Safety Net Hospitals | Dr. Olusegun Ishmael | Sinai Chicago | Part 1 of 2

Maria Romano:

Welcome everybody to the Patient Flow Podcast powered by TeleTracking. My name is Maria Romano and I am the Global Clinical Executive that works at TeleTracking. The subject that we are going to be talking about today on the podcast is Safety Net Hospitals. Safety Net hospitals are known as a type of medical center in the United States that are by legal obligation to provide health to citizens regardless of insurance status and to service all populations. The mission of safety net hospitals are to focus and emphasize their devotion to providing the best possible care to those in the United States that can not have it. TeleTracking absolutely partners with multiple hospitals across the United States that are known as Safety net hospitals. And on today's podcasts with TeleTracking, we have a very special guest from one of our very special hospitals that we work with, Sinai Chicago. And today I would like to introduce to you Dr. Ishmael. Hi, Dr. Ishmael, how are you?

Dr. Ishmael:

Good. Hi, Maria. How's it going?

Maria Romano:

Good. Good. Thank you for joining our podcast today, Dr. Ishmael. Can you please give the audience an idea of your medical background and also the hospital size and the demographics for Sinai Chicago?

Dr. Ishmael:

Well, first, thanks for having me on. It's a pleasure and it's definitely an honor for you to have me here. Thank you very much. So my clinical background is kind of interesting. I actually went to medical school in Nigeria. So even though I grew up in the States, somehow by the twist of fate, I ended up going to med school in Nigeria, came back home to the States and went to residency in Gary, Indiana. Very impoverished city, a struggling city at the time I was doing residency in family medicine. It was known as the crime capital of America, so lots of traumas. But I really wanted to learn how to train and teach physicians, medical students, physicians, et cetera. So I did a fellowship at University of North Carolina Chapel Hill. It was a great, one year after that, became faculty, then stayed on as Chair of the Division of Family Medicine at Methodist Hospital in Gary.

One day, sitting in a meeting with the president of the hospital. Literally walked out of the meeting when it was concluded, and signed up for an MBA. So I ended up getting an MBA because of the statements that was made to the physicians about how we didn't understand business. So I wanted to understand business. So that's how I became a physician executive and then joined some health plans. I think I worked for every Medicaid health plan in the country, except in the blues.

Now, demographics, and I always joke around, if you look at me, you've probably seeing our demographics. It's black and brown people in the inner city of Chicago. So our Mount Sinai facility is located on the west side. Our Holy Cross campus is located on the south side. We have the largest number of penetrating injuries at Mount Sinai. Well always the top three penetrating injuries. So gunshot injuries there. It starts from April, we call it our trauma season, which pretty much coincides with as the city gets warmer, the trauma season starts. So from April through September is our trauma season when we compete with either Cook County, University of Illinois or University of Chicago. In terms of penetrating injuries. Our south campus, which is our Holy Cross campus, actually has the largest number of EMS runs. So we get the largest number of trauma one side for the city, and we get the largest number of ambulance runs for the city on both campuses. So we're busy.

Maria Romano:

You're book ends, right?

Dr. Ishmael:

Merged from both sides. We're busy. And like I said, the demographics is predominantly inner city, black and brown people. We recently acquired a practice actually in Chinatown, so we are beginning to see a lot more people of Asian descent, of Chinese descent coming to Mount Sinai. So we're an interesting goulash, smorgasbord board of individuals. But most importantly is that it's unfortunate that it's a lot of people who are underserved and underrepresented and who have a lot of socially determinants of health or impact them. So things that you and I may not be thinking about is may not be front of mind for us, is definitely in front of mine for the population that we serve. Simple things like transportation, do we have a supermarket in our neighborhood that is easily accessible? So simple things that you and I don't think about that our patient population do have to think about on a day to day basis.

Maria Romano:

Can you take a moment and tell me about why you are choosing to work at a safety net hospital when you have the opportunity with your experience really to go anyplace else and not have to carry this burden?

Dr. Ishmael:

It's a personal thing. So you wake up every morning, you ask yourself, there both for the grace of God [inaudible 00:05:58]. So like I said, initially I came to the States when I was four. My parents were struggling students. We accessed community services such as Safety Net Hospital. So for me, it's a personal opportunity. When I chose to do residency in Gary over during residency at a hospital in Chicago, it was because I wanted to treat patients that I could see myself in them, the struggle. When I chose to come to Sinai Chicago, it was also, once again, it was a decision to see how I could help change the face. And it reaches all the way back to even during when I said as a medical student, I saw this elderly gentleman who is struggling and the delay in care because that's where that system work. And I said to myself, "No, just like the WHO, nobody should have to do that." So how can I make the world a better place with me in it versus what can I benefit personally for myself? So this is more of a personal statement.

Maria Romano:

Well, I'm going to let you in on a little secret. You're absolutely doing that. You are making our world a much better place. And I really honestly thank you for that. In 1946, the World Health Organization declared the highest attainable standard of health as a fundamental right for every human being. And with this action that was made, it was clearly stated that there was an understanding and noted that as an understanding that health is a human right for all, and it's a legal obligation on states to ensure access of timely care that's acceptable and affordable. So my question is, from your perspective with knowing that with what the World Health Organization stated back in 1946, from your perspective, how are safety net hospitals adequately funded to deliver this appropriate conditioning to ensure that it's human right access of care?

Dr. Ishmael:

So I'm going to give you a life experience first, a long winded answer to a very long state question. I remember being a medical student in Nigeria, an elderly gentleman came in with acute urinary retention. Now you and I, imagine you're on a long road trip in the middle of nowhere and the next bathroom, you got to go and urinate is 20 miles away. So this gentleman had not gone to the bathroom to urinate, and I think it was about almost a day. So what happened here... Showed up in our ER, and I was a medical student, so he shows up in our ER, we give him a grocery list of things that he needed to go purchase and then sent his family to go make a payment arrangement before we treated him. That's a third world country. Fast forward, just like you said about United Nations and WHO have said that it's a fundamental right of everybody to get healthcare.

So this gentleman had been in acute pain for almost 24 hours. We still delayed the care until he made a payment, made a payment to arraignment, and his family went out to purchase down to the catheter and gloves. That would never happen in the United States. So that's part of my impetus for joining Safety net hospitals. I was working with a Medicaid population is... I never wanted a situation where we as a country get to that level of delay in care. And that's what safety net hospitals do. We accept everybody irrespective of whether you can pay, whether you're on Medicaid, whether you're Medicare, whether you have the best commercial insurance out there or whether you have no money at all. So that's what we do. Now, having worked for Medicaid health plans and managed care organizations, I realize that safety net hospitals struggle because of that payment and payer mix.

We're very dependent on federal funding. We're dependent on disproportionate pay. So the whole dish payments, if everybody's not aware, it's just to offset the amount of monies that we don't get through commercial insurers. So I think at some point we're going to have to rethink the way we pay safety net hospitals and their funding sources because right now we're perpetually, and I hate to say it on the brink of financial ruin. Majority of safety net hospitals are always on that very prepetice of falling over the cliff. So we've got to change the payment structure, we got to enhance the amount of monies that we get from Medicaid plans and the timely payment and the administrative burden. And I know this from first hand because I used to be the guy on the other side of the fence, as most physicians say, I have been on the dark side of healthcare in terms of paying, working for the insurance companies.

So we got to reduce the administrative burden for safety net hospitals. We also got to figure out how to pay them appropriately and in a timely manner for the services that we render. And also from a federal perspective, we really have to look at how this impacts people that come to our facilities because we are usually treating the sicker of the population. And a lot of times it's because these same individuals also have social determinants of health, psychosocial issues that make their healthcare worse. And Covid has truly exacerbated all of this. So, sorry, long winded answer to a very-

Maria Romano:

No, there was so many different buckets with that answer, just like in the question too. So let me ask you this question to follow up with all of what you had said. So with the pandemic, did payment get affected... Reimbursement? Let me restate that. With the pandemic, did reimbursements get affected for the care that you were delivering to the patients?

Dr. Ishmael:

It's not necessarily the payment got affected, the biggest bang most hospitals get are in terms of margins for services that most hospitals render are under surgical services. So most surgical services were pretty much either canceled, delayed during the pandemic. So most of our payments that we would've expected for our higher margin procedures were pretty much gone during the pandemic. So we were compensated through a lot of federally financed processes, but a lot of that money is needed to be paid back also. So from a safety net perspective, most of our margins got either shut off or delayed. But when you look at even payments from managed care, that's also delayed. And during this period, because people cannot get their preventative services like check your cholesterol, get your mammogram, get your colonoscopy. So by time you started getting back into the hospital setting, they were sicker. And then because of also psychosocial issues and everybody being cooped up at home, you had a lot of other issues. So all those social determinants of health exacerbated.

Maria Romano:

It was like a domino effect, everything came crumbling down.

Dr. Ishmael:

Exactly.

Maria Romano:

And I know we talked multiple times where efficiency had to be that top goal, right? To be able to stay open.

Dr. Ishmael:

Correct. Yep.

Maria Romano:

Right? So with that being said, how do you feel the hospital could have responded better during the pandemic. By ensuring services were, I would say, load balanced to make sure reimbursement... With losing that high reimbursement, do you feel that there could have been anything else that you could have done to improve that med purge?

Dr. Ishmael:

I think one of the biggest things that... And you and I have talked about it, is even now, how do we load level between even all the safety net hospitals? So for example, how do I know where all the beds are within the safety net system within Chicago alone? Does one hospital have beds versus another hospital being fully packed? So for example my hospital, we're always bursting at the seams, but we may have a sister safety net hospital who may have an extra two, three beds. Can we leverage technology to find out where all the beds are within the city or even within the county, transfer patients appropriately. And then even if we don't have the specialists at these facilities, can we leverage them telehealth at compels? So is it a pulmonology consult? Is it a cardiology consult? So that we're all basically working as a effective system versus each one against each other.

Maria Romano:

So a system of safety net hospitals in the great Chicago area. Even some of your safety net hospitals, your sister safety net hospitals are literally possibly down the block from you. Where that balancing really could help you from that perspective of what the World Health Organization is stating that we have to do. It's a human right to provide access of care along that you need to get that reimbursement efficiently too, while providing immediate access of care. So juggling that with load balancing and coming together as a system of safety net hospitals in your area would be the best for the patient.

Dr. Ishmael:

Exactly right. And because for me, delayed care sometimes could be worse than no care at all.

Maria Romano:

We will continue our conversation with Dr. Ishmael in our next Patient Flow podcast episode that's powered by TeleTracking.