nonetheless, they're due at 2 that period of time. 3 Once the plans are there, that initiates, of 4 course, the strategy interventions, and then we'll 5 get to see whether or not those, in fact, work. 6 But it's, realistically, the first time -- 7 I would say, close to the first time, that we have a 8 close coordination between prevention and the 9 acute-care side and community organizations. 10 And it really speaks well to the 11 Health Department and the State, in establishing a 12 structure that identifies those components. 13 SENATOR YOUNG: So that -- those are due in 14 November. 15 And then, as far as implementation, Jim, 16 what's the time frame for getting things in place? 17 JIM CLANCY: You know, I'm not sure. 18 I'll go back and check on the time frame for 19 that. 20 I think the initial -- the initial hurdle to 21 get over, was to get folks to start thinking -- all 22 of us, State included, to start thinking 23 differently, and, what the different challenges that 24 the different sections of the state had in front of 25 them. 1 I just want to also, though, just to kind of 2 be on the record with that: 3 So, PHHPC did an awful lot of work, and these 4 were kind of regional, the regional districts that 5 came out. 6 Also very clear, though, like, brick walls 7 aren't built up, and there's no -- there's no 8 commun- -- we encouraged communication to happen 9 everywhere at facilities, and whether that, you 10 know, regional line comes down a route number or a 11 county line, it doesn't mean there's not going to be 12 continued conversations too, though. 13 So I want to be very clear about that. 14 But, you know, we do need to think different. 15 We do need industry to think different. We 16 do need communities to think different. 17 And that's our challenge. 18 SENATOR YOUNG: Thank you. 19 We are joined -- I'm very pleased that we're 20 joined by Senator Betty Little, who represents the 21 North Country. 22 SENATOR LITTLE: Thank you. 23 I'm very sorry for being late. I had 24 something in my district first. 25 So, thank you. 1 SENATOR YOUNG: SO, glad you're here. 2 Yes, Senator Valesky? 3 SENATOR VALESKY: Thank you, Senator Young. 4 I just wanted to follow up on that point, and 5 share a situation that I'm sure is not unique to my 6 district. I'm sure all Legislators here have been 7 going through it. 8 And then, I guess, ask question of either the 9 Health Department or Dr. Rowe, or both. 10 I have a small rural hospital in 11 Madison County that, over the last year to 12 18 months, has taken it upon themself, as a result 13 of their fiscal condition, to seek out a partnership 14 with one of the three hospitals in Syracuse, and 15 enter into a corporate-governance structure that is 16 going to, for all intents and purposes, continue 17 services in a very rural part of Central New York. 18 And I'm kind of wondering -- and Gary and I 19 have spoken about this and worked on this for a 20 while. 21 I'm wondering, I guess the question for the 22 Health Department would be: To what degree is the 23 Health Department actually encouraging these 24 corporate relationships? Or, you're not? 25 Is there something that is an organic process 1 that is happening from the administration of rural 2 hospitals? 3 JIM CLANCY: I'm going to kind of answer that 4 question because, the word "corporate," I think, you 5 know, raises some red flags, because we have federal 6 antitrust issues that are hurdles, that are separate 7 and apart from the health-care delivery system, 8 which we certainly encourage. 9 I mean, that is, really, what I spent an 10 awful lot of time on. 11 Again, Senator Ritchie -- I just keep 12 pointing to Senator Ritchie -- understands this 13 firsthand because of the conversations that we have 14 had over the last few months, of: How do we -- how 15 do we make relationships happen? 16 And, I know we can't force relationships to 17 happen, but we can recommend collaborations. 18 And, again, it's about the services provided 19 to that community. 20 And, so, we are all in favor of having 21 these -- these, you know, facilities talk together. 22 What that structure looks like, though, 23 Senator, that's the problem. Right? 24 Those are the -- that's an issue that we have 25 to deal with, and that's kind of outside of just the 1 Department of Health, but, we continue to help 2 entities get together, and we will do so. 3 SENATOR RITCHIE: Can I make a comment? 4 SENATOR YOUNG: Yes. 5 SENATOR RITCHIE: Just to go along with that, 6 Jim, you know, we were fortunate, and, Gouverneur, 7 that you were willing to come up and take a look at 8 the situation, and talk to some of the area 9 hospitals about partnering. And I think the outcome 10 was very productive. 11 It was a very, you know, tense time for the 12 community and the employees, but I think, in the 13 end, it turned out, you know, really well. 14 Before my time, we had the issue in Fulton 15 where the hospital closed. 16 And I will say, even though Oswego Health has 17 put a lot of time and energy into trying to open an 18 urgent care, that community was so damaged because 19 of the way that thing -- the whole thing played out, 20 that for many, you know, they're never going to use 21 the facility because there's such hard feelings. 22 So, when you're talking about the community 23 playing a part of it, it really is important 24 because, once the issue has settled, whether there's 25 a hospital there or not, if the community is so 1 damaged, no one's going to go there anyway. 2 So, you know, once again, I can only, you 3 know, say again, how much I appreciated your team 4 being on the ground in a really tense situation; 5 coming up, spending the hours, listening to the 6 community. 7 You know, you talk about weather. 8 We have the worst weather up there. 9 We have an Amish community. 10 I actually got a call from a constituent 11 after the hospital was closed for a few days, saying 12 that, "I have to go to the ER. I don't have enough 13 money to put gas in my car to get my family member 14 over there." 15 You know, I have a really economically 16 challenged district in St. Lawrence County, and 17 every one of these factors come into play. 18 But, the community aspect, you know, if it's 19 not done the right way, is -- really can either make 20 it or break it. 21 SENATOR YOUNG: Yes, Mark? 22 MARK WEBSTER: You know, if I could comment 23 on that too, being in the same county, that's the -- 24 the Gouverneur Hospital, now, is part of Fort Drum 25 Planning Group, and we have a HEAL 21 grant that is 1 helping us do the planning. 2 At least, in our area, the hospital has been 3 fiercely independent, and the communities have, you 4 know, prided themselves in kind of going it alone. 5 And I think those days are gone now. 6 I think collaboration is an essential thing. 7 Hospitals that aren't considering 8 collaborating in some form or fashion, I tell my 9 board, I think the -- you know, boards need to ask 10 the CEO if they need a checkup from the neck up, 11 because it is doesn't make any sense to think that 12 we can, somehow, make it alone. 13 But, to say the Department of Health 14 encourages this, and to think that's adequate, is 15 really under-resourcing the situation. 16 There are opportunities out there. 17 So I know our planning is going to say we 18 need to come together. 19 But in the absence of resources to actually 20 do this, it's a plan that -- it's the equivalent of 21 building a boat in the basement: you get done, you 22 feel good about it, but it goes nowhere, and it 23 accomplishes nothing. 24 And, so, there are some issues out there. 25 In the absence of funding, things like, VAP, 1 funding enabling funding for true collaboration, the 2 State will continue to move from crisis to crisis, 3 and kind of a mini Brooklyn experience in the rural 4 areas, which everybody wants to avoid. Nobody wins 5 under this scenario. 6 But there are opportunities to do that. 7 And, so, you know, the money, actually, the 8 State can reduce the number of bailouts that they 9 get caught into in bad situations, by actually 10 looking at organizations that are serious about 11 collaboration and creating some enabling funding to 12 let the structures form. 13 The Department of Health is not going to 14 impede that, but in the absence of some funding, all 15 they can do is recommend. And that recommendation I 16 don't think allows them to go. 17 So, under-resourcing something is really a 18 prescription for failure. 19 SENATOR YOUNG: Thank you. 20 I think that's a great segue too, because, as 21 you pointed out, there are great opportunities out 22 there that we should be thinking out of the box, 23 regarding. 24 And one of the things that the 25 Rural Resources Commission has been working on over 1 the past couple of years has to do with telehealth 2 and telemedicine. 3 And, so, as you form those collaborations 4 with some of these larger, more urban hospitals, I 5 think that the technology is there to maximize those 6 collaborations, and provide new access to people in 7 rural areas. 8 And we've actually made some strides, working 9 with the Health Department and the Governor, 10 regarding telehealth and telemedicine. 11 And -- but I think that we need to build on 12 those policies that we've put in place. 13 So, there's been concerns expressed regarding 14 the transition of telehealth services into managed 15 care. 16 And I know that DOH, actually, has taken a 17 lead, and they have an internal workgroup that has 18 been looking at the current telehealth landscape. 19 And, so, I guess I'm curious about what the 20 workgroup's findings are so far. 21 And, what are some of the challenges that we 22 see with the rollout? 23 And, are there things that we can be working 24 on together? 25 And maybe some of the people around the table 1 can give some input regarding telehealth and 2 telemedicine also, because, I commend the 3 department. They've been working on this, and we'd 4 like to hear how things are going. 5 JOAN CLEARY MIRON: Thank you. 6 Yes, we have formed an executive workgroup to 7 look into telehealth issues. It was formed about 8 three months ago. 9 A report was written by Rae Ann Vitali, 10 looking at a number of issues. 11 We are subdividing it now into subcommittees 12 that are going to focus on reimbursement issues. 13 That appears to be the largest issue to 14 helping it to move forward throughout the state. 15 We're also looking at technology issues, 16 broadband, et cetera; is it available throughout the 17 state to enable this? 18 And, lastly, provider-patient issues. 19 So we have three subcommittees that are 20 forming, and we're doing this on an internal basis 21 currently. 22 And we hope to have some recommendations 23 early fall, so that if there any changes that -- to 24 be recommended, that would require the Legislature, 25 et cetera, we'll be prepared for the next session. 1 I do want to compliment HANYS and some of the 2 provider associations. 3 HANYS reached out to us in the last month, 4 and, almost simultaneously, they formed a workgroup. 5 And we are, together, working on a couple of 6 initiatives, with HANYS, and some other members that 7 they have recruited. 8 So, it's working well. 9 SENATOR YOUNG: Fred, did you want to address 10 what HANYS is doing? 11 FRED HEIGEL: Well, we've done several 12 things, one of which I'd like to thank the 13 Commission, and applaud the Commission, for its 14 efforts on the legislation with respect to 15 credentialing, and how much that was assisted our 16 members and the feedback I get. 17 As Joan indicates, clearly, reimbursement 18 parity is still an issue. 19 I know there's legislation with respect to 20 that as well, but different payers recognize 21 telemedicine. 22 Some pay, some don't. 23 The amounts vary all over the place, 24 particularly when it comes to specialty care. 25 I even learned last week, there's issue 1 across state borders. 2 A whole range of reimbursement-related issues 3 that have yet to be worked out. 4 And we do have a workgroup, and we are trying 5 to partner -- we are partnering with the 6 Department of Health, very positively, to work 7 forward. 8 What we've tried to do, at least initially, 9 is to showcase what our members have been able to 10 accomplish in New York State. 11 Because, the initial response we got was, 12 basically: Well, that's all well and good in 13 Colorado, but you can't do it in New York. So, how 14 me a model that works in New York. 15 And there are some, and we have been 16 demonstrating that. And, you know, we come up with 17 this glossary of approaches, everything, from 18 technology, to, you know, the physician component. 19 And so, you know, we've got to start. We 20 want to roll it out, we want to grow it. 21 We think it will help, with respect to, both, 22 access, particularly specialty access in rural 23 areas, as well as, to some degree, address the 24 physician shortage; utilizing physicians that are 25 already there. 1 And, you know, our relationship with the 2 department is very positive on that, and we hope it 3 grows, but, the issue of reimbursement is the main 4 issue right now. 5 SENATOR YOUNG: Right. 6 And I do -- it was brought up, but there is 7 the issue with broadband also, and access to 8 high-speed Internet, and the lack of broadband in 9 Upstate New York, in the rural areas. 10 And the Rural Resources Commission has been 11 working on that with the Governor's Office, of 12 broadband, and trying to come up with some 13 solutions. 14 And I do know that Senator Maziarz also is 15 working on some legislation. 16 But, that really is a need that must be 17 addressed, as we move forward, because it's just not 18 workable in some areas. 19 SENATOR LITTLE: Yeah, and just saying, the 20 North Country, I think we're pretty good right now 21 on the broadband, from the -- DANC has been helpful 22 by some of the grants. 23 So, the hospitals are set in that way. 24 And there is a lot of coordination and 25 collaboration right now between the CVPH and 1 Elizabethtown, with Fletcher Allen. 2 So, we're seeing an interstate, you know, 3 collaboration. 4 But I think, in general, a few years ago, in 5 my first three months into the Senate, was the 6 closure of Mary McClellan Hospital in Cambridge. 7 And, in all honesty, you know, 8 Glens Falls Hospital took over the health clinics, 9 enhanced them, put in a building. And, there isn't 10 a lot of medical care that can be given there. 11 And, really helping the community understand 12 what they could get from an urgent-care center. 13 And, you know, a lot of times, they don't 14 understand what is available through those centers. 15 So, that was very helpful. 16 But at least, in the last, I would say, 17 number of years, we've gone away from competition 18 into collaboration. And I think that's major for 19 these rural health clinics or hospitals, because you 20 really can't go it alone anymore. 21 And even Glens Falls Hospital, where, you 22 know, I'm from, is finally beginning to see that, 23 you know, they need to do more. And they -- and 24 some of the things they're trying to do, they don't 25 need to do there. There isn't enough volume, and 1 they need to work. 2 And I believe they're working with Albany Med 3 right now, which is a great sign in the 4 North Country. 5 But, thank you. 6 GARY FITZGERALD: Senator, can I -- Fred 7 opened the door on physician shortage. 8 I know it's on your list. And I don't -- 9 SENATOR YOUNG: Right, it's next on the list, 10 so if you want to go had to that, that's fine. 11 GARY FITZGERALD: All right, you don't mind 12 if I can jump there, because, you can have all the 13 great planning -- 14 Finger Lakes has done some great things in 15 that area. And, Watertown area, Fort Drum, great 16 plans. 17 -- but, if you don't have the physicians, or 18 even the mid-level practitioners -- the nurse 19 practitioners, or PAs -- it doesn't -- we're not 20 going to have health care in our rural areas. 21 And we are at a crisis point now in 22 Upstate New York. I think in all parts of upstate. 23 In our region, we measured it, our average 24 age is in the mid-50s, the doctors. 25 The only way we can get new doctors into our 1 communities is, the hospitals have to employ them, 2 which is really expensive. 3 And, quite frankly, I think our hospitals are 4 paying more to get a doctor to come into the 5 community than the doctor is generating in revenue. 6 So, that is a long-term, not a very good, 7 formula for survival, because you need those doctors 8 so badly, and they only come if you, sign-on 9 bonuses; you know, loan forgiveness if the hospital 10 has that as part of it. 11 So, it's really become an issue for our rural 12 hospitals. 13 GME is a huge taxpayer-funded initiative, 14 both at the federal and state level. 15 We have some of the best teaching hospitals 16 in the world right here in New York State, in 17 upstate and downstate. 18 But the statistic that blows me away, is that 19 only 4 percent of the doctors that are trained in 20 New York State end up in a rural setting. 21 4 percent of the total. 22 That's got to change. 23 We're spending all the money in GME. We 24 should get more doctors into shortage areas, whether 25 it be urban or rural. 1 And there's got to be ways that we can have 2 some legislation or regulations that move more 3 people into the rural areas from our great teaching 4 institutions. 5 And we're working with Albany Med and SUNY in 6 my region, and they're actually working with us very 7 well. 8 But, we just had an experience last week, 9 where we brought up five residents, two-year 10 residents, from Westchester County, and toured them 11 around our -- five of our hospitals; Cooperstown, 12 Oneonta, and Utica. 13 They had never been north of 14 Westchester County. None of them. 15 They were amazed at what we're doing in 16 Cooperstown and Basset with its satellite hospitals 17 and its clinics. 18 They just were blown away by what we're doing 19 in the rural areas, and the care that's being given 20 and the attention to the patients. 21 But, they never would have seen that. 22 They're not going to get that on a website, 23 or, quite frankly, a headhunter or a 24 physician-recruiter who's calling them up. 25 So we've got to come up with more interesting 1 ways to get the physicians that are being trained 2 downstate, quite frankly, to understand their 3 opportunities in Upstate New York, or we're going to 4 have great plans and have no doctors. 5 Obamacare is coming. More people will be 6 insured if things work the way they should, and 7 there will be a shortage of primary care and 8 specialists, quite frankly. 9 SENATOR YOUNG: Right. 10 Yes, Doctor? 11 DR. DON ROWE: I'm glad you mentioned the 12 primary-care-physician issue. 13 One of the things that we do know, from a 14 population perspective, is that the health of a 15 population, to a large extent, can be influenced by 16 the different distributions of the kinds of 17 practices that are operating within those 18 communities. 19 What we do know, is that there is a positive 20 correlation with the number and distribution of 21 primary-care physicians in the community. And if 22 they are appropriately placed, the health of the 23 community can be demonstrated to rise. 24 This is not, in any way, to criticize 25 specialties, but from a population perspective, to 1 move the health of a population, it is that 2 primary-care physician that you really need. 3 And now look, then, at the reimbursement 4 structure that we have. 5 Who are the least-compensated physicians in 6 New York State, and, frankly, across the country? 7 Is it the neurosurgeon, with no disrespect to 8 them, or is it the primary-care physician? 9 It's the primary-care physician who works 10 inordinate numbers of hours in order to provide the 11 services to the community. 12 And this is not just me. 13 This is data from the Center for Disease 14 Control and Prevention. 15 SENATOR YOUNG: Thank you. 16 You know, I know personally, in my district, 17 we have primary-care physicians, and they have 18 caseloads of five to ten thousand people. And it's 19 almost impossible to take care of that many people 20 effectively. 21 I know that we've been strong supporters of 22 the Doctors Across New York program, and it's a good 23 program. I believe, though, however, it's probably 24 underfunded, and it needs more funding to be more 25 effective. 1 But, Gary, you said we need more ideas, and 2 I was wondering what your input would be: 3 What can the State do to address the primary 4 care, and just the physician shortage in general? 5 GARY FITZGERALD: Well, Doctors Across 6 New York, obviously, it was a good step. 7 It needed to be funded in this budget, and I 8 think we're working off of the old funds right now, 9 so we need to go forward next year. 10 We worked with Caleb and his staff to make 11 that program easier to live with, if you will. And 12 the DOH has made a lot of changes, so it does work 13 better now than the first time. 14 But there needs to be, I think, even more 15 creative thinking. 16 With our medical schools, hospitals -- 17 teaching hospitals, we need to allow more 18 communication between those hospitals and the 19 community hospitals, the rural hospitals. 20 We're doing some things on our website which 21 says: Here's all the vacancies that we have in 22 rural areas across our region. 23 And we're pushing that out to the medical 24 schools downstate. 25 And it's very hard to, quite frankly, 1 penetrate the residency directors in some of these 2 large hospitals. They have certain places they want 3 to put certain of the residents downstate in some of 4 their hospitals. 5 The residents don't even know what's 6 happening up here. 7 So, I hate the word "mandate," but, if there 8 could be some way that we could open the doors or 9 open the windows to let all these residents that 10 were -- by the way, 50 percent of the ones we train 11 in New York go out of state after they're trained. 12 If we could just grab a small portion of 13 that, and say: There are opportunities upstate, 14 where the cost of living is pretty good. You know, 15 the community, you can make a big difference in the 16 community. 17 So we could come up with some suggestions for 18 you on how we can link the need to the supply that's 19 being generated in our teaching hospitals. 20 SENATOR YOUNG: Okay, thanks. 21 Fred, did you -- 22 GAIL SPEEDY (teleconference): This is -- 23 Senator Young, can I jump in? 24 SENATOR YOUNG: Sure, Gail, go ahead, and 25 then we'll go to Fred. 1 GAIL SPEEDY (teleconference): This is 2 Gail Speedy. 3 We actually have a rural residency-training 4 program, so we have what's called a "one-two rural 5 residency track" program," and it is in family 6 medicine. 7 It's a unique collaboration between 8 SUNY Buffalo, Olean General Hospital, and, 9 ourselves, Universal Primary Care, as the outpatient 10 teaching. And we actually boast a success rate of, 11 75 percent of our residents stay in rural family 12 medicine, which I think is really unique, and it's 13 wonderful. 14 It is extremely hard. 15 I would not say that this is always 16 replicable to do a rural residency-track program. 17 What I would say is, that I really see this 18 disconnect with folks, even being trained in 19 Buffalo, when they come down to a rural area. 20 They don't understand rural medicine, and we 21 actually have to teach it as a subspecialty. 22 There's a couple of other things I've 23 noticed, is, we are losing, now, our rural 24 family-medicine physicians. 25 These folks that we have trained, three of my 1 graduates in the last two years, and we only 2 graduate three a year, have gone into hospitalist 3 programs. 4 And I think that's wonderful for the 5 hospitalist program, but now we're losing 6 primary-care docs to hospitalist programs. 7 So I do think that, as a state, as we work 8 with medical schools, one thing -- I don't 9 necessarily know if we can teach patient-centered 10 primary-care and inpatient medicine in the same 11 training program any longer. 12 I'm thinking that, potentially, we need to 13 see a -- sort of a manifestation of a hospitalist 14 residency-program-type training, and get family 15 medicine and primary-care medicine back to an 16 outpatient setting. 17 And I know that sounds scary to the hospital 18 folks, and what's happening with hospitals, but I do 19 think that that would give you well-trained folks, 20 folks who are really interested in it. 21 And that's where opportunities are. 22 [Unintelligible] help to draft some of those 23 downstate stats into an upstate area. 24 The other thing that I would also say is, as 25 an actual provider or an employer of primary-care 1 physicians, it does create a dichotomy as well, 2 because our hospitals are able to pay significantly 3 more for primary-care physicians, where we can't; 4 and, therefore, we almost enter into a competition 5 with our hospitals to hire primary-care 6 practitioners, and it creates an escalating salary 7 range. 8 And I wonder if there's a way to address that 9 effectively so that we both don't get caught up. 10 And I have a wonderful hospital in my 11 community, and we work great with them, but it does 12 seem to escalate salary range. 13 And I think that that's something we have to 14 address, either as communities, or, maybe -- and I'm 15 not sure that there's a policy answer to that, but I 16 do think that's another, sort of -- sort of 17 outgrowth of hospitals directly employing 18 physicians. 19 SENATOR YOUNG: Thank you, Gail. 20 CALEB WISTAR: [Unintelligible] a little bit, 21 just some background of those great ideas. 22 And I think some of the issues related to 23 salary differentials are certainly true, and that's 24 where I think incentives do definitely come into 25 play, and I think they're really important. 1 Doctors Across New York reported about 2 9 million in practice reports [unintelligible], and 3 about 8 million in loaner payment. 4 Across the state, I'm happy to say that 5 53 percent of those have gone to rural areas. 6 And about, again, 50 percent of the total 7 works to date have been to primary-care physicians 8 looking to serve in underserved areas. 9 And the Cycle 3 that's rolling out, that Fred 10 and Gary talked about, working together with us, to 11 streamline the application, actually, you know, 12 changing the law to allow that, has allowed us to 13 have another $8 1/2 million [unintelligible] out 14 there for the, loaner-payment, practice-report, 15 segment. 16 We definitely need to continue that. 17 The other program that you probably heard 18 about is the Primary-Care Service Corps, which is a 19 $500,000 State match, with a million -- with another 20 half a million dollars in federal funding, for the 21 non-physician clinicians, for those folks. And 22 that's all primary care. 23 That's going to be limited to the 24 health-professional shortage areas that are, you 25 know, in primary care, mental health, and oral 1 health as well, and that includes dentists, and the 2 behavioral-health clinicians as well. 3 So, in that vein, what we've also done, 4 you've probably also heard about the MRT 5 Medicaid Reform 1115 waiver. 6 We have put in -- it's been a while now, but 7 we've put in another half of a billion dollars, over 8 a five-year period, to expand training capabilities, 9 and expand these kinds of programs, in New York, to 10 get those -- you know, get more money out in the 11 field. 12 So, you know, we're working on all of those 13 areas, you know, together. 14 And, so, the other thing is, that we have 15 another 500 clinicians, of different stripes, in 16 HPPSAs, in National Health Service Corps, is 17 something that we've worked on. And, you know, 18 probably about 190 or so of those currently serving 19 on an under-obligated, you know, status are in rural 20 areas. 21 So, I mean, these are all areas that we 22 definitely need to go further, and -- but we have a 23 serious backlog of folks that are in the Cycle 3, 24 that we may not have enough funds to accommodate 25 everybody. 1 So, there is a lot of interest in it. It 2 seems to be a very popular program. It is more 3 streamlined. 4 Gary's point, I think, that what we might 5 want to do -- we did talk about this a little bit -- 6 was have folks who were either native New Yorkers, 7 or better still, those folks who are in rural areas, 8 born and raised, and there's a lot of evidence that 9 suggests that folks who are born and raised in rural 10 areas will, in fact, come and stay longer, and 11 practice, and have a better, what we call, 12 "recruitention" [ph.] record. 13 SENATOR YOUNG: Thank you. 14 And I believe this is how we're going to do 15 this. 16 Senator Little has a question regarding what 17 was just said. 18 Jim Clancy wants to piggyback, I believe, on 19 that? 20 JIM CLANCY: No, I was, actually, just going 21 to introduce Caleb, but I didn't -- 22 SENATOR YOUNG: Okay. 23 JIM CLANCY: -- to make sure that Caleb -- 24 and just mention that this was, obviously, very 25 important. 1 This became a subcommittee of the MRT, and 2 that Caleb and staff had been working on. 3 So, and then Caleb went. 4 SENATOR YOUNG: Okay. 5 And I can tell Donald Rowe has a point 6 related to this. 7 And then I want to go to Fred Heigel, because 8 I know HANYS has been working on this issue, and 9 then we'll go from there. 10 And then I know Chandler has a point that she 11 would like to make. 12 So, Senator Little, why don't you ask your 13 question. 14 SENATOR LITTLE: Well, I was just going to 15 ask: On the Doctors Across New York, and, you know, 16 definitely needing more funding, because that is a 17 program that has worked in my area very well, but 18 someone approached me one time, and thought that we 19 should be doing a similar program for physicians 20 assistants. And, they wouldn't replace doctors, 21 but, certainly, they are hard to attract in a rural 22 area as well. 23 And I don't know what your thoughts are on 24 that. 25 GARY FITZGERALD: No matter how many doctors 1 we try to recruit, we're never going to have enough. 2 SENATOR LITTLE: Well, that's good news to 3 me, because I have a son who is hoping to get into 4 medical school -- 5 [Laughter.] 6 SENATOR LITTLE: -- at -- I have to tell you 7 this, at age 42. 8 [Many members say "Wow."] 9 SENATOR LITTLE: He quit his job. 10 GARY FITZGERALD: We'll get him a job, 11 Senator. 12 SENATOR LITTLE: Good. 13 GARY FITZGERALD: But the point is, we need 14 those PAs and nurse practitioners. 15 We need -- in rural areas, they are going to 16 be doing more and more, whether physicians like it 17 or not. 18 The numbers just aren't there to support the 19 number of doctors we would need. 20 SENATOR LITTLE: So that would be a good 21 program if we could -- 22 GARY FITZGERALD: If we had money to -- 23 SENATOR LITTLE: -- begin something like 24 that. 25 GARY FITZGERALD: -- for a similar program. 1 STEVEN KELLEY: Yeah, the term "doctor" 2 doesn't mean "physician" anymore. 3 Nurse practitioners are doctors. Pharmacists 4 are doctors. Physical therapists are doctors. 5 There are many emerging staff types. 6 And -- but I think that the term "doctor" is 7 even sort of changing. 8 It used to mean strictly "physicians," and it 9 doesn't anymore. 10 I think that we're going to need to look at a 11 couple of things. 12 We -- there's a huge economic imparity, or 13 lack of parity, between primary-care providers of 14 all stripes, and their specialists. 15 It's not an accident that 85 percent of our 16 physicians go into subspecialty, because if they do 17 a residency in medicine, and they can make 18 100-and-change a year for the rest of their lives, 19 or, they do a two-year fellowship in cardiology, and 20 they can double or triple that for the rest of their 21 life, physicians are very smart people. That's how 22 they get there. 23 We have really negative incentives for 24 primary care, from real financial incentives. 25 So I think that that is somewhat 1 market-driven. 2 And I think that's something that the 3 Department of Health, and you as policymakers, need 4 to look at, and look for types of long-term 5 incentives -- not short-term incentives, but 6 long-term incentives -- that may be through your 7 Medicaid program, to enhance the reimbursement for 8 primary care, and have that be much more on a par. 9 I mean, I think most people would think that, 10 if you go to a subspecialist, that you would pay 11 more for that, but, 20 percent more? 12 I mean, in the overall amount of education, 13 it isn't that much greater. 14 You know, four years of undergrad, four years 15 of medical school, three years of your initial 16 residency, and then a fellowship of a couple of 17 years, I mean, you look at that in proportion, it 18 might be a 20 percent differential, not a 19 250 percent differential. 20 And I think that's something that really 21 needs to be looked at. 22 So, I think we're going to see an emergence 23 of many different providers [unintelligible] in 24 different roles. 25 The role of the pharmacist, I think, is going 1 to change. We're not going to see pharmacists as 2 folks that are in the dispensing role. They're 3 going to be in a clinical role. 4 We'll have our health-care providers, the 5 physicians and the nurse practitioners and the 6 PAs, are going to be focusing on diagnosis. 7 I think we'll have the pharmacists, who look 8 at all of the medications that a particular patient 9 takes, being -- have much more of a role, and be 10 paid for that consultation, in determining what the 11 pharmaceutical intervention that will be best, so 12 that they won't be canceling each other out for 13 efficacy, or, poisoning the patient accidentally 14 because each provider is focusing on their own 15 particular issue. 16 And, so, I'm just using those as examples. 17 I can tell you, in our hospital, we are 18 growing our own. 19 We worked out a primary-care residency, and I 20 am very big on education. 21 We train nurse practitioners also. 22 So, physician, primary care, family 23 physicians, nurse practitioners. 24 We train physical therapists, which are 25 doctors. 1 We train pharmacists, who are doctors. 2 We train rad techs. 3 We train nurses. 4 We really focus very much on growing our own, 5 because, in a rural area, people stay where they 6 train. 7 That's just part of why we don't have any 8 providers in rural areas, because they didn't train 9 with us. 10 If they train there, they're more likely to 11 stay. 12 So I think having training programs, and they 13 don't have to be subspecialty programs, because 14 those are more appropriate in a tertiary medical 15 center. 16 There needs to be incentives to help us, as 17 providers of -- in rural areas, to be able to fund 18 that. 19 I do all this with no funding. 20 This is just something that we've been able 21 to put together, and -- because we think it's the 22 only way -- well, not the only way, but we think 23 it's the cornstone to our recruitment process and 24 our retention process. 25 I think my staff practice at the top of their 1 licenses when they have students and residents who 2 they're training. 3 So, thanks. 4 SENATOR YOUNG: So you're doing this, Steve, 5 without any funding, but you feel that if there were 6 funding available, that that would help you build on 7 that success? 8 STEVEN KELLEY: Well, as soon as you say 9 you're doing it without funding, then everybody gets 10 interested. 11 [Laughter.] 12 STEVEN KELLEY: I think we have to do it. We 13 don't think we have any choice. 14 I think having funding would certainly 15 encourage it and make it possible. 16 We've been in a position, where we have a 17 very close relationship with our main-provider 18 organization for family health, which is a large 19 federally qualified health-care center, that has 20 multiple residency programs that worked with us to 21 do this. 22 In fact, our -- we're two years into it. We 23 have four residents. We're about to get two more. 24 And one of the two who are entering their 25 third year is going to be staying with us. 1 And, we raised money in the community, 2 through a program, to help fund that. 3 We're going to have -- the community is 4 raising enough money -- or, actually, you know, we, 5 through the community, raised enough money for a 6 down payment for this physician's home. 7 That's, you know, kind of an interesting 8 thing to be able to do, and helps to provide an 9 incentive for her to stay. 10 SENATOR YOUNG: Thank you. 11 Dr. Rowe? 12 DR. DON ROWE: Yeah, I would just like to 13 call attention to one of the programs that exists in 14 New York State that does work on that, and that's 15 the area health education centers, known as "AHECs." 16 They have a workforce-development program, 17 and they provide an opportunity for physician and 18 other primary-care-practice individuals to spend 19 time in rural communities -- MASH camps, experiences 20 with physicians in ERs, et cetera -- with some 21 success. 22 But let me also then jump -- 23 SENATOR YOUNG: By the way, I go to MASH camp 24 every year, so -- 25 STEVEN KELLEY: Okay. Well, that's great. 1 And so -- and there are two rural AHECs. 2 I happen to sit on the board of one of those. 3 And so I think they're very, very effective, 4 especially if you find a way to integrate with them, 5 your needs, with what it is that they are able to 6 do. And, I think that's a piece. 7 With respect to the long-term issue, often we 8 start a recruitment for health-care professions when 9 the student is already in high school. 10 I would suggest to you that the data 11 indicates that that's way too late, and that we need 12 to be looking at the integration of health 13 components in our primary grades, and encouraging 14 students, through their experience with math, doing 15 a health-related thing; with social studies doing 16 another health-related activity; so that that is on 17 their mind as they proceed and progress through 18 their education. 19 If we do that, and we do it locally, we're in 20 a greater probability of having a pipeline for those 21 very practitioners that we need. 22 SENATOR YOUNG: I think you're absolutely 23 right, Dr. Rowe. 24 One of the things that I've noticed, and it's 25 not a criticism of our education system, but, there 1 is a disconnect between what the labor-market needs 2 are locally and what we're focusing on during 3 students' school years. 4 And, so, I see it across the board, from a 5 lack of manufacturing technicians, to welders, and 6 so on. 7 But in the health-care field, it especially 8 is a glaring deficiency that we have, in that, we're 9 not getting these kids on track to even have an 10 awareness about a health-care career that's 11 available to them. 12 And if there's a way that we can integrate 13 those local labor needs with the curriculum, I think 14 that we would be much further ahead. 15 So maybe we need, as the Commission and the 16 Health Committee and the Department of Health, to 17 work together -- and the Assembly, to work together, 18 to come up with policies that encourage, in addition 19 to AHEC and the MASH camp. 20 If you don't know what that is, and I think 21 probably most people do, but it's a way to give 22 students exposure to health-related careers. 23 And, so, they come into -- for example, 24 Jones Memorial Hospital in Wellsville, and they come 25 in and they spend the day, and they go to the 1 OB unit, and they go to take part in other 2 activities that educate them about the different 3 careers that are available. 4 And I think it's a great effort, but I think 5 we need to really build on that effort. And there 6 may be ways that we can do that, by working 7 together. And also getting State Education involved 8 in this, somehow. 9 So, I think that's an excellent point. 10 Fred, you've been waiting patiently. 11 FRED HEIGEL: Thank you, Senator. 12 SENATOR YOUNG: And I wanted to get to what 13 HANYS is doing -- 14 FRED HEIGEL: Thank you. 15 SENATOR YOUNG: -- because I know that you 16 have some initiatives that you're working on. 17 FRED HEIGEL: Yes, thank you. 18 And, clearly, HANYS is very supportive of 19 Doctors Across New York. 20 We appreciate the efforts, working together 21 with Gary and Caleb, and the folks at the 22 Department of Health, to streamline the process and 23 make it work. 24 And I guess I would have to agree with your 25 earlier comment that, it's working so well; it's 1 underfunded now. And I think a little money goes a 2 long ways in that area, and can really help. 3 I'll put in a plug for that. 4 And there's been discussion earlier in 5 today's discourse about hospitals hiring physicians. 6 And when we talk about Doctors Across 7 New York is attracting new physicians, but hospitals 8 also hire physicians, retain physicians, within 9 their community. 10 They need to do that, just like they need to 11 attract new physicians. 12 But -- but that's when we run into 13 impediments through CON. And those are very 14 challenging, from the standpoint of, how long it 15 takes to get approved, and then the physical plant 16 requirements, if I can use that term, to comply with 17 Article 28 standards, costing hundreds of thousands 18 of dollars to refurbish a physician's office to, 19 essentially, treat the same type of patients, 20 perhaps increased access to Medicaid patients. 21 And, you know, some of the CEOs here, I'm 22 sure, can talk from experience better than I can. 23 You know, I hear from them about, you know, 24 the challenges in doing that, but that sort of flies 25 in the face of expanding primary care to meet the 1 needs communities. 2 And that's something we have addressed at 3 PHHPC. You know, we have had discussions with the 4 Department of Health. 5 But, still needs some work in that area. 6 SENATOR YOUNG: Thank you. 7 Ann? 8 ANN ABDELLA: I just want to circle back on 9 the concept around growing your own, and kind of 10 hitchhike on what Mr. Kelley was talking about. 11 We've been doing some work, trying to pipe 12 kids, locally grown, into specifically looking at 13 physician careers. 14 We -- I applaud the fact that you're doing 15 all the pharmacy and the PT, because there's a lot 16 to learn from that. 17 But we've gone out and gotten a list, by hook 18 or by crook, of about 50 to 60 kids that were raised 19 in our county, that are currently in various stages 20 of medical school, and we started to court them. 21 We have worked with them, and giving them -- 22 with the local foundations, trying to figure out 23 shadowing internships in college. 24 We have a program that we've now got a tiny 25 endowment, where we pay a stipend for M1, M2, 1 students to come back. 2 The qualification is, you have to have grown 3 up in Chautauqua County and graduated from a 4 high school there, and give some glimmer of an idea 5 that you want to come back. 6 But I think there is something here for the 7 rural community to think about, as far as, some kind 8 of an internship, or apprenticeship, program that 9 could be grown. 10 Doctors Across New York is a fabulous thing. 11 I think Jarrod might hit me. 12 The J1 program is -- you know, it's a finger 13 in the dike, and it's not a solution. It's a patch, 14 at best, and we cycle people through there. 15 We need folks who know what life is like in 16 the rural community. 17 And we've been surprised by the number of 18 kids who want to come back, but they had no idea 19 that their community needed them or wanted them, or, 20 to our friend's here point, you know, the exciting 21 things that are going on behind the walls of those 22 hospitals that they grew up in. 23 So, you know, do a better job of selling 24 ourselves, but, they tell us, "I would come back, 25 but I have $200,000 worth of medical loans that I 1 have to pay back, and I'll never earn that." 2 So if there's a way that we could help pay 3 for their tuition as they go through, kind of like 4 our own National Health Service Corps, as we're 5 moving them through. 6 But, manufacturing is taking that approach of 7 apprenticeship programs to train their engineers. 8 Why can't we do that in the rural areas for 9 our physicians? 10 GARY FITZGERALD: Senator, I have one 11 comment, because the Governor's Office is here, I 12 need to get this in: Regional economic development 13 councils. 14 The Governor has done great things with 15 upstate economic development using those regional 16 councils. 17 I think the health community has really not 18 been doing a good job in getting in front of those 19 councils and developing proposals, like, a mini 20 Doctors Across New York for a region, or, loan 21 forgiveness, or, something. 22 If you don't have health care and doctors, 23 you can't develop your economy in any of these 24 upstate communities. 25 That's one of the first things that they look 1 at when they try to move into a community. 2 So, we met with the Lieutenant Governor's 3 Office a few months ago, and just threw this out: 4 Are we crazy? Could we put a proposal 5 together? 6 Do you consider developing physicians, or 7 health-care practitioners, if you will, an 8 economic-development issue? 9 And we got a little bit of a lukewarm, said, 10 "Yeah, yeah, it's out of the box, but maybe we could 11 configure that." 12 But I think it's really -- it is one. 13 And I think, if there's money coming out of 14 those regional councils, and there is, I think the 15 health-care community needs to step up and get 16 before those local councils and try to make a pitch. 17 Maybe you've done that out -- 18 ANN ABDELLA: Well, it's interesting, the 19 STEM initiative that's going whole hog with regional 20 economic development and manufacturing, just 21 recently, in our area, decided: Well, I guess 22 health-care should have a seat at the table. Maybe 23 it has an interest. 24 SENATOR YOUNG: And I think that's an 25 excellent point, that it's a very important part of 1 the community. 2 In fact, rural hospitals sometimes are the 3 largest employers that we have in rural areas. 4 UNKNOWN FEMALE SPEAKER: Absolutely. 5 SENATOR YOUNG: But one of the things that 6 I would like to point out, is that, I think that the 7 Legislature would be very interested in being 8 involved in those solutions too. 9 So, during the budget process, or, you know, 10 this time, before we even start up session -- we 11 haven't closed the session yet -- but, I think that, 12 as we prepare for this coming year, if there are 13 policies and initiatives that you think we should 14 look at as a State Legislature, I would encourage 15 and welcome your input, and I know all of my 16 colleagues would too, in some kind of -- because we 17 have done -- for example, we did a demonstration 18 project in telehealth in Chautauqua County. Very 19 successful. 20 We have taken on those challenges. 21 And, so, if there's a way that we can work 22 together, and get the Legislature involved in that 23 too, we would be very happy to look at any 24 initiatives that you have. 25 Yes, Chandler? 1 CHANDLER RALPH: I think one of the most 2 important things we can do, is try and get some 3 flexibility. 4 The health care is changing at an exponential 5 rate. 6 I mean, I think most of the states are behind 7 the wave that we're seeing. 8 It's being driven by financial incentives. 9 And I'm not sure that's the best public policy, or 10 we get the best result, when it's driven that way. 11 But I'll give you an example. 12 We're part of the Adirondack Medical Home 13 pilot project. 14 And, six years ago, we lost a third of our 15 medical staff. They moved, retired, et cetera. 16 So, we got together with John Rugge from 17 Hudson Headwaters, and Stephens Mundy from CVPH, and 18 worked with the Health Department. 19 And it would not have happened if the Health 20 Department had not taken a leadership role in 21 helping us put a multi-payer medical-home project in 22 place. 23 I'll tell you, the results we're getting are 24 phenomenal, as far as patient satisfaction and 25 quality. 1 Our physicians, who are generally pretty 2 grumpy, are a little bit happier than they have 3 been. 4 One of our private practices told me they 5 never could have recruited their new young physician 6 without the medical-home project. 7 The bad news is: Our ER visits have gone 8 down 18 percent. Our inpatient census has gone down 9 25 percent. 10 But, that -- 11 UNKNOWN SPEAKER: It's a success. 12 CHANDLER RALPH: -- I mean, it is success. 13 It's great for the patient. 14 The doctor is a head of a team, using their 15 critical-thinking skills. 16 They're using all those partners -- the 17 pharmacists, the nurse practitioners, the case 18 managers -- to really do great job with our 19 patients. 20 It was absolutely the right thing to do. 21 But, if we box ourselves in, and we can't get 22 some creative and flexible models that we should be 23 trying right now for our physicians, I think that 24 really will hold us back. 25 So, we really thank the Health Department for 1 having fostered this, and take the lead, in bringing 2 all the payers to the table, which we never thought 3 could be done. 4 And now we're a Medicare demonstration 5 project as well. 6 That is the best thing for the patients. 7 And that's really, I think, what we need, is 8 some flexibility and some new models to try out, 9 because, physicians, I don't care how much money you 10 give them, if they're not happy in the way they're 11 practicing with their patients, they won't stay. 12 SENATOR YOUNG: Fran? 13 FRAN WEISBERG: I couldn't agree with you 14 more, and I think that is happening around the 15 state. 16 And, we received a CMMI grant. 17 What you guys are doing in the medical-home 18 pilot, we don't need to actually go to Denver. 19 Around New York State, there are very 20 flexible models, and that's, a lot of the money that 21 is coming from CMMI. 22 And, again, the State Health Department is 23 trying to go after some of those dollars. 24 We got one of those. 25 And I think what the State is also trying to 1 do, though, is learn from each of these grants, what 2 are the best practices, hand them, so that we don't 3 need to replicate. 4 But the shared savings is a very big part of 5 all of it. 6 And the primary care, one of the major themes 7 in all of this is, transformation with primary care 8 is critical. 9 It will have a huge effect on hospitals. 10 But, I just want to say one other thing about 11 the economic development councils, and this can go 12 back to, not the Health Department, but somebody a 13 lot -- the Legislature and the Governor's Office. 14 We did have a health committee. 15 We have a very strong health committee 16 that -- of our economic development council, chaired 17 by Danny Wegman [ph.], and the head of the 18 university. 19 We kept giving ideas, and they kept saying: 20 No, no, no, we can't do health care because there's 21 no health-care dollars in it. 22 So we could just -- one, I love the concept 23 of the economic development councils because it's 24 regional. 25 Okay, you getting that? 1 And then, that -- if we could get that model, 2 and then have somebody change the policy, it would 3 be terrific. 4 I think that's just -- 5 SENATOR YOUNG: But, again, Fran, you know, 6 you should come to your local legislators about it 7 also, and work with them. 8 FRAN WEISBERG: That's a great idea. 9 SENATOR YOUNG: So, I would recommend that. 10 And the reason we, as legislators, have 11 staff, is that they can take the time and follow up 12 on these things. 13 So I know that the Commission staff, for 14 example, they're here today, but they would love to 15 have you, as resources, be able to reach out and get 16 your ideas. 17 Because, today is a great discussion, but, 18 also, as you know, there's always a lot -- there are 19 always a lot of details that go along with some of 20 the successful initiatives that we've seen around 21 the state. 22 And, so, we'd like to have some more of the 23 details from you, and more of your ideas. 24 So today is not, you know, just a one-time 25 event. It's the opening of a conversation, that I 1 hope will continue, and it's something that we can 2 build upon as we move forward. 3 Quickly, I wanted to ask about 4 health-information technology, and, as you know, 5 there are initiatives underway to transition to 6 electronic health records. 7 And, so, I was wondering how that's going. 8 Although there's some federal money, I think, 9 that's available, but I was wondering how that's 10 going for folks. 11 And, what is the projected cost to the 12 facilities that we see? 13 And, I'm sorry. 14 Assemblyman Palmesano, before we do that, did 15 you have something -- 16 ASSEMBLYMAN PALMESANO: Yes, if I could 17 just -- first of all, I appreciate this discussion. 18 I think it's very valuable. 19 I just kind of wanted to play on a couple of 20 things, some that's been repeated already, but, 21 mainly, to reinforce, but then just to, I think, get 22 to a point that might come a little later too. 23 But, just regarding the physician training, I 24 think, you know, you did mention about the AHECs and 25 the MASH camps. 1 I mean, the key is to pique their interest 2 early. 3 So the more we can do to pique their interest 4 early. When they're in high school, they're not 5 really thinking about, necessarily, the student 6 loans. We want them to be interested in the 7 profession. 8 So, the more we can expose them to the 9 profession and the need for health-care workers, I 10 think that's a good thing. 11 The challenge comes, like I believe you 12 mentioned, or a lot of us have mentioned, when you 13 get out of graduate school or medical school, you 14 have to face hundreds of thousands of dollars in 15 debt. And if your choice is to go into a specialty 16 area or you go into preventative care, you know, 17 that salary makes a big -- weighs a big difference. 18 So, we have to find a way to address that 19 issue, whether it's through loan forgiveness, or 20 incentives to go into a rural area, or into primary 21 care, because, I mean, quite frankly, that's where 22 the -- that's where health care is going. 23 I'm not a health-care expert, but you can see 24 it. Even in the areas -- because we talked about it 25 earlier. I mean, there's a lot of collaboration 1 going on. 2 Some of the smaller rural-based community 3 hospitals are affiliating with bigger hospitals that 4 have the ability to invest in in capital, because 5 that's the only way they're going to survive. 6 In my area, hospitals are 20 miles apart from 7 each other. 8 If one of those hospitals were to shut down, 9 not only are you probably getting rid of one of the 10 largest employers, if not the largest employer, in 11 that community, you're devastating rural health care 12 as we know it. 13 So, I mean, that's something we have to be on 14 the forefront. 15 So these -- you know, when I talk to the 16 CEOs of our rural areas, they're already having 17 conversations, or are already working for these 18 affiliated agreements, across the state. 19 So, I think that's vital. 20 But as you said, the model of health care is 21 changing. It's going more to preventive. 22 Even where you see rural health-care 23 expansions in capital projects, it's all more to 24 deal with the preventive side. 25 Most of the hospitals are lessening the 1 amount of inpatient beds they have in their facility 2 because, the reimbursement is not there; the 3 incentive, the financing, is not there. 4 My wife's a nurse at a local hospital. 5 And one of the things that I was able to find 6 out from conversations I've had, the reimbursement, 7 if you're a nurse and you're dealing with 8 five patients in a hospital, you're, essentially, 9 dealing with five patients who might not need a lot 10 of attention, but you're dealing with three patients 11 who need a great deal of attention, the 12 reimbursement's the same. 13 So, the amount of services you're providing 14 to that individual in that rural setting could be a 15 major problem, and they're not getting -- it's all 16 based on a per diem rate of the number of people 17 you're serving. 18 So that can be a challenge, and I think that 19 needs to be something to look at. 20 But at the end of the day, and I know we're 21 going to talk about this later, it's just -- whether 22 it's a business, whether it's a local government, 23 whether it's a hospital, it's about revenue and 24 costs. 25 And we've talked about Medicaid 1 reimbursement, and, you know, when those cuts have 2 come down, they directly hit our providers. 3 Usually when we talk about control, a lot of 4 us want to see more done on the fraud-prevention and 5 waste side. 6 I think there's a lot of room to do that. 7 But also, unfortunately, a lot of times, when 8 it comes down into place, we're looking at, they go 9 after the rural, they go after the hospitals, the 10 physicians, nursing homes. 11 And I'm glad our friends from the 12 Department of Health are here because, if you're not 13 dealing with the reimbursement, the revenue side, 14 there's a cost. 15 And I think we need to have -- year after 16 year, even if it's a longtime staff person, we've 17 always talked about the costs associated with 18 health-care delivery. 19 And, I mean -- and I know regulations are 20 important for safety. But, when we look at the 21 federal regulations, who we -- our health, 22 hospitals, and nursing homes are regulated by 23 federal mandates and federal requirements, and then 24 we have the state on top of it, and, oftentimes, I 25 think if we look at those, we have the federal, and 1 then we have so many more on the state side that go 2 on top of it. 3 And I think that's something we have to look 4 at very thoroughly if we're going to address this 5 issue, because we can -- I'm just afraid, you know, 6 we have great ideas, but it might be a dog chasing 7 its tail if we're not going to get at some of these 8 costs that continue to rise, not keeping up with the 9 revenue side. 10 It's just a matter of putting a Band-Aid on 11 a, you know, bleed that's going to continue to 12 slowly bleed until there's no ability to survive it. 13 And I think we have to look at these costs, 14 these mandates, and maybe it's as simple as looking 15 at: 16 Here's what the federal government requires. 17 Why can't we bring our state regulations down 18 to that, and then look at them one by one, and build 19 from there, rather than just continuing to add more 20 costs and regulations onto our health-care industry? 21 Because it's -- we're in a critical crisis. 22 And if it's not dealing with the revenues, it's the 23 costs. 24 And all these other things are great things, 25 I think they're important, but if we don't get down 1 to the costs and the regulations that are coming 2 down on a regular base, I think it's just prolonging 3 the inevitable. 4 And that's -- and if we want to have a rural 5 health-care delivery system for our people, we need 6 to make sure we're addressing those issues, 7 especially with the federal health-care act being 8 implemented and the additional changes that are 9 going to come on at that end. 10 So, those are the points I just wanted to 11 make. 12 SENATOR YOUNG: Thank you, Assemblyman. 13 So as far as the transition for 14 health-information technology, does anyone briefly 15 want to give feedback on that? 16 STEVEN KELLEY: It's going great. 17 SENATOR YOUNG: It's going great? 18 STEVEN KELLEY: Yeah, we completely 19 implemented ours [unintelligible]. 20 SENATOR YOUNG: Excellent. 21 STEVEN KELLEY: [Unintelligible] -- 22 GAIL SPEEDY (teleconference): Senator -- 23 STEVEN KELLEY: -- it's really big. 24 GAIL SPEEDY (teleconference): Senator Young, 25 I would like to jump in on that. 1 SENATOR YOUNG: Yes, Gail Speedy. 2 GAIL SPEEDY (teleconference): I think we had 3 a very innovative thing that happened in our 4 community, and that was, that our local hospital 5 took the lead and selected a community-based CHR. 6 And that those of us who elected to buy into 7 the community-based CHR, we could -- with respect to 8 the [unintelligible] clause, we could receive 9 certain benefits. 10 And I thought that that was a great policy 11 decision, because it really gave access to smaller 12 operating physicians, one- or two-physician offices, 13 to really adapt in electronic health records, and to 14 begin this continuum of electronic transfer of 15 information. 16 I don't think, and I know there's a lot of 17 criticism out there at a national level about the 18 electronic health-record incentive, and, why it 19 isn't moving the mark on care yet. 20 And I really think that, as a country, and as 21 a state, we need to understand that this is a huge 22 transition. And we have [inaudible] that can do 23 certain things, but they haven't, sort of, come to 24 that space-age level, where they can push 25 information into the electronic health records yet. 1 And I think as that comes along on, it's really 2 going to impact patient care. 3 We've got -- you know, we have a huge list, 4 of getting every single practitioner across the 5 country electronically plugged in and away from a 6 paper chart. 7 And as that transitions, and I think the 8 state and federal moneys that were available to do 9 that, I think we really are going to see an 10 improvement in quality of care. 11 I also think that we can never, sort of, kid 12 ourselves that electronic health records would make 13 a physician's job easier. 14 I call it the "Does this dress make me look 15 fat?" lie. 16 It does make your life more difficult. They 17 do duplicate what they do because, now, they are 18 doing two things: 19 They are documenting patient visits. 20 That's what we teach them to do in medical 21 school. That's what we teach them is their 22 liability. That's what we teach them is their 23 obligation as a physician; 24 But then they're also capturing data points, 25 because now we're teaching them [unintelligible] 1 management, and how to track a patient over time. 2 So they're duplicating records. 3 It does take a little bit longer, it does 4 reduce productivity, but I think, in the end, it 5 brings us to a higher quality of care, and it will 6 allow us to work smarter, not harder. 7 SENATOR YOUNG: Thank you, Gail. Thank you 8 very much. 9 So, that's good input regarding this. 10 I do want to move along to financing, access 11 to capital, and sustainability, because those are 12 really huge issues. And, you know, reimbursement, 13 Medicare reimbursement, especially because of the 14 aging population in rural New York, there are issues 15 related to that. 16 I've heard that, as far as private equity, 17 there are issues that are going on related to 18 private equity. 19 And, so, I just was wondering if people had 20 input or feedback on those, because they're very big 21 issues. 22 And, so, Steve, did you want to give some 23 information? 24 STEVEN KELLEY: Yes, thank you, Senator. 25 One of the issues for small hospitals, 1 particularly critical-access hospitals, is that our 2 costs are pretty much fixed. 3 So, our ability to -- our cost of care on a 4 per-unit basis is really very much volume-dependent; 5 so, as our volumes go up, our costs go down. 6 I know that doesn't make sense, but it really 7 does make sense, because that denominator, as that 8 rises, then the costs goes down. 9 One of the things that has been an item, and 10 I believe you have helped us with this, is having 11 Medicaid have a cost basis. 12 And there was something that made it through 13 the Senate and the Assembly this year, and was 14 vetoed by the Governor. 15 This is something that would really make a 16 difference. 17 It's not a gigantic budget item, but for a 18 small hospital like mine that has 20 or 25 percent 19 Medicaid, it would be an enormous -- it would be an 20 enormous benefit, because Medicaid doesn't quite 21 cover the cost of care, and so we're slowly losing 22 money on every Medicaid recipient that we care for. 23 With Obamacare coming, we're not so sure what 24 that's going to mean. 25 We're gonna -- we think that the bad-debt and 1 charity-care pool will be impacted because, 2 supposedly, we're going to make it up on these new 3 people. 4 And the -- all the payers seem to be 5 interested in getting contracts at the Medicaid rate 6 where we lose money, and they say: Well, you're 7 going to be better off because you just won't lose 8 as much as did you before. 9 When -- and I am just very suspect. 10 I think that we're at enormous risk during 11 this transition without having Medicaid at least 12 paying for the cost of the care. 13 SENATOR YOUNG: Thank you for that. 14 Does anyone else want to give input? 15 GARY FITZGERALD: Like I said -- well, I -- 16 you mentioned that -- high Medicare volumes. 17 We have some of the highest Medicare volumes 18 in the country, in Upstate New York, because of our 19 population; and, so, we have hospitals that have 20 between 60 and 80 percent Medicaid and Medicare in 21 our hospitals' inpatient. 22 So, there's very little room to move to the 23 Blue Crosses of the world and try to get -- make up 24 the difference when you lose money on Medicaid and 25 Medicare. And that just is going to get worse as 1 cuts continue and as the population ages. 2 So there's not -- because -- you've got that 3 issue, but then you have hospitals trying to get 4 access to capital in that financial position. 5 It's impossible to go anywhere privately and 6 get that -- or, excuse me -- to the Dorm Authority 7 or to a private bank or to a local bank, it just 8 won't happen. 9 So our organization, and this is 10 controversial, and I know some associations don't 11 agree, we're supporting the Senate bill which would 12 allow demonstration projects for private equity in 13 Upstate New York, just because we have nowhere else 14 to go at this point. 15 The hospitals that are moving towards 16 systems, small hospitals with larger ones, it's the 17 right thing to do in some cases, and there are 18 efficiencies that they can get from that. 19 But the larger -- it's a myth to think that 20 the larger hospital will make capital available to 21 the smaller hospital. 22 That's a dangerous myth, because I think 23 people think that you just go get an affiliation 24 with your larger hospital down the street. 25 That larger hospital has problems of its own, 1 and so they're not writing checks to the smaller 2 hospital. 3 So, we need to find ways to capitalize, not 4 to keep the hospital in the shape that it's been in 5 for the last 100 years, but to move it to the next 6 iteration: To reduce its inpatient. To make them 7 private rooms, but half the rooms they have now. 8 Those are the things we're trying to do, but 9 we have no capital to get there. 10 And I don't -- the 1115 waiver has been 11 talked about for a year or more, and, hopefully, it 12 comes in some shape or form. It's not going to be 13 as big as we thought, I'm sure. 14 But, without a place to go, that's the only 15 reason that some people on my board said: Maybe we 16 should take a look at some other ways. 17 We don't like big, scary HCA investor-owned 18 hospital companies coming in. 19 We're the only state in the union, by the 20 way, that does not have private equity in their 21 hospital system of some sort. 22 So, it's very controversial within the 23 hospital community, we don't all agree, but that's 24 why we went there, and I don't see any other -- 25 any -- a lot of other solutions out there. 1 SENATOR LITTLE: Can I? 2 SENATOR YOUNG: Yes. 3 SENATOR LITTLE: I agree with you, that the 4 larger hospital isn't going to invest their capital 5 in a smaller hospital. 6 But, I thought I understood that part of the 7 advantage of a collaboration and an affiliation, is 8 that your bonding ability or your borrowing ability 9 would increase. 10 GARY FITZGERALD: It depends -- 11 SENATOR LITTLE: And it's not a -- it's not 12 free money, for sure. 13 GARY FITZGERALD: No, it depends upon whether 14 that larger hospital has a rate -- a good rating. 15 And most of them are either just breaking 16 even or losing money as well, so it's not like 17 they're sitting on cash. 18 What it does do, is it brings efficiency and 19 reduces costs. 20 If you do the affiliation right, you can hook 21 into the information systems, you can use the 22 purchasing systems, you can reduce costs, but it's 23 not like there's a lot -- there's a bunch of capital 24 sitting in the larger hospital waiting to tap 25 into -- 1 JIM CLANCY: No, and I -- sorry, Karen. 2 KAREN MADDEN: No, that's okay. 3 We've also found, though, that larger 4 hospitals aren't interested in affiliating with 5 smaller rural hospitals that aren't financially 6 stable. 7 GARY FITZGERALD: Right, so if you go too 8 long -- 9 SENATOR YOUNG: But they view it as a drag 10 on -- 11 KAREN MADDEN: Yes. 12 JIM CLANCY: But that gets to Gary's point, 13 though, of helping. 14 And what we're trying to do, as a department, 15 and, you know, as an administration, at the 16 Governor's direction, is to help these smaller rural 17 facilities transition; that transition to what -- as 18 a community-appropriate service-delivery system that 19 we talked about earlier. 20 And that's what we're trying to do, to get 21 to. And we continue to hope. 22 And the capital-access program, pilot 23 program, that Gary mentioned, was in the Governor's 24 Executive Budget. 25 We are hopeful that our colleagues and 1 partners in the Legislature will be continue to have 2 conversations. 3 And I know it's in the Senate, and, we will, 4 hopefully, continue to have conversations with your 5 colleagues in the Assembly, and we all to get to 6 where we need -- and I hate saying this, I know 7 everyone around the table hates saying this -- but, 8 out-of-the-box thinking of how we can help 9 financially unstable or struggling facilities become 10 much more stable. 11 SENATOR YOUNG: Yes, did you want to go 12 first, Mark? 13 Go ahead, Mark. 14 MARK WEBSTER: Yes. 15 You know, as you look at access to capital, 16 and stuff, I mean, a long-term creditworthiness is 17 driven by profitability, liquidity, and efficiency, 18 and so you go after all three of those. 19 The biggest threat, I think, to every 20 hospital in New York State right now is the 21 "nurse-staffing ratio" bill out there. 22 Whether it will make any progress whatsoever 23 this year is questionable, but I'll tell you, it 24 would be devastating. 25 I actually -- let me give a copy of a letter 1 I sent to Senator Ritchie, and it talks about my 2 hospital, but also, hopefully, about other 3 hospitals. 4 We're doing okay. 5 We win some awards, and a lot of the 6 hospitals around here win awards. 7 We would have to add 53 nurses, based on this 8 ratio bill, and it's masquerading under patient 9 safety. 10 SENATOR LITTLE: Which you don't even have in 11 your community. 12 MARK WEBSTER: Right, right. 13 And it's a powerplay. 14 So I feel like I'm doing everything I can to 15 make the boat more shipworthy and seaworthy, and 16 trimming the sails. And this thing, essentially, is 17 somebody drilling a hole in the bottom of the boat. 18 There is no way we recover from something 19 like this. 20 And I think it's so bold and audacious, the 21 hope is that, somehow, the hospital community and 22 nursing homes will compromise on this. 23 And, again, it doesn't make any sense 24 whatsoever. 25 California is the only state that has this, 1 and you look at California's safety and value-based 2 purchasing scores, compared to some of our 3 hospitals, or across the country, they're no better. 4 So this is a powerplay. 5 I hope it gets absolutely no traction 6 whatsoever, certainly in the Senate. 7 I think the Assembly has proceeded with this. 8 Hopefully, that can get thwarted at some point. 9 Because, it is an unfunded mandate of 10 proportions that I've just -- I've never seen. And 11 it would devastate us. 12 And Chandler and other CEOs, you can 13 comment on that. 14 CHANDLER RALPH: Absolutely. 15 UNKNOWN MALE SPEAKER: Horrible impact. 16 CHANDLER RALPH: Yeah, it's -- and, again, 17 moving towards evidence-based medicine, how about 18 looking at evidence-based on this? 19 They've never directly linked the high-level 20 ratios in California to any increase in quality or 21 safety. 22 So why are we doing this? 23 SENATOR YOUNG: Well, as you stated, it's 24 under review right now, but money is always an 25 issue. 1 And, so, if you're going to do it, you have 2 to find the money to do it; and, so, that really is 3 the factor that needs to be considered before you 4 advance it. 5 Ann, would you like to say something? 6 ANN ABDELLA: Yes, a couple of things 7 about -- with this activity that we're having in the 8 accountable-care space, it's strictly for Medicare 9 fee-for-service-only patients, and it's a 10 shared-savings model. 11 And our network is community hospitals. We 12 have no tertiary care directly in our 13 accountable-care organization. 14 It's a primary care, three community 15 hospitals. 16 And we're just getting to the data now, so 17 that whole point about what Gail was saying earlier, 18 about the HIT and health-information exchange, 19 you've got to have the data. 20 We've all got to have data. 21 We've all got to be dialed in for the future 22 for any of us to be able to survive or do anything. 23 But we're looking -- trying to start to look 24 at what happens to those patients that we all, as 25 rural hospitals, ship out somewhere else for 1 tertiary care. 2 And we're doing a pretty rotten job of 3 bringing them -- of having them come back into our 4 communities and managing those transitions of care. 5 And one of the things that we are just 6 starting to look at and think about and business 7 model, before we even take to it our hospitals and 8 physicians, is: Is there some kind of a role for 9 the rural hospital? 10 We know that when people come home, and when 11 they're in our hospital systems, they do pretty 12 well. 13 You know, close to home, they've got family, 14 they've got supports, they do well. 15 And one of the hardest and worst things is, 16 for them to be 100 miles away, 120 miles away, in a 17 big center where family can't get to you. 18 So how do we -- we know we have to do a good 19 job of bundling them up and sending them out. 20 We've gotten pretty good at that. 21 But we need to have the tertiaries, and those 22 people we're supposed to be partnering with in 23 different ways, bundle them up and send them back 24 home to us sooner than they do. 25 And they need -- and if they're in our 1 communities and coming back to our hospitals for a 2 few days, how can we -- you know, then we can pass 3 them off in a good way to their primary-care 4 physician and to their pharmacist and to their PT, 5 and bring them home to give those support services. 6 But, the ACO has all the handcuffs off of how 7 the money gets used, if you will, in Medicare. 8 So we have some laxity there, to be able to 9 experiment, and say: Okay, does it make sense that, 10 you know, Hospital X in Buffalo, or in Erie, you get 11 paid for, you know, X amount of dollars to take this 12 patient. And then you hand them back off to 13 Brooks Hospital, to keep them for the other two or 14 three days so they can stabilize, and then we put 15 them back out. 16 But I think we're going to need to get very 17 creative about that, sort of, intermediary role that 18 I think community hospitals are going to start to 19 play in the future. 20 There's a whole other conversation to be had 21 around the concept of the virtual patient-centered 22 medical home. 23 I think to Chandler's point about, you know, 24 the doctors are -- they're getting this. 25 The patient-centered medical home is an 1 innovative model. 2 We are proving it, they are proving it. It 3 works. 4 But we don't have in those communities all of 5 the supports of care transitioning, care management, 6 care coordination, behavioral-health services. And 7 I think that is a space that these rural hospitals 8 really have an opportunity to move into. 9 FRAN WEISBERG: I think that's wonderful. 10 One, I think the ACOs can provide the 11 flexibility of financing. And other ways that other 12 kind of MLTC, there's other kinds of financing that 13 we can look at. 14 I really do think that's the whole future. 15 So going back, it's a good way, maybe, to 16 look at some of this, is: What do you need to have 17 a high-performing regional health-care system? 18 Everything, from the whole continuum, from 19 prevention, to when somebody does need the highest 20 level of care, so coaches and care coordinators and 21 transportation and social, the whole social system, 22 how do you build that? 23 And, so, that whole idea of, the right care 24 at the right time, what do you do back in one 25 community, and what do you do somewhere else? 1 And look at it by community, and, then, how 2 do we pay for it? 3 CHANDLER RALPH: And I don't want to forget 4 post-acute care, because this is not in the dialogue 5 of a lot of people, and that is going to be 6 critical, going forward, particularly in rural 7 areas, for the resources. You know, the home 8 health, assisted living, adult home, they really 9 don't exist. 10 So, I think we really have to shine a light 11 on that also -- 12 FRAN WEISBERG: Elder care. 13 CHANDLER RALPH: -- and see how we can get 14 that, because that's definitely the right place at 15 the right time at the right cost. 16 SENATOR YOUNG: Right. 17 SENATOR LITTLE: You know, with this penalty 18 for hospital re-admissions, and all of that, what 19 you're talking about would seem really logical. 20 That, from the bigger hospital, if they would 21 agree to send the patient to the rural hospital, 22 where then the family, if you could provide a 23 training program for the health care at home, and 24 have the family there, you know, maybe there would 25 be some way or some name to name this, because 1 they'd be giving up a few hospital days. 2 But on the other hand, they'd be having more 3 assurance that that patient isn't going to be 4 re-admitted, and they're not going to get penalized. 5 FRAN WEISBERG: And it would be cool, from a 6 policy perspective, to take State Office for Aging, 7 there's a lot of different services that are now not 8 connected between the health-care system and the 9 whole community-based system. 10 A lot of us have worked many years for social 11 HMOs. 12 I mean, now is the time to really -- 13 SENATOR LITTLE: But they're right there in 14 your rural hospital community. 15 FRAN WEISBERG: And it's, actually, rural 16 communities have done better, because they've had 17 to, but, they're still not paid for it that well. 18 SENATOR LITTLE: It would be a great idea if 19 we could -- 20 ANN ABDELLA: And I think your rural 21 communities are the places to do those pilots, 22 because people know where all the bodies lie. 23 They're -- we have been married and joined at 24 the hip. You know, we know how to work with each 25 other because we are so sparse on our resources. 1 But the opportunities, and we're hearing it. 2 We heard it at the SCHIP ad hoc committee the 3 other day, you know, that it's going to be community 4 health, population health, blended into the clinical 5 model. 6 And, how are we going to figure out to do 7 that? 8 I mean, you know, everybody's just sort of 9 scratching their head, "Okay." 10 Well, Office to the Aging is absolutely the 11 perfect marriage with the State Health Department 12 programs and primary care and the community 13 hospitals, through the community health-planning 14 initiatives and prevention agenda, to really start 15 that. 16 SENATOR YOUNG: So maybe we should look at -- 17 GAIL SPEEDY (teleconference): This is -- 18 SENATOR YOUNG: -- some ideas. 19 GAIL SPEEDY (teleconference): I'm sorry. 20 This is Gail again. 21 I was just going to say, also from a policy 22 perspective, I would love to have access to payer 23 data. And I think that the State could force the 24 payer to actually start to begin to share payer 25 data. 1 It's just sort of a ultimate product -- 2 process, and we don't know how to structure a system 3 that's going to add value and -- from patient care, 4 and from the payment perspective, so we're always 5 working from one-half of the equation. 6 SENATOR YOUNG: Thank you, Gail. 7 I do think that the hour is getting a little 8 late. It's 1:15, and I know that people have other 9 things to do. 10 But I do want to point out: 11 We have -- you know, the Department of Health 12 brought their all-star cast, and I do want to point 13 out this all-star cast here, so why don't you go 14 down the line and introduce who you are and what 15 your role is. 16 UNKNOWN FEMALE SPEAKER: My name is 17 [unintelligible]. I'm the director of the 18 commission on rural [unintelligible]. 19 UNKNOWN FEMALE SPEAKER: Hi. [Inaudible.] 20 UNKNOWN MALE SPEAKER: [Inaudible.] 21 UNKNOWN FEMALE SPEAKER: [Inaudible.] 22 SENATOR YOUNG: So I do want to thank the 23 staff for being here today, and I wanted to 24 introduce them, so that -- most of you probably 25 already know them quite well, but just, that, 1 they're a resource also. 2 And -- but I would encourage all of you to 3 continue the dialogue with us, and with your local 4 representatives, because we do want to hear from 5 you. 6 Obviously, we get our best ideas from people 7 like you who are out there working every day on 8 behalf of the people of New York State. 9 We identified, I believe, several really key 10 issues that need some work. 11 And my commitment is, that I'll work with 12 Senator Hannon, and the Commission, to try to flesh 13 some of these things out. 14 I do want to point out, again, Senator Hannon 15 was so disappointed that he couldn't be here today. 16 I know that the minute that this is online, 17 because we're going to have this session online, 18 that he will sit down and watch it. 19 I know him. 20 I know he will do that, and, he'll have a 21 million questions, I'm sure, for all of you as 22 follow-ups. 23 But, we will continue to work on these 24 issues. 25 This is such an important, crucial thing, for 1 rural communities, for the future of this state. 2 You're part of the discussion, you're part of 3 the solution, so I want to thank you for that. 4 And, we got so many great ideas today. We'll 5 continue to try to work those up. 6 But I would encourage you to reach out to 7 Senator Hannon's office; my office; Caitlin McGowan, 8 who's the director of Rural Resources Commission, on 9 the Senate side; because we have our work cut out. 10 And I especially want to thank the 11 Department of Health for being here today to be part 12 of the discussion. 13 We truly appreciate all that you're doing, 14 and, I know you work incredibly hard on behalf of 15 New Yorkers also, so, thank you for that. 16 So that concludes our roundtable discussion 17 on rural hospitals, so, we're ending the session, 18 but we're not ending the conversation. 19 So, thank you again for being here today. 20 (Whereupon, at approximately 1:20 p.m., the 21 roundtable discussion jointly held before the 22 New York State Senate Standing Committee on Health 23 and the New York State Senate Legislative 24 Commission on Rural Resources, concluded, and 25 adjourned.)