AHLA's Speaking of Health Law

COVID-19 GC Roundtable - Part 1

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In this podcast, Sarah Swank, Counsel, Nixon Peabody LLP, speaks with three hospital general counsel on the front lines of the coronavirus pandemic—Marc Goldstone, Senior Vice President, Prime Healthcare; David Rowan, Chief Legal Officer, Cleveland Clinic; and Richard Korman, Executive Vice President and General Counsel, Avera. Participants discuss the multitude of issues they’re facing and how they are dealing with them. From AHLA's In-House Counsel Practice Group.

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Speaker 1:

Welcome everyone, uh, to ALA's Covid 19 GC Roundtable podcast. Uh, today is March 31st, uh, 2020. And, uh, today I have with me, uh, three general counsels, uh, mark Goldstone, uh, from Prime Health. I have, uh, David Rowan from the Cleveland Clinic, and Rich Corman, uh, from Avera Health. Uh, thank you all for joining us today. Um, today we're gonna talk a little bit about your role, um, your, your day, your department, and your organization, and, and how Covid nineteen's changed that. Let's, I think, let's start first with, uh, how, you know, how do you believe your role as a general counselor chief legal officer has changed, responding to Covid 19? Um, I, I haven't imagined that your days are not the same as they were before. Um, uh, Dave, why don't you, why don't you start and tell us a little bit about that.

Speaker 2:

Thank you. I think that, uh, first of all, it's a time with crisis where you, you, uh, have people working 24 7, which in healthcare it's, that's normal. But I think that it is a time when, uh, the rest of the law department, I'm on our main campus, but the rest of the law department is working remotely. So we had to check and get our cadence As far as our meetings, uh, we have meetings, uh, with executive administration, probably four or five a day, uh, with various work streams. So that, uh, it is obviously a stressful period for frontline caregivers, everyone. And I think that it means that you're really helping in a, um, I think a significant noble mission. But your role includes not only the legal issues that helping coordinate, and we found that communication you can never communicate enough. It's a very fluid situation. And so I think, uh, getting quick decisions made, which means I have to call on lawyers to do things. I also have government relations. So it's, it's trying to respond quickly in realizing that we're all here for the, uh, patients, and it's a fearful time for them. So that, uh, it's, it's very rewarding to see the teamwork that happens.

Speaker 1:

Mark, how about you have, how has your role changed? Um, and, and what is your, what, how does your department responding to COVID 19?

Speaker 3:

So, you know, Sarah, a couple of things. We are a physician-led company, and I have had more contact with groups of our physician leaders in the past two weeks than I have may have had in the past two months. And, and I think that's, that's a very good thing because it helps me have, you know, true visibility onto the clinical decision making that's going on in response to the emergency. And it also gives me real time access to them to anticipate needs. We are as remote as we can be. We would like to be more remote if we could be, but, you know, we have to ensure business continuity, and there are some things that you have to do in person. But overall, my role has changed from more of a, you know, hands-on. I will pitch in and help out with contract review or, or offer some guidance to my ops councils to more of a, um, much more top level strategic advisor. I am trying to anticipate needs, you know, many of you know, I was a paramedic before I was a lawyer, and I have a ton of emergency management experience. I'm trying to bring that to the table. And the other thing I'm doing is I'm just trying to let our people know whether they are in the law department or yesterday when I was on the phone with some local physicians, just how much we appreciate what they're doing. We know how hard they're working. We know that these are less than ideal conditions. We know that we wish we had better leadership at all levels of government, and I've been a cheerleader because people need to know that they're appreciated, whether they are the ceo, the emergency department physician, the janitor, the dietary person, everybody needs to feel appreciated during this to stay at their best.

Speaker 1:

Great. And, and rich, how about, how about you? Um, can you tell us a little bit about what you've been working on as, as general counsel and a little bit about your department?

Speaker 4:

Oh, sure. Thank Sarah. And I, and I do echo others comments as well, that, um, it just seems to be at a more heightened level that we become involved in reviews and issues right now. Um, I have various attorneys in various locations throughout Avera and each one I've assigned specific, um, duties. Two, with regard to employment matters, regulatory matters, um, emergency matters, and really being available for all of our decision makers all throughout Avera on a 24 7 basis. Because as we all know, uh, what is occurring, um, throughout our country changes, um, let alone hour by hour, but certainly day by day. So we have to be prepared, and as Mark just said, anticipate the needs of, uh, the individuals really on the frontline so that, uh, our patients are cared for, um, either through this, uh, COVID 19 pandemic or just in their everyday, um, healthcare encounters, um, that they have and that they bring forward to our care locations. So always being prepared and always anticipating what's needed in order to ensure the mission as we move forward into the next days and weeks ahead.

Speaker 1:

So, uh, rich, what do you, what percentage of the time do you think you spend on, um, covid 1919 versus other, other areas of your job?

Speaker 4:

Well, it seems like right now, um, if it's not a hundred percent, it's pretty well into the nineties to the hundred percent level. Um, I do have other, uh, attorneys who we have, um, assigned non covid work duties too, so that those other, um, aspects of our business continue. Um, we are still involved in, um, hiring, um, individuals to come serve at Avera. Uh, we still have discussions going on with potential, um, partnerships or joint ventures, you know, all of the business continuity things are still happening because we still need, um, to grow as a ministry and to, um, seek revenue where we can. Um, because as all of us are experiencing, um, with the suspension of certain services, um, the revenues that we are having are being reduced. Um, and so we have to continue to be open to other opportunities to grow the ministry.

Speaker 1:

Dave, are you seeing that too? Are you, what percentage are you working on covid 19 items, and are, is there still an element of business as usual as well?

Speaker 2:

Well, I would say that it's, it's a hundred percent are pretty close to it. Uh, obviously there are other things that are, uh, happening and, uh, I'm blessed with having a, a great, uh, teamwork within the lawyers, the legal assistance and the business unit. So that is all, uh, continuing, but it is a singular focus with regard to covid and, and then when you look at, uh, we're all looking at what this may play out to be, where the surge, the, the height of the, the curve. And so I think that, uh, there's really that focus on my day. But having said that, it goes into, I mentioned before, communication. I think that, uh, it is something that we have daily, uh, messages from our ceo. Uh, those also go to our trustees and directors and governance is something that I also have to, uh, work on. And I think that, uh, the communication there and we have operations across the US and some international operations, uh, keeping all of the governance, all of those things moving. It's interesting, again, I mentioned teamwork, and I think that you also have to deal with, uh, government officials, you need to deal with supply chain issues. All of those are interesting and, uh, challenging. And I'm not certain I knew what an N 95 mask was before all of this, but I certainly know now.

Speaker 1:

Yes, I think, I think a lot of people in this country know more about N 95 masks than they ever thought they would and how, how needed they are. Um, mark, how about you? What percentage of your time are you spending on covid 19, and, and how is your response? You know, you have, I think, is it 40, 45 or several hospitals in your system in different geographical areas? How does, how do you manage that?

Speaker 3:

So I'm spending 162000% of my time on covid 19. Um, I am, I'm very proud of my team. In addition to business operations continuation, which is necessary, they've all risen to the task, and they've all agreed to handle additional covid 19 responsibilities as they come in. We've added some more team huddles. We do a weekly, uh, zoom meeting where we can actually see each other. I tried it once. I asked them if they liked it. Surprisingly, everybody thought it was a great idea. So I guess I have a good idea. Every once in a while we're gonna continue that. Our senior lawyers have a huddle once a day, and then a few of our most senior lawyers are on our company-wide executive leadership huddle every day. Um, but again, you know, we have only two missions in this. The first is support our operators. Everything we can do to support our operators is, is what we need to do. And the second is continue business operations. We have to get through this, and we have to have a health system that exists after we get through this. And we can't focus on just getting through this because we won't have the other thing when we're done. So we're spending an awful lot of time with that. We do have a large contingent, I have about 25 lawyers and, uh, at least 20 paralegals. We do cover 45 hospitals in 14 states. A third of those are non-profit, and they have their own special issues. Um, we are all just expending as much energy as we possibly can. Recognizing that stay at home means we're safe at home, means we're not in hospitals. We're not worried about where the next N 95 mask is going to come from. We're not worried about whether or not people are drinking fish tank cleaner because they heard that it'll prevent covid 19. That's, that's the summon substance of it for us.

Speaker 1:

So, mark, what are, you know, Dave mentioned the masks and you mentioned some of the, the misinformation, and we've got supply shortages, ventilators, shortages, um, missing resources, clinicians testing, positive. Um, what are, what are some of the biggest concerns that, that you see, mark, and especially given your EMT background and preparedness background, um, what are some of the things that you're doing or thinking about right now around those concerns?

Speaker 3:

So, on the one hand, we're thinking through the period of the crisis. What's the worst case scenario? What's it look like if social distancing doesn't work, what's it look like if we don't flatten the curve? And how do we prepare for that? And on the other hand, we're thinking, well, look, let's figure out how we get home on this, this, if these things work, and what, what is our best case scenario? So for me, I worry about things like, are my staff okay? Are they gonna be able to come to work? Are my executives okay? We had a Chief medical officer that got a, uh, subclinical covid 19 infection, and, and she's recovered well. But again, those are things I'm thinking about as well. Then with respect to ppe, I think about how can we get more, how can it be equitably distributed? How can we get it to where we think we're going to need it? Um, end of life issues. They're different in every state. How can I forecast what the need is gonna be for legal assistance? Because I can tell the doctors till I'm blue in the face, I want you to do the right thing, and I'll always back you if you do the right thing. Sometimes it's just really comforting for them, and, and, and it takes one less thing off of their mind if they know in advance, this is what the law says, and this is what we're gonna backstop you with. So those are some of the things that we're thinking about.

Speaker 1:

Um, how about you, rich? Um, what are, what are some of the things that you're concerned about and what are some of the things that you're doing to try to help support your, your, um, hospitals and health systems? Uh,

Speaker 4:

Just, oh, you bet. Just to echo what Mark said, you know, we all have to take care of ourselves in order to, um, service those who need our, um, reviews, advice, and, um, interpretation of the state and federal avalanche of legislation and regulations and the waivers from the, um, uh, regulations and, and laws that currently exist. Uh, one worry, um, that I have, uh, right now is really responding well across state lines. Um, seeing a lot of patchwork done by the states that, um, we are a part of with regard to licensure of, um, physicians and nurses, um, and other healthcare providers. Uh, respiratory therapists are an important need, um, for us right now. And we're trying to work with our states so that, um, the certifications or licensure are registration that exists for that profession can go across state lines, um, because, uh, in one area we may need, uh, more of a provider presence than in another area of Avera. So we're really working hard. Um, I have government relations as well that reports to me and with our, um, government relations professionals and, um, CEOs on locations into, um, those other states. Um, we're working hard to make sure that that's as seamless as a process as possible to make sure our providers can cross state lines, take care of people.

Speaker 1:

Yeah. So it's interesting cause I know for example, in New York state, there's, um, the governor has, uh, put out an executive order that talks a little bit about immunity for, uh, healthcare providers. Oh, in covid 19, and there was some immunity that was put into the, the last, uh, congressional bill that passed around volunteers. Um, so it's, it's interesting to, when we think about personnel and, and legal issues, where we're, where we might be headed with that. And again, rich, you said it's like a pa, it's a patchwork. Um, Dave, do you, what are, I mean, you brought up the MA mass as a, as a critical concern. What, what other concerns do you have and, uh, how are you working to address those?

Speaker 2:

Well, I think that, uh, it's something where there's so many regulatory changes and many of them vary productive, that, uh, lawyers working with the business units and the clinical units, um, it, it's a situation where we've tried to streamline the decision making. I mean, you don't have time for, on the one hand, on the other hand, kind of analysis. And that, uh, I find that to be rewarding, that we get that teamwork to come up with what's best for patients. And then I, I will say one thing we do is to maintain a log of those decisions we make based on the information we had, so that, uh, not that anyone would second guess down the road, but I think it's good for you to keep track of what it was and why you did it. I think that, uh, first and foremost, the patients and the safety of the caregivers, and I think that working through questions as far as what PPE is involved, um, no one knows how long this is going to last. So I think most of us do the plan for the worst and hope for the best, so that, that judgment as far as what the experts are telling us about where the curve, where we are on the curve and what's gonna happen, I'd also say that it brings out some very good traits. Um, I think we've seen unprecedented cooperation among local and state hospitals. I think we we're, we have a governor in Ohio that's been very proactive, and we have a very close working relationship. And also, I think what we have done is because it is something that, as I mentioned, nobody knows how long it's gonna go, that we also try to, with our own, uh, caregivers, employees, that we try to, uh, gather stories that are, uh, grateful patients, other situations, so that there's not levity that's not the issue, but at least they see the value of what they're doing.

Speaker 1:

Dave, I saw, I actually watched, um, on social media, one of those stories about, uh, a patient who the nurses and caregivers were writing on the window, and he wrote, left a, a message for the next patient. And it was really, it was really powerful.

Speaker 2:

Exactly

Speaker 1:

The Cleveland Clinic,

Speaker 2:

That was, I think that, uh, you get people who are truly grateful. One thing that we've done also is to try to set up along with another local hospital, uh, the response for first responders as far as testing and talk about a group that's, uh, very, uh, uh, happy that that's happening, and that it, it pays dividends for the community, and they're on the front lines to emergency workers of all types.

Speaker 1:

So, mark, I'm gonna ask you about that because you, that's your background and you're very involved in, um, those associations. Uh, we saw a change in HIPAA around it. We're seeing, um, people, uh, uh, guidance from the CDC around, you know, calling ahead and people under evaluation. So we make sure we have first responders. What would you like to tell us about first responders? What are some of the things that you, you're thinking about even outside of your job as a, a general counsel for a prime?

Speaker 3:

So, you know, Sarah, the first thing I'm thinking about is my lawyers and my operators to all think with the same mindset. We're focused on what's best for the patients and what's best for the system right now. So I personally think about the very front door of the hospital. You think it's the emergency department, I think it's the ambulance that's bringing the patient to the hospital. And I think about how we facilitate that. How do we improve their turnaround time? So more ambulances get out onto the street. How do we support the caregivers with whatever they need, whether it's blankets on their stretcher, whether it's resupplying oxygen, whether it's giving'em a hot meal, whether it's giving'em a 10 minute break to go to the bathroom, or whether it's just showing them some appreciation. They are bearing the brunt perhaps more than anybody because they have no physical support system other than the ambulance. So I think about those things. Then I think about what does the interface look like in the hospital, because sometimes the EMS teams are part of your health system, sometimes they're not. And there can be some parochial issues that arise. And I encourage everybody, remember, we're all on one team today. We're all on one team this week. We're all on one team for a good long time, and that's the COVID 19 team, and that's what we ought to be thinking about.

Speaker 1:

Great. Um, you know, one of the things that I was, I've been thinking about, and I think there a pretty vivid image of, uh, the line outside of the Brooklyn Hospital. Um, you know, two, I think two things. One, the sirens that, that people talk about in New York, going off all the time in their ambulances. And the other is the, the lines of people desperately trying to get tests. And we know under emtala, when people come to the emergency room and wait in those lines, they need to, um, be screened. And a lot of times there's not, not necessarily a test, and they're sent home after sitting in a line, not socially distancing and not necessarily meeting the criteria for testing. Um, uh, rich, what are are some of the things that, you know, you're thinking about, I don't know if you've got, if you're not, uh, maybe in New York City, you have a different patient population, but what are some of the things you're thinking about around emergency departments and testing and testing centers to prepare? And then Mark and Dave, I'm gonna ask you those same questions as well.

Speaker 4:

Oh, sure. Yeah. That's been, uh, a constant conversation here at, um, each one of our locations throughout South Dakota, Minnesota, Nebraska, and Iowa. Each one of our hospitals, um, has designated, um, a second location just for testing purposes, so that, um, individuals who call to our emergency room or to our one 800 number that we've been advertising all throughout our communities, we emphasize those individuals who they believe, uh, themselves, uh, may have, uh, covid 19 to not go to our main emergency rooms and go to those alternate testing locations. Firstly, um, secondly as well, if an individual does present at one of our main emergency rooms, um, you know, seeking, once again a covid 19 testing, uh, you know, those individuals are a, obviously, and each one of our staff members are, uh, uh, in our ERs are, uh, protected, um, uh, against, um, contracting Covid 19 virus. And the questioning continues, and then they are brought to a different, um, location within that emergency room. Uh, because what we're trying to do is, as I'm sure Dave and Mark and everyone else, is, um, trying to not only, um, take care of patients, but protect our, um, staff, because obviously we need them all, um, during this time, um, and for the next few weeks and months as we, um, uh, deal with this pandemic.

Speaker 1:

So, Dave, how about you? What are, what are you, um, working on? You know, again, we see the lines out the door. We also see in certain places, tents, um, out in the parking lot of, of hospitals for triage and screening. Um, what are, what are you doing at the Cleveland Clinic to work through these emergency room and screening and testing issues?

Speaker 2:

Sure. And we have, uh, our main campus and then, uh, 18 hospitals total. So that we're trying to have uniformly, we have, uh, uh, four hospitals in Florida where it's a little bit different, but basically we established tents early on to do some of the triaging. Uh, we also, with respect to, uh, uh, first responders have the ability to test them, uh, at each of the emergency rooms, realizing that we may need to change that depending on what kind of surge and patients we get. We also established a drive through testing facility with one of our buildings where they can go into a garage. So there's a little bit of privacy, uh, also, uh, but they're on the street. And I think that we've timed visits and made that, uh, a fairly easy way. Uh, and that has to be with a doctor's order. I think we're evolving this as we go and evolving it as we get additional testing capabilities and hoping as all of us are, that we have, uh, the ability to test more people more quickly. Uh, but I think we've found that people are, yes, they're fearful, but for the most part, um, very thankful and, uh, fairly easy to deal with.

Speaker 1:

Great. Um, one of the things that's kind of a tool bo, uh, tool in our toolkit right now is, is telehealth and the weight waivers, the 1135 waivers, and then the opening up of ability to be reimbursed even in the commercial market is something that appears, um, might be a game changer. Um, but how are you all using it? And I'll, I'll start with you, Dave, because I actually went onto your website and saw that you had a, a, a tool that you could use, um, to, uh, to try to see if you, you know, to, to go put in your symptoms, and then it gives you a, what you should do next, uh, response. Um, and one of them was telehealth. What kind of, what, you know, what kind of telehealth services are, are you using and, and how are you, your legal department supporting those, those efforts?

Speaker 2:

Sure. So I think we've been, uh, working on telehealth, uh, projects for years. And I think that most recent regulatory changes made it a lot easier, uh, from a regulatory standpoint. And frankly, I hope that, uh, many of the waivers and the, uh, ability to do telehealth of virtual visits, telephone visits, uh, Skype, whatever it is that we probably have just, uh, opened up a door and people see how beneficial it is. And a lot of people don't want to come into a main hospital in a situation like we've got right now. So we use a whole variety of platforms, be it, uh, a virtual visit, uh, just a telephone call. And I think that there's always a few glitches when you start out, uh, any kinda system like that. Uh, we do have a, I think a pretty progressive platform, uh, and it's people like it. And what we've found is that, uh, because we have a lot of elected procedures, which are now on pause, uh, in the state of Ohio, and, uh, really across most of the country, that we take those physicians who, uh, cannot, uh, perform whatever procedure. It might be a dermatologist, uh, whatever it is. And we are retasking them, uh, so that they can help with covid patients and, and, uh, really all, uh, caregivers looking so that they can practice at the top of their license. So we have a number of new participants, and what's nice is that, uh, physicians, nurses, others can practice from home and, uh, still serve our patients. And I think that that will be something that, uh, there will be no going back from the standpoint, nor should there, I think that it's a, an opportunity. And then being able to practice across state lines or even internationally is something that will, I think, change forever, uh, uh, really how a lot of people view telehealth, virtual visits, et cetera.

Speaker 1:

So, mark, how do you, how are, are you all using telehealth and, um, do you agree that with, with Dave that this is a game changer?

Speaker 3:

So, Sarah, the first thing we're doing is we're leveraging every telehealth platform we can, because obviously that care that can be provided remotely, especially during this time, is that care we wanna provide remotely. Um, one of the things I do, and I encourage all of the lawyers to do, and in fact we evaluate them on this every year, is to know our business, to know exactly what each hospital and what each business unit does, how they do it, who they do it for, who they do it with. So when new regulations or waivers are published, especially during this emergency, we don't just push'em out, Hey, here's an email, fyi. We read it, we parse it. Sometimes we talk amongst ourselves, and when we send it out, we say, here's a new regulation, here's the facilities we think it'll impact. Here's a potential business opportunity, or more importantly, a potential opportunity to improve efficiency or to keep our people safer or to deliver more care with the same resources. Here's how, here's why. Please let us know if we can help you do that. That's how I've asked the legal team of focus its efforts over the years, but especially now more than ever, you know, forwarding a, a law firm submissive or forwarding a regulation with a cover from CMS isn't very helpful to these folks forwarding information with a really brief and to the point analysis of how this is going to help work, if it's gonna change things or hinder things. That's what's really useful. I don't know if this will change the game or not. I can tell you one thing for sure. We are all gonna know after three months which meetings are necessary in person, and which meetings can be held by teleconference or voicemail.

Speaker 1:

Great. Yeah, it's interesting to, it's change. It might change. There's a lot of cultural shifts and changes, hopefully, um, mostly for the, for the better. Um, and I know for Rich, um, you in Avera, you, you've been, um, one of the leaders in telehealth and, and even a telehealth certification program. It's been interesting cuz we saw this telehealth almost surge that happened, and immediately after ocr, um, said, well, we're not gonna enforce the use of Skype and FaceTime and other platforms that are very accessible, um, on a patient's phone and that the patient could be at home and not in a facility or rural area. Um, and then also it looked like they were opening up and acknowledging that there might be mental health services that are needed during this time and other service lines. Um, so a lot of ability to be creative and, and meet the needs of, of patients across the country. Uh, rich, what are, what are some of the things Avera has done given, like, just similar to Prime and, and the clinic have had already had, uh, you know, good telehealth services? How are you building upon that?

Speaker 4:

Oh, definitely. Thanks Sarah. Uh, yeah, Avera, we've been, uh, well, I guess to brag a little bit, a national leader for telehealth services all throughout our communities, since we're very rural and we're very spread out. Um, right now, uh, we contract with I believe about 15 to 20% of the critical access hospitals in the United States, um, to deliver telemedicine into their emergency rooms. And what you've said and what, uh, mark and David have said with the expansion of the abilities to participate in telehealth, we are, um, of course, uh, taking advantage of those as much as, uh, we can via the other, um, modalities and platforms. Um, and honestly, I don't know if, um, the delivery of medicine will ever go back to how it was prior to Covid 19. I think more and more individuals will become more and more accustomed to using, as you indicated, Sarah, um, Skype, um, FaceTime, and other, um, um, really readily available communication vehicles. Um, and I don't know how that genie is gonna be put back into the bottle. Um, in addition to that, we are really emphasizing and trying to have our patients access us, um, uh, virtually even more so than before. Um, we are seeing, uh, a major expansion of our virtual visits into our clinics in other care locations, um, that not only benefits, you know, the patients and the providers then themselves, um, but also keeps them safe and keeps them, um, away from possibilities of contracting covid 19. So I think all of the expansion, um, in the rules and the regulations, and actually all of us, uh, um, expanding our abilities to offer medical services via telemedicine is a win-win for everyone involved. And, uh, once again, I don't see the genie going back into the bottle on the offering of telemedicine.

Speaker 1:

Yeah, it should be, I mean, there'll be so much data on its usage. Um, there might be a use case we just couldn't have before until this time. Um, and one of the, so one of the things I, I've been thinking about, and I'd love to get your thoughts on this, is sort of the phases of preparedness and response. And so we see telehealth, we see testing centers and tents going up in, in emergency departments. And so what, what's next? Like we, we read about the potential for, um, surges to, um, happen across this country and, um, just, you know, in China we saw hotels being used so people weren't discharged necessarily to home. Um, we just saw, um, CMS kind of loosen up some of those requirements about, uh, moving patients from hospitals into potentially hotels or other, or other buildings. Um, we're also, I I've been seeing and I've, um, and, and reading about, for example, the AMA guidance on, um, scarce resources such as ventilators and standing up your ethics committees. Um, Dave, what are you seeing or or doing to prepare for what I would, I guess call the next phase of, of preparedness here? And what do you see sort of on the horizon?

Speaker 2:

Well, I think you summarized it very well. I think that, uh, as I mentioned before, we do a great amount of time trying to model and using, uh, the studies that other people have put together. I think that we're all looking at what's happening in Washington state, in New York City, other countries around the world. So I think that we're preparing, uh, a surge for a surge so that we've looked at, uh, how we can get more ICU beds, uh, put into our facilities. Uh, we've looked at using a major building on our campus on main campus to convert it into a, uh, temporary, uh, facility. We have three hotels on our property that we intend to use for a variety of purposes. Some, uh, people who, caregivers who test positive that might not want to go home and, uh, potentially infect their families and we can house them there or exhausted workers. Uh, so we're looking at a whole range of things that, uh, also support our caregivers. Uh, so for example, those who test positive and, and, uh, must be quarantined that in, not quarantined, but, but treated those individuals. If they're not on main campus, we have food services, other things that we can do to support them. And I think somebody mentioned before the mental health aspects that, uh, really can, some kind sometimes go undiagnosed, but you have to be very aware. It's certainly been a concern in other areas. So I think it's always, uh, trying to prepare and realize too, that during these periods of time, you have to be very careful and not take your ball off or your eye off the, uh, cybersecurity issues and risks because, uh, bad people do bad things during these types of periods. And I think I've had more hand sanitizer in my entire life. Uh, and so I, it's all the little things taking care of yourself as well.

Speaker 1:

Yeah. Mark, what do you see on the horizon and what have you been working on for this sort of next wave, um, knowing that you have hospitals in different states and different, um, stages of the, of, of a potential surge?

Speaker 3:

So first I can tell you we have hospitals in two hotspots right now, um, New Jersey and Michigan. And then we, um, became aware this morning, there's a third hotspot in Georgia where we have a hospital. So one of the things we're doing is we're leveraging our institutional knowledge and we're having nationwide CEO huddles to share best practices. And an awful lot of great information is coming out of those hospitals that are in the surge to help the hospitals that may be in a surge later prepare for them. From the legal perspective, um, we've been parsing really carefully the CARES act to figure out what business continuity options there are. You know, we've got for-profit nonprofit hospitals, and some of the CARES Act support is for nonprofits, and they're, um, strict deadlines. So we're trying to make our hospital finance people and our corporate finance people aware that, hey, we need to meet these deadlines and we may not be able to get this incredibly necessary financial support. Um, I personally, having again been in the field, I'm thinking about end of life issues. What do we do if, um, demand exceeds supply on vents? Are we gonna go to two vents to support one patient? You know, are we going to be in a situation where we're gonna have to make some really, really difficult triage decisions? And if so, how do we support our providers in making those decisions? Um, I'm thinking about what the alternative care sites look like. If we get to a place where we physically can't manage the surge, how do we use the new authority? We've got to maybe establish lower acute units in hotels or in college dorms in one case to make sure that patients who need care but don't need to take an acute care hospital bed during this time can be cared for in that scenario, can be cared for. Well, we can feed'em, we can have line service for'em, we can have care for'em while at the same time not stretching our hospital resources too thin.

Speaker 1:

Rich, how about you? What are some of the things that you've been working on to, to look to the potential future of, of surges?

Speaker 4:

Well, I would just echo what, uh, both Dave and Mark have said thus far. We are, um, looking at all options, working with all units of government, uh, throughout our footprint, um, even working with our sponsors as well. Um, both of our sponsors, presentation Sisters and Benedictine sisters actually have, um, vacant, um, old, uh, housing or, or, or actually there were old convents, um, that they, uh, no longer use. And we're looking at whether or not those can be brought back online. Um, and as Ben mentioned before, working with, um, the hotels and other hospitality industry folks. Um, so everything is on the table. Um, there's, uh, nothing that will not be looked at, um, so that we can effectively deal with the upcoming surge that we expect to, um, be hitting our areas within the next few weeks.

Speaker 1:

You know, we have a lot of people that will be listening to this that are, um, in-house council or perhaps, um, working in health systems or healthcare, um, space. If you had to give, you know, in-house counselor those, uh, folks, one piece of advice, um, rich, what would that piece of advice be?

Speaker 4:

Well, I tell you, the one piece of advice I tell folks, as you mentioned, and once again it's been mentioned before, is about communication. Not only communication with your own, uh, um, staff and giving, you know, uh, specific and um, uh, direction on the task at hand, either, uh, issue management or promulgation of, uh, new, uh, um, um, modalities to effectively care for people. But it's communication with, um, your peers. Um, as well, I've been hearing from peers throughout the entire country, essentially with regard to best practices and trying to delineate each one of those and really get them out to, um, my folks at Avera so that those best practices can be followed. Because all in all, as been said before, we are in this together to take care of people and get us through this, um, pandemic episode.

Speaker 1:

Um, Dave, you know, there's a, I don't think healthcare will ever be the same. I don't know if our culture will likely change. Um, how do you see Covid-19 changing healthcare delivery in the, in the,

Speaker 2:

It's a long list. Uh, I think that clearly, uh, the preparations that, uh, we needed to make so that this can't, well, it will happen again, but hopefully not the same way that supply chain issues everything for, uh, where drugs are developed, manufactured. I think it has really focused on the value of, uh, healthcare workers of every stripe. And I think that it will, uh, show that we have to have the resources, uh, for a situation. How many years ago did we think, gee, we didn't have enough beds or we had too many beds. Uh, something like this proves that we're all scrambling for ICU beds, ventilators, that kinda thing. So I think that you can never be totally prepared, but I think this was a wake up call and, uh, we will learn from it and frankly, hopefully optimistically not be in the same situation again.

Speaker 1:

So, mark, why don't we, I wanna end with you and ask you, did you, do you think that this is a wake up call to our healthcare system? And what, what do you think, what do you think will happen with this wake up call?

Speaker 3:

So, a couple of things. Um, I've said for years that Medicare and commercial payers have bred surge capacity out of our system. And regrettably, I'm right. Payment policies will need to change or will regrettably be in almost the same place next time. You can't cut healthcare reimbursement to the bone. You can't carve 5 billion out of healthcare reimbursement a year for managed care profits and expect to also have surge capacity. That's not, you know, that's being kept just in reserve. It, it's not possible. It's not an economic reality. The second thing is I think people will begin to vote with their feet. I think that we're seeing a lot of political dysfunction. This is not a political problem. This is not a red state problem, it's not a blue state problem. This is a human problem. And the more our politicians dither about who's gonna get credit for what or which states get priority over what, without regard to clinical needs, I think people are really begun be gonna begin to see, gosh, there are just gaping cracks in the political system that underlies our healthcare. And then I guess the last piece is that people will stop taking for granted that everything they need will always be there when they need it. And we as a system are gonna have to figure out, well, how do we manage their expectations? Because in addition to the actual caretaking of people, they have to have faith in the system. They don't have faith in the system, they won't go to the hospital, they won't go to the doctor. And in the case that we are now, where we're trying to flatten the curve, and we need people who are symptomatic to get treatment, and we need people who are not symptomatic to stay home. If you don't have faith in the system, you don't have faith in your leaders and you're not gonna have faith in the recommendations, and we're not gonna be able to manage as well as, as we otherwise could have.

Speaker 1:

Mark, thank, thank you for that. Um, I really appreciate, um, mark, uh, Dave and Rich joining us today, uh, to talk about what's happening with Covid 19 and, and really boots on the ground learn. Um, what, what are some of the solutions so that other people in the country who maybe are not, are working through these issues can hear some of, uh, I mean, I think some of the, the top institutions in the country work through some of these, some of these issues. Um, thank you everybody on the webcast for, for joining us. This is Sarah Swank from Nixon Peabody. If you need any, um, information, I would direct you to the, uh, a H l a, uh, coronavirus hub. Uh, there's, uh, just a whole host of information and definitely stay tuned. There'll be more podcasts. We wanna get information out to you to help. Thank you everybody. Have a good day.

Speaker 3:

Thank you, sir. Thank you sir much. And Sarah, if I could just add one thing, if everybody could go out and thank a caregiver, thank an environmental person. Thank a paramedic. I've never been prouder to be part of the healthcare system than I am now, but the people who are really bearing the brunt of this emergency need our thanks and support more than ever. I have an amazing team at Prime, both on the administrative and the care side, but gosh, I'm letting them know that every day because they need to know that. I appreciate

Speaker 1:

It's, that's the perfect to end this. Thank you. That's.