Keeping Rural Hospital Doors Open Through Advocacy, Collaboration & Storytelling with Craig Thompson

JH: Fully agree with you. Great perspective Craig. Certainly, not a day that goes by that the Becker’s articles don’t pop on my email and I’m going, wow, that’s something new and interesting that we’re going to have to tackle. It is an industry that is so dynamic. I know every year that I am serving in this role, I say it every year, that it’s more and more dynamic. But it is it is incredibly challenging right now for us. We’re going to talk about that in just a minute. Today, for our listeners, we’re talking about maintaining local access to care in rural, remote areas and how rural hospitals must think outside the traditional box to solve those problems facing our health systems today.

Craig is here to provide insight and experience as a chief executive officer of 10 years and 20 years prior to that, in leadership roles at a rural independent healthcare system. We’ll talk about local access to care, federal funding, and of course, what all this has to do with rural health. So, let’s jump right into it, Craig. So, you know, you’ve been a health care leader, it sounds like, for decades, most notably the last decade. As the chief executive officer. What today, what would you say are your primary concerns about local access of care for your community? And I want to do that in a two-part series. And in what ways is your hospital system tackling these challenges today?

CT: I think my biggest concern as it relates to access is understanding what access is, because, you know, I think we many of us likely provide primary care services and, and primary care services for us is really the heart and soul of who we are. It’s the entry into everything that we do and the relationships that our patients have with their primary care providers, those are sacred. In a lot of cases, and for many of us outside of our spouse and our children and our loved ones, it’s our most trusted relationships. But even that relationship right now, to some extent, is under assault. We can all pick up our cell phone and we can have a primary care visit. I would argue it’s not the same quality. I would argue that it doesn’t provide the same continuity, but someone’s trying to chip away at that. So, when we think about all the things we do, nobody wants to chip away at the stuff like emergency services or birthing services that have zero margin and have high risk. Nobody wants any of that, but we have all kinds of disruptors in the world who are trying to chip away at the stuff that are vital to our ability to provide care to our community.

In rural communities, access is not just their lack of public transportation, but access is also driven by the lack of a pair source. Access is sometimes driven by the fact that even if there is a payer source, there are high deductibles that get in the way of a patient’s desire to receive the care that they really need. Beyond that, there’s technology components that really impact access. So, we’re doing a number of things to address that. We know that at times our patients simply can’t or won’t travel for the care they need. We do everything we can to provide as many services as possible to our communities so that they don’t have to travel. Just recently, we unveiled this to our community last month. We were fortunate to have received a grant and then had some private donations to help to purchase a 36ft long RV. Within that RV we’ve added, it’s equipped with a 3D mammography machine. So, we have several clinics that offer mammography services, but there are several communities around us that don’t have access to those services. So, we now plan to take that care to those individuals. We are so excited about that service, really to expand that reach, with any cancer, early detection is key for the best outcome is an easy screening opportunity, but if you can’t access it, you don’t have that same opportunity.

JH: It’s incredible work that you and your team are doing. What a visionary. You know, it’s so costly. If you look at it from a CFO perspective and so far, CFO friends are listening, I’ll apologize in advance. Oftentimes they tackle us with, well, there’s no ROI here, but you and I know as leaders in the organization, sometimes it’s not about the ROI. It’s about the quality of healthcare that we can provide to our community, healthier communities, readmission rates lower. They’re not coming into the air sicker. And so, it sounds like you’ve got a great handle of it in your corner of the world. So, congratulations to the work that you’re doing. Now let’s shift a little bit, because each of the guests that we have on here, the staff give me a bio. I sent an email back and said, this guy should be interviewing me, not the other way around. You have done a lot in advocacy, and I want to get into your specific work with the Ways and Means, some testimony that you provided and some work you did.

Before that, let’s just talk about advocacy in general, right? There seems to be a lack of it. There seems to be a lack of telling our story. There’s this there’s this assumption that we’re nothing more than waste, fraud and abuse. There is this assumption that we are, you know, deep pockets and it’s just the opposite of that. We are one catastrophic lawsuit away from closure. We’re one average commercial rate departure from Medicaid with a one big beautiful bill, from closure. All of those challenges are present. One of the areas that I think we can exercise our voice is in advocacy. So, I want to ask you this question. It’s a general question first before we dive into it. How can advocating for health care at both the state that you’re in and federal level, help us as an industry maintain local access to care. Let’s talk about it broadly at first. Then I want to get into the weeds a little bit.

CT: You’ve mentioned it already. The reality is we have to tell our story because if we don’t, someone’s going to tell a story for us. I spend a lot of time in Jefferson City, Missouri, which is the state capital. Right now, our legislators in session. So, during session, I try to make it to Jefferson City at least one time a week. Then throughout the year, I try to make it to Washington, D.C., to meet with our Missouri delegation there at least four times a year. Sometimes I have very specific advocacy topics. Sometimes it really is just to show up and make sure that there’s a face with a name. But to your point, telling our story is vital because there are all kinds of industries and all kinds of entities that are trying to undercut what we do and get a piece of what we do, but without us taking the time to tell our story. There’s going to be a story that legislators listen to because that’s what they’re hearing. I think it’s uncomfortable at times. If you’ve never done it, it’s uncomfortable to walk into a lawmaker office and meet with their staff or to meet with them, but reality is, and if you’ve ever had this experience, you understand it. You actually get more face time and attention than a professional lobbyist. They see professional lobbyists all day long, all day long. They’re more willing to listen to someone who does it, sees it, feels it, and hears it than they are those professional lobbyists.

JH: Absolutely agree. And to our listeners today, you’ve heard it directly from someone doing that work. Craig Thompson with us, chief executive officer of Golden Valley Memorial Healthcare, who’s leading the discussion in Washington and his state regarding the importance of local access to health care. There’s too many challenges facing us today. But you heard it directly from him. Let your voice be heard. Make your contact with your state and federal authorities. Take a tour. Make it a point to go visit and then invite them back onto your campus to see what’s happening firsthand. The constituents in their community who need to lift their voice until their congressional leaders and their state legislators why it’s important to keep local hospitals. Craig, some of the work that you’ve done has been on the Committee of Ways and Means, which is a very powerful committee, and you’ve had the opportunity to address specific topic as it relates to rural hospital reimbursement or at times, what you and I feel is a lack thereof. So why don’t you talk to us a little bit about that work that you’ve been engaged in?

CT: I’ve met with the Ways and Means Committee staff on several occasions on the topic of residency. We are in the process of standing up a residency program which will be a family practice residency program. We were fortunate to have received a grant from HERSA to help us stand up this program. If anyone’s ever set up a residency program, it’s complicated. All the work around graduate medical education has to be done right. We all want highly trained physicians. There are specific things you have to do along the way to become accredited as a residency program. So, we were fortunate to receive this three-year grant. So that really helps. It’s really holds our hands and helps us stand this program up. So that piece we have covered.

What we recognize along the way, and other rural hospitals who are also trying to stand up, these residency programs are about three others in the state of Missouri right now who are on the same timeline as us and trying to stand up a residency program. What we recognized is that for Medicare dependent hospitals in soul community hospitals like us, we receive about $75,000 less in reimbursement per resident per year as opposed to our urban and suburban counterparts who offer residency training. They’re really two different components of reimbursement for residents one’s through the GME process and one’s through the IME process. Well, for whatever reason, soul, community and Medicare dependent hospitals do not get IME reimbursement, which means we receive about $75,000 less per resident per year. Now, if you think about that, the more residents you try to put through your program, the more it costs you to do so. There’s really a financial disincentive.

You know, JJ, you understand another other rural hospitals understand, we can provide a great training ground for family medicine physicians because our family practice physicians and I suspect yours are the same, they’re not just family practice physicians, they’re cardiologists or they’re urologists. They do it all. It’s a great learning environment. What we also know is physicians are more likely to practice in areas in which they train. So, if we can train more physicians in rural areas of the country, they’re more likely to practice in those rural areas because they recognize, like you and I do, the beauty and joy of living in rural parts of the country.

JH: So how would you characterize your success so far in trying to lobby for this?

CT: I need to give credit where credit is due. There’s a lot of people who are really advocating for this same fix. Jason Shenfield, who’s the CEO of Phelps Regional Hospital in Rolla, Missouri, has also been a strong advocate around this same topic. I appreciate his engagement, involvement. We are very fortunate right now that Jason Smith, Chairman Jason Smith, is the chair of the Ways and Means Committee. He is from Missouri and he does recognize the importance of rural health care. So having that support has been beneficial and we believe we are making significant progress. Matter of fact, the last time I met with Ways and Means staff, they promised some legislative text that would fix this problem and would start to provide not only this equalization in reimbursement, but in addition to that, for these real residency programs, also some start-up costs to help offset that startup component. So, it’s not in hand just yet, but they’ve promised we’re going to have that in a relatively short period of time.

JH: Well, congratulations, and it’s proof that advocacy does have a reward. Obviously, to our listeners today, you have unique issues, just like issues that are facing Craig in his hospital. Lift your voice. You know, reach out to your congressional leaders. I think that’s our lesson for today. Let’s shift gears a little bit, because as you know, the H.R.1., also known as the One Big Beautiful Bill comes down, we’re told by 2032, $1 trillion cut majority of that Medicaid program. I’m not sure if Missouri is a Medicaid expansion state. What that does is it removes that average commercial rate that you were getting that delta between what you were getting paid for Medicaid, and then with the expansion, the ability to pick up that uplift.

Hospitals in our region and the state of Michigan, for example mine, $6 million loss every year annually in that reimbursement. And when we’re on a shoestring budget and a very razor thin margin, $6 million is; you’re out of business. You can’t do that. It just doesn’t work. So, there’s been a lot of conversation from congressional leaders, that it’s all going to be fixed with the Rural Health Transformation Fund. So, they took away $1 trillion. They give us back 50 billion of a trillion, and of that it’s divided by the states. I’m not sure we’re Missouri, how you fared in terms of the number. You divide that by all the hospitals. You divide by who’s eligible. How do you define rule. Then all of a sudden, you’re looking at mere pennies. But then each state designed their program based on whoever the governor of the state appointed to be the lead. I would like to learn a little bit more about how it happened in Missouri, what you feel about the outcome, because I can tell you in Michigan, it’s a hot mess. None of these funds are going to be used to help supplant any of the losses that we’re going to sustain, either from the tax credit rollback under the rollout, or is it going to help us at all in the reduction through H.R.1.? So, give us an overview of what your state went through, if you would. How do you see these dollars being allocated as a benefit to your organization.

CT: So, Missouri is an expansion state. We actually expanded Medicaid through a constitutional amendment from the vote of the people, which actually complicates a few things right now. So, Missouri actually did very well in terms of their application to CMS for Real Health Transformation program funding. Missouri is the ninth highest award in the country, even though in terms of rurality, we’re about 21st in terms of actual across the country, we received 216 million here in year one. The challenge, though, is there are about 2.5 million rural residents in the state of Missouri. If you do the rough math, 2.5 million residents at 216 million total, that’s about $83 a head. So, the opportunity to be transformational, I think, is going to be a little bit of a stretch, and it’s going to be a challenge. When H.R. one was being deliberated, it was actually Senator Josh Hawley, who’s a Missouri senator who helped to champion this rural hospital stabilization fund.

So, if you remember, it was not a rural I do remember transformation program. It was a rural hospital stabilization, which is very different. What I am beginning to worry about and recognize, among other things, is because this has moved from a stabilization program to a transformation program. The only real way to achieve transformation is to take the training wheels off and let us try to do some things that are transformational, but what I’m beginning to realize is, no matter what the state’s plan and no matter which state it is, there aren’t opportunities to really color outside the lines, which is going to make it harder to be transformational. As a matter of fact, I learned this week for all states, even when those states are putting out a press release about their program, they have to send that press release to CMS and CMS has to edit an approved press release before they can send it out to their constituents. That just speaks of bureaucracy. We know every single day and have to live in a world every single day, where limits the ability to be transformational and creative.

JH: Powerful and absolutely on point. That’s exactly what our states across this union are facing today. As whoever the fiduciary is of that respective state builds their boilerplate templates and the processes that they go through. Some are going to be a heavy burden and a heavy lift for rural hospitals to fill out applications go on to state portals, apply for program in nature. Programs in nature create legacy costs. How do we continue legacy cost? A lot of questions still have not been answered, but certainly I would venture to say to take out the word transformational because it’s far from that. I do want to go back just a little bit. You gave it you raise an interesting fact. When the people of the state of Missouri enacted this expansion, I don’t know if any other state that did it by virtue of the people. It’s usually the legislative body that did it. So, does it have implications for setting within statute this requirement to provide that uplift? How does that work?

CT: It does. So, what now becomes complicated with H.R.1. And I don’t I don’t want to get into all the specifics around H.R.1. What we do know is there are differing levels of reimbursement and differing levels of support based upon the Medicaid population and the expansion population. Because Missouri expanded Medicaid through a constitutional amendment, Missouri can’t separate the two. So, any reductions in any kind of services to the expansion population, the state has to pick it up. So, it has really created a lot of statewide discussions around how do we manage this cost for our traditional Medicaid population. It would have been X for the expansion population would have been Y, but we can’t separate the two and have to provide the same benefit to the entire Medicaid population, expansion or not.

JH: Craig, you better close in prayer on that one, because I’m telling you right now, you’re blessed beyond measure because it’s statutorily required now. In states like Michigan, that delta does not have to be made up by the state legislature. They just drop it. So, you’re in a unique position to force the hand of government to actually cover those costs, which means you’re going to have less loss than most hospitals in our nation. It’s a great position to be in.

CT: It is now the challenge with that is, and where will they take the money from? Missouri has been one of the states that’s been unique in our ability to leverage the provider tax specifically. Without that process in place at this point, they’re going to have to look at general revenue to support the Medicaid program. So, are we going to see cuts to education? Are we going to see cuts to transportation, you name it? I think the state’s worried about where do we now find the funds to cover the Medicaid program or increase your tax basis, which of course always cause concern.

JH: So, it’s might be a great spot for your rural hospital, but maybe not such a great spot for everything else. Well, let’s dive into one more item before we close. It’s hard to believe time is already upon us. You know you’ve been a leader for decades. You know, most importantly, you’ve led through the most difficult times in our careers, Covid, lack of reimbursement coming in. Finally, there were some uplifts. You know the story. But at the end of the day, I think what we see is a bigger challenge is what we just talked about, which is those cuts to Medicaid programs. It’s the cuts to 340B, it’s the cuts to low volume adjustment. LVA survives yet another year, maybe, but that’s a big number for us, right? Disproportionate share. All those things that we rely on are really right now at the forefront of discussion of elimination. Big Pharma logged over two dozen visits to Mara Lago last year, and that’s a challenge.

So, at the end of the day, with all of these factors that are surrounding us, what advice would you give regarding the issues of rural health sustainability and hospital sustainability, for a new leader listening to this today, that’s like, how are we going to make it? First of all, share with us any strategies that you’re deploying because I’m sure you’re around your boardroom having those conversations. What are those? What does that look like? And then what? How would you direct another hospital to survive this?

CT: Well, there’s really three things. The first we’ve talked about and that’s advocacy. We’ve got to tell our story or someone’s going to tell a story about us that may not be accurate. So, I would encourage everyone get to know your legislators, both at the state and the federal level. Take time to make sure they know who you are. Take time to make sure they know how to access you and make sure you have access to them. That’s vital. You got to do that. The second piece is collaboration. You know, I think we’ve all got to come to terms with the fact that what we have historically may be viewed as competition, we need to figure out ways to be collaborative. As I look at just the regions that we provide care for in Missouri. There are other hospitals that overlap part of those service areas and 7 or 8 years ago we’d have fought over some of those areas. That doesn’t work any longer. We’ve got to figure out ways to collaborate. We’ve got to figure out ways to share resources, because if we don’t do so, we’ll never be able to provide services to our community.

Then the other area that I think is so very important, and it goes beyond advocacy, but kind of ties into some extent. We’ve got to be able to tell a story. You mentioned the 340B program, which is vital, if I would suspect, for every rural hospital across the country, three plays a part. For us, if it goes away, we don’t know how we would make anything work. Talking about the 340B program itself is complex, and I don’t understand all the complexities of 340B program, but I understand what that 340B program allows us to do. I can put a face to that program because it is it is the mom who comes in and delivers at our hospital. It is the ambulance service that we provide to our communities without any tax support. It’s really all the things we do because it covers the gap between the reimbursement we get from the governmental payers who don’t cover our costs or come close to it, but being able to make that personal matters and being able to tell a story around those complex issues resonates with people.

JH: Absolutely agree. Excellent advice. Excellent strategy. You know, there are the most tumultuous of times ahead of us. I believe the phrase allergy, you ain’t seen nothing yet. Even if individuals are counting on any type of mid-term relief, we know you and I both know it’s going to take 3 to 5 years to turn anything at this point. So, we’ve got to get in our boardrooms. The advice I think you would give, I would give as get inside your boardroom, create it as a war room, have those discussions about prioritizing the services that you offer. Community benefit. Look at your growth strategy. Develop a plan and hit your legislative body very, very hard with the reality that you need your local hospital. I would venture to say, Craig, you’re probably one, if not the largest employer in your region.

CT: We are three times larger than the next largest. So absolutely.

JH: So, you’re absolutely leading the way. You know, it’s always great to talk to a leader of your caliber to learn about what you’re doing in the corner of your world that could impact others in our industry. It’s so insightful. One last thing that I would ask you. We have this on each of our podcasts. For new listeners who are maybe new to healthcare, there’s a lot. I mean, our heads are swimming every day. We get interrupted by all of the things that are happening nationally and at the state level, and then we still have to step back and run a hospital, right? We still have to worry about the temperature in the OR and the humidity. We’re worried about all these things, but we have to balance that. We have to balance our board, our community, what’s happening all around us. It can be very challenging for young leaders. What advice would you give to a young leader today? Sage advice. Aspiring advice about how to deal with today’s times?

CT: Two things, one, get involved with an association. Our organization is very involved with the Missouri Hospital Association. I’m actually the immediate past chair of the association. We find great value in that association membership. We receive a lot of resources. You know, as an independent hospital, you just don’t have access to all the things you need. That association helps to fill the gap and provide a lot of those resources. So, whether you have a professional association, a hospital association, get involved with those associations because they can help provide resources. The second is, and JJ, you understand it, I understand it. The saying is true, it’s lonely at the top and find trusted resources because someone has likely figured out a solution to a problem you have. If you have a trusted resource and you have a network, rely upon that network, rely upon those resources. I have I have a friend who’s the CEO of a hospital in Hannibal, Missouri. Todd Aarons is his name. We talk every single week and we compare notes and we bounce ideas off one another. Next week there are five hospitals, all independent rural hospitals, who are meeting in Hutchinson, Kansas. Hospitals from Iowa, Texas, Missouri are getting together to share best practices. Someone out there is doing something better than you. Figure out who it is and then replicate it.

JH: That’s incredible advice. Craig, thanks for the work you’re doing. When you go to Washington, I think it’s important to understand you’re not just representing Missouri or your memorial hospital. You represent me. You represent small hospitals. Critical access. We’re a midsize vital. You’re a mid-size vital representing hospitals across the country. So, thank you for your advocacy. What you do in DC has so much implication on how we run our business as well. I want to thank you for being a champion and an advocate. Based on this interview, you’re going to be back for 2 or 3 more podcasts, my friend. So, thanks for joining us. It’s been great to have you.

CT: Well thank you, JJ I’ve enjoyed it.

JH: And thanks to our listeners for tuning in to Rural Health Today. Catch our next segment, Rural Health News to stay up to date on the current state of rural health every Monday, wherever you get your podcast. And don’t forget to check out our latest updates and resources at Rural Health Today at ruralhealthtoday.com, and make sure you subscribe so you never miss an episode. Until next time, remember rural health strong.