Ep. 115 - Rural Hospitals Are Vanishing - Tom Campanella Explains Why It Matters

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I am Meredith Hirsch, and this is working healthcare. Rural healthcare is not a side issue. It is where the major problems in American healthcare show up first: primary care shortages, hospital instability, rising consumer costs, fragmented policy, and too many powerful players working in silos while smaller communities are left to fight for access. I just interviewed Tom Campanella, and he is one of the most well-versed and educated people in healthcare that I've ever met with.

He has spent more than 40 years inside healthcare as a consultant, an attorney, payer executive, professor, associate dean, and now policy advocate. In this episode, he explains why rural healthcare and primary care have been overlooked, how the economics of healthcare shape access, and what collaboration, policy, and smarter system design could do to protect patients, physicians, and communities. Tom Campanello, welcome to Working Healthcare. Thank you, Meredith.

I am looking, really looking forward to this discussion. I am looking forward to this discussion too, because we are going to talk about something that I think is so silenced right now, and there isn't a lot of discussion, as you and I have talked about it on mainstream media. So we get to have podcasts like Working Healthcare to be able to discuss all of these challenges going on with our American healthcare system and hopefully come up with solutions because you have a newsletter, you're an attorney by trade, you have worked in so many sectors of healthcare, you are a wealth of information.

And I'm really old, so I've uh been out there a lot. You said it, I didn't, but no, it's it's better than the alternative, right? Right. Amen to that.

I want to ask you if rural healthcare is such a clear warning sign for the rest of the American healthcare system, why do we barely hear about it when a hospital closes or a doctor leaves the community and loses access to this care? Well, it all comes down to, I hate to say it, the almighty dollar. So from a media standpoint, especially national media, you know, from that standpoint, you know, obviously the people in urban America, the big cities, and that, that's where, you know, is pretty much their revenue base and they get all the attention.

And that's not just from a media standpoint, but it's from uh a lobbying standpoint and everything else. They just don't have the political voice. And uh, and sadly, there are communities in so many different parts in every state where it's dominated by rural, but they don't necessarily collectively come together as one voice, and uh, even though there's associations doing it. So it really is a big challenge.

I think because so many of us, and I'm so happy you and I are collaborating now, and we are working in this greater community of these small voices to have one more powerful voice. But it does seem as though a lot of these smaller regional areas are working in silos, and so they're not integrated to have a larger voice. You're so true. And again, because they're small and rural and don't have the lobbying dollars of the big urban urban centers, especially healthcare, uh, you know, they they really don't have that voice and they don't get that attention.

You've worked in healthcare for over 40 years. Can you describe your career path? How did you get to where you are now writing a newsletter, being such a strong healthcare advocate? Well, uh actually goes back many, many years ago.

I and we won't uh bore the listeners uh and the viewers with uh, you know, of a two-hour overview of my background. But uh, bottom line, I actually started in politics. I was a Cleveland City Councilman, grew up in the inner city, and wanted to make a difference. And I and I was in my 20s, and I quickly discovered politics wasn't for me.

It's a rough world, even at the city councilman level. And but I still wanted to have a career that impacted people's lives. And uh and I have a background educationally that's diverse. You know, as you mentioned, I'm a lawyer, I'm a CPA, I have my master's in economics.

And um, but I wanted to use that uh to really uh impact people's lives and actually have a positive impact society from a societal standpoint. Got into consulting with Ernst and uh Arthur Young before the merger with Ernst. That's where I discovered health care, and then ultimately, and we can go back and forth a little bit, but ultimately a headhunter from Blue Cross and Blue Shield of Ohio uh reached out to me from that role to be able to come in and start an area called Manage Care at Blue Cross of Ohio in the mid-1980s.

I would say that might be the dark side. It it was it depends on what you call dark side because it was really interesting. You got to walk, you know, that one of the terms you always walk in the shoes of someone else. Because of my diverse background, I've walked in the shoes of the payer or the dark side.

I've walked in the shoes of providers, I've walked in the shoes of community health advocates, medical schools. So it allows you to look at issues from different lenses, you know, from that standpoint. And just a quick thing for the viewers in the 70s and 80s, uh healthcare providers, hospitals, physicians, and that called that the golden years of healthcare because there was no managed care. They could charge what they want, and the problem was abuses were all over the place.

So employers then, you know, wound up reaching out to man, you know, organizations like the Blue Cross to sort of address it. So, as I tell people, you know, no offense, but in many ways you created that evil character that you now uh uh swear about, you know, on a daily basis. You've worked in finance, you worked in law, managed care, consulting, medical education because you were an associate dean of a medical school, and health economics. What role do you think changed your thinking the most about our American healthcare system?

That's a great question, by the way. Uh, you must do these podcasts a lot of times. All the time, never. It's like, you know, I'm a novice.

Yeah. Well, when you're in an organization, like working for a health insurance company, being involved working with a provider, uh, being involved with medical school, it's easy to sort of uh sort of narrowly focus your um, you know, uh attention, where it's all about the self-interest of that particular organization or mission, whatever it is. So you become a little bit siloed by, you know, just from a practical standpoint. So if I had to say that uh experience that broadened my perspective, that uh I call healthcare the big giant puzzle uh piece, where you have it like a jigsaw puzzle, and there's all these different pieces: the hospital world, the pharma world, the managed care world, the government world, you know, whatever, but they're all sort of separate all by themselves.

My experience as a professor of health economics and policy for 20-some years, uh also directing the healthcare graduate program at Baldwin University, where our students were from executives from all different sectors of healthcare, was probably the experience that allowed me to sort of bring in all the pieces because I had to have a broader perspective in developing curriculum, in discussing and teaching and everything else. So that was probably the most rewarding, and it also allowed me to sort of take a step back and really start doing that deep thinking as to well, why is this happening?

Why not, why doesn't it happen in other sectors but occurs in healthcare? What are the key issues? So it brought up those questions and it allowed me to sort of probe for answers. You said something that was really impactful.

And one of the reasons why I have Working Healthcare podcast is I, like you, love to teach and I love to learn. And it gives me opportunities to meet with people like you and to gain a deeper knowledge of subject area like healthcare that fascinates me. And I really think I've learned more in these last two years, even more so than when I was teaching medical business management at Florida Atlantic University or acting as CEO or other positions in which I held at the Hirsch Center.

Being able to meet with a multitude of people from different backgrounds and do the research that I do for podcast interviews has actually been the most impactful. And I've changed my thought process in a lot of different areas within healthcare because of this. Yeah, I couldn't agree more. And I think that obviously uh sh shows through in regards to how you do both the guests that you have on your podcasts and the exchanges and the thoughtfulness, both in related to your questions, but the back and forth with your, you know, with your uh visitor, you know, in regards to sharing a podium.

But uh, but I think that experience is, you know, so critical. And even like in my case, when I was a professor, I never knew if I was a professor or a student, or like we're doing right now, you know, when I'm uh having virtual meetings or uh writing articles or whatever and doing research on it. Uh I'm sort of expanding. It's it's great to uh at even though my body's falling apart from knees and back and everything else, in many ways, I think my mind is expanding.

It's uh I think in some ways I sort of get it more now than I did 20 years ago. And uh, God willing, you know, I know I'm gonna have other issues, but it really is starting to come together. And it's through uh, you know, exchanges like we're having today, the writings, the readings, um, you know, uh the experiences with experts in all different fields that allow me to do that. You had a radio show in the 90s, which I think is fascinating and cool.

What were you trying to teach people back then? Or what were you trying to learn? Why did you have the radio show? Well, what was interesting, I'm down in here, first of all, as I said before, I'm this inner city kid, you know, uh from Cleveland, Ohio.

And uh, and it was kind of interesting. In my neighborhood, uh, few people went to college and hardly anybody went away to college. And here I go to the Ohio University in Southeast Ohio, College Town, in the foothills of Appalachia, which is really rural. So the experience is like, woo, it's a whole different world.

And what happened is that sort of opened up my mind or uh views on a lot of things at that stage of life, you know, 18 to 23 or so. But uh 25 years after I graduated, the dean of the medical school, who was Barbara Ross Lee, Diana Ross's sister, uh, reached out to me when I was at Blue Cross and said, How would you like to come down as the associate dean uh of our medical school? Get involved, don't wait until you're in your 60s to come and you know get involved in a college town.

And so that was sort of my catalyst to be down there. And I was not only over clinical services, but population health. And what I wanted to do as part of the population health is educate. So, what I would do is there was a public radio station tied in with uh Athens, Ohio, the university, and they would interview me.

The uh Connie Stevens was her name, and she was a legend in that world. And she would interview me once a week about the history of health care or whatever. And then after six months, she said, How would you like to have your own radio show on that? And so uh, and meet once a week talking about health care, but bringing in speakers and stuff like that.

And that was really cool. And then actually, a local uh radio station in Southeast Ohio, which was not public, uh, you know, not a uh part of the uh the public radio, also reached out to me about doing something similar with them. So I was like a little kid in the candy store. I had my headphones on, and you know, and I just loved it.

I loved obviously talking, but the exchange with people and everything was just so cool. I'm surprised that you don't have a podcast now. You're like the pre-podcast guru. Yeah, ironically, um I get interviewed a lot, which is kind of nice.

It's a lazy person's approach, you know, from that standpoint. But I thought about it back and forth sometimes, or you know, doing a collaboration with an existing podcast and stuff like that. But uh, but it is so much fun. It is fun.

I actually like to be on the side though, interviewing as opposed to answering the questions, because I actually think I'm a better host than I am an interviewee. But you could be the judge of that by listening to all of these lovely interviews that I seem to uh be a guest on. What do you think the public understood back in the 90s when you had your radio show about healthcare that we don't seem to get right now? Is there any difference?

Well, there's good and bad there. I think sadly, uh ignorance is out there. We do not have an educated public in regards to the broader issues. And we now we're probably more than ever siloed.

And it was probably a little less siloed in the 90s in regards to media and everything else, but you know, where you get slanted perspectives. But the problem with um so many individuals, and I can understand this, when the healthcare issue came up comes up, they really narrowly focus on how does it affect me individually, and they don't necessarily understand the broader power structure issues that are impacting their lives, and uh and how even their political, and that's sadly in the political world, um, our politicians, and it goes back to prior to the 90s, are not really held accountable because when you think about it, you know, they, the congressmen, senators, the administrations, the issues that we have in healthcare were there in the 90s, 80s, 70s, and uh and they are really haven't been addressed adequately from both sides of the political spectrum.

So I think part of the challenge is um the there's no checks and balances from the people standpoint. We don't have a strong enough voice, ground uh, you know, sort of a ground-up approach, and uh and we and we sort of rely on our politicians to sort of take care of us, which isn't necessarily their main priority, it's to get elected. And I really want to talk about how expensive healthcare has become, even comparing it 30 years prior. And I want to go into your experience at Blue Cross, Blue Shield of Ohio, and now Medical Mutual of Ohio, which I believe is what it's called.

What did that teach you about how money moves through health care? Well, first of all, as I mentioned earlier, Blue Cross and Blue Shield of Ohio, uh probably 11 of the 12 years that I was there, I was it was under the umbrella of Blue Cross and Blue Shield of Ohio. And then the last year uh it was uh uh Medical Mutual because we actually lost our Blue Cross license, which is a story in itself. And uh, and that was, you know, because Columbia uh HCA Healthcare Corporation of America uh was working on acquiring us and making us uh the, in effect, the managed care arm for the largest for-profit uh health care hospital organization in the United States.

Ironically, and you'll love this, guess who was president of Columbia back in the 90s when this all occurred? Rick Scott, Senator Rick Scott. Bingo, you got it. Yeah, he was the president of uh Columbia during that time period, and it was going to shake up the health care world, especially the hospital world, big time, because they were acquiring nonprofit hospitals in almost all the major urban areas throughout the country.

And we were going to be the managed care arm. And um, but the bottom line, which is again ironic, the Blue Cross and Blue Shield Association said, well, we can't be affiliated with a for-profit organization. That's not our mission. Well, guess what?

Uh, Blue Cross plans throughout the country now are you can you're buying stock on them, you know, with anthems and everything else all over the place. So they changed their tune, but in the interim, we wound up losing our license. Uh the the bottom line, though, um, that experience I think was great because being there in the 80s and 90s with the growth of both managed care, uh, we were the first Blue Cross plant in the country, and I won't get too nerdy about payment methodologies, but uh right after Medicare to develop a payment methodology called DRGs or diagnostically related groups.

So we got that out. Uh I got to be able to work with stakeholders, hospital CEOs, not just in Ohio, but we managed Blue Cross of West Virginia. So I was down in West Virginia a lot, which also got me to appreciate rural health care challenges even more. Um, there was so much going on during that time period.

And this was also the time period later on when you had the major hospital consolidations that were occurring. You had uh the Clinton care, Hillary Care type thing. So it was a fascinating learning experience, and uh and I was in the middle of it, and it was definitely something that uh uh I think ultimately provided me even somewhat more of a foundation of some of the challenges and maybe potential uh uh answers in healthcare. And this year we are expected to reach $5.

6 trillion in spending on healthcare, and that was just a prelude as to how we got to where we are now. So the insurance companies, hospital reimbursement, physician contracting, how does that all interplay and lead up to this five point six trillion dollar spend? Well, first of all, um sadly. And it's not because of Tom Campanella not being in the payer side anymore.

But the fact is, I've been able to get back to and get a better understanding of what's occurring in healthcare. And in the last 25, 30 years, we haven't really evolved that much. We still have a payment system that's fee-for-service mostly, which the more you do, the more you make. Which, if there is a key word in healthcare, and it goes back to Adam Smith, the famous economist from Scotland in the 1800s talking about self-interest and the drive for self-interest.

If I had to put one word to talk about why we have escalating health care costs in America, it's self-interest. It's the stakeholders, the pharma industry, the hospital industry, the managed care industry, the device industry, you name it out there, trying to protect their piece of the healthcare pie and grow it. That's where they're at. No one's looking.

And then sadly, each of those stakeholders are major lobbying forces in DC and in every state capital to make sure that they're protecting their piece of the pie and growing it. And that is the major reason why we have, you know, you know, we talk about healthcare costs, but every one of those sectors in the healthcare arena, that's their revenue stream. So cost to us is their revenue, their profits. So anything that does a radical change to that, they have a problem.

So they perpetuated and want to continue to perpetuate the status quo, which ultimately is now become unbearable. 20% of our gross domestic product is now on health care. And uh and you just can't do that, especially in a global society. It's interesting that a few minutes ago we talked about Rick Scott, governor of Florida, former governor of Florida, right?

Now a U.S. senator from the state of Florida. And we are in Florida, the most litigious state by far, where doctors can't even get insurance for professional liability claims.

And now you have this man as one of a hundred senators in the US making rules, but how did he make his money? By overseeing a health insurance company. And so there's definite self-interest. And even when we look at it on the political side, there's self-interest.

When I go to Tallahassee or when I go to DC, I ask our legislators or our congressmen, why would you even vote this way? Like I don't understand how this lobbying group from this insurance company or this PVM comes in and persuades you to go along with their ability to make billions and billions of dollars. And it's just interesting the perspective. How can we as patients and even doctors?

Because I say if you help doctors, you're helping patients. If you help patients, you're helping doctors. And you talked about fee for service. Is there a solution to all of this spend?

There is. One of the phrases that I've come up with over the years to sort of summarize why we have some of the challenges is uh, and think about it, a healthcare system, and I mean by system as it relates to a broader focus on the country system, uh, is shaped by what you pay for and how you pay for it. So the what you pay for, for example, is we do we pay a lot for stuff after you're sick, after your cancer, after you have this major issue, after you know, procedures that are in the year when you're in your 90s, you know, doing uh procedures that you know really have a lot of cost to it, but ultimately uh, you know, from a value of life and quality and where money would might be better spent, you know, with younger or whatever, you know, is a big issue.

The other part of that, too, it's how you pay for it. So the how you pay for it is the more you do, the more you make. And so, for an example, this that phrase, the more you do, the more you make. And people talk about the demise of primary care, especially sadly, uh, and I write about this a lot, is uh primary care associated with the big health systems, especially the big urban systems, is mostly focused on being a gateway to the specialists because they make money off the specialists.

So going back to the 90s, one of the reasons why hospital systems started to acquire primary care practices, independent practices, family, and they still continue to try to do that, is because that's a referral mechanism to them. They wanted to lock up that referral to the specialist. So now, if you're a primary care doc, especially tied in with a big health system, you're in effect told we need to see as many patients as possible so we can then funnel them through the specialty side.

And so that how you pay for it is terrible. That's why you know we need to have payment methodologies focused on you get more money when you take care of people and keep them healthy. And and one way, and I don't want to again get real nerdy, is uh payment methodologies like capitation, which uh basically is a form of paying uh a larger, say, a hospital system or accountable care, uh, X number of dollars per month to effectively take care of all the health needs. Then their priority is to keep them healthy, because the way they make money is to keep them healthy instead of providing more and more unnecessary services.

The challenges I had in this ease capitated plans, though, is that doctors understood that their reimbursement would decrease. And I'm not saying the majority, because people don't go to medical school and residency and fellowship and delay gratification for all of these years to hurt patients. They obviously do it for an altruistic reason, doctors do, but they will no longer see patients who are severely ill because it will count against them. So I saw this happening with not necessarily MIPS, but affordable care organizations, accountable care organizations rather.

And I also started seeing this uh uh when we talked about wanting to go toward the cost of health care, and that is related to MIPS with the low-cost, high-quality care and dismissing certain patients from your practice who are costing you a lot because that will bring your rating down and you're competing with these other physicians or group practices. That's my concern. How do you see this as a challenge within these capitated plans? Well, first of all, I was involved with capitation back in the 90s, and uh, and there were good things and bad things related to it, and hopefully we've learned a lot from it.

One is there definitely needs to be uh very much of a collaboration between the payer and the provider side. So, and ongoing communication and exchange of data, including as it relates to the health of the individuals. Uh, I think, and this is a hot issue even in DC with the Medicare Advantage plans, one of the others is acuity adjustments. And again, I don't want to get too nerdy, but you know, the fact is, you know, based on the health risk factors of individuals, uh the in this case Medicare Advantage plans or even ACOs that are tied into it, they will get more reimbursement from the payer, either from a managed care company or directly from the government, you know, CMS, you know, as it relates to Medicare.

So the question is that's where uh I hate to say it's self-interest, that's the big debate in DC. Do Medicare Advantage plans find ways to make people uh coding-wise much riskier than they really are so that they can get more reimbursement. And that's, you know, and there's back and forth going on there. But coding is a way to be able to address that.

It needs to be, you know, done in a legitimate way. And so where you ultimately would have, in the ideal scenario, a population base that might have high-risk individuals, but also individuals that don't need any health care, you know, that they very rarely need to go to a hospital. They're reasonably healthy and you have more of a pooling effect where they offset each other. Um, it's I think the key is to recognize that it is an issue, but to sort of throw the baby out with the bathwater and say, well, that won't work because of because of.

No, you say, okay, so then how do we address this issue? And that's one of the other challenges we have in healthcare. You can take a lot of creative initiatives, somebody can come up with a reason why not to implement it. But I think what you the approach, the mindset needs to be this could potentially work.

We do have issues, and this is how we address those issues to make it work. And I think that needs to be uh sort of a better approach, you know, from that standpoint. I think it needs to be a whole overhauled system, though, because what happens is it's so regimented and it's so difficult to make changes, and the voting that needs to take place and obviously the lobbying money that goes into it, that if a decision is made and the American people realize that it was the wrong decision to pivot away from it or to bandage it or to amend it or to completely overhaul it, takes years and years and years.

And so we just keep piling on crap over crap over crap, which seems to be where the problem is. I'd love to go back into primary care a little bit and talk about it because you were the associate dean of an osteopathic school. My dad's a doctor, my brother's a doctor, my husband is a doctor. And I remember growing up my dad saying, Brian, if you want to be a doctor, you need to do something that's cash based.

Do not rely on these insurance companies because my dad practiced primary care. My brother is now a dermatologist, so yes, very cash-based. But he does most surgery, but he he definitely is not a primary care doctor. If primary care improves outcomes and lowers the costs for individuals, why do we still underinvest in it?

Well, that's a great question. But you know, think about it. You know, it is a pretty obvious question. You say to yourself, well, wait a second, healthy people have less healthcare costs.

Duh. You know, that's something that, you know, should be a no-brainer on both sides. But going back to what I said before, healthcare cost to you is revenue to somebody else, one of the other big stakeholders. So the healthy, I'm not saying there's this sinister, evil people running our hospital world or you know, uh physician side or uh manage care or uh, you know, device, uh whatever it happens to be.

But the fact is their mission is to basically focus and protect their piece of the pie, or they're not going to have a job. You know, I hate to say it. And so uh they, in many ways, the big payers have uh, as well as the major providers, have submerged uh the primary care family medicine world. Uh two examples.

One, as I mentioned before, and also ties into a subject rural health care, which we touched on a little bit before. But uh, but the fact is, you know, primary care is needed not just in urban areas, but it's it is greatly needed in rural America, and uh and including a broad a broader focus, you know, from a foundational focus with primary care. Uh the bottom line, though, is to be able to attract physicians in rural areas as well as to attract nurse practitioners, physician assistants, you know, team-based primary care, you know, you should have rural residency programs.

And there should be a major focus of rural residency because data is shown individuals will practice in 90% of the time of where they had their residency. So they're and they could have you know loan forgiveness and everything else tied to this. Well, the fact is 90% of residencies are in major urban health systems. And uh, and so they capture it at the expense of rural America.

So, I mean, that's one example of goes there. The other part is um, you know, the, you know, and you may your husband may disagree with me on this, but uh, but this on the specialty the American Medical Association. Historically, they have really controlled the uh Medicare fee schedule. And it just so happens, the majority, it's the medical society, the American Medical Association, but it's dominated by specialists.

You know, when you think about it, you know, all the different specialists in that. So when it comes down to how the money gets distributed, uh distributed between all the various areas, guess who is the low person on the totem pole? Family medicine and primary care, because all the different specialists are getting it. To their credit, and I don't necessarily agree with everything coming out of DC right now, but to their credit, uh, the current administration is saying that we need to have uh a more neutral or objective force in deciding how those dollars, in this case on the physician fees, get distributed and who makes the decisions and who benefits from it.

And it so happens the first go-through on this, uh, primary care and family medicine actually got bigger increases than the specialists, which you can imagine the specialists were not happy about that. But but again, I'm not saying people are evil one way or another. They're all protecting their pie and they're and you know, and they rightfully believe that, you know, deserve, but primary care, because they don't have the voice, just like rural health care doesn't have the voice, they get sort of uh lost in the shuffle.

And it's a very small piece of the pie. If you look at physician services as a factor of this expected $5.6 trillion a year spend, physician services is a very small percentage of that. The money is really going elsewhere.

I would love to look at primary care specifically in rural areas, because 43 million people live in rural areas with primary care health professional shortages. What does that look like in real life with these shortages going on? Oh, let's put it this way going back to my um, again, one of the advantages of being real old is you have a lot of experiences. And going back to the 90s, um, you know, when I was associate dean of both uh clinical as well as community services, one of the areas that reported to me was uh our mobile health vans.

So we actually were able to, through state grants and everything, we had two mobile health vans that literally provided primary care services and other baseline stuff that were rolling out to those nine counties because of those nine counties, there were two or three that had hospitals, but the majority of them not only did not have hospitals, they didn't even have physicians in the entire county. So we would go out, roll out there, they knew where we would be, X number, you know, what day of the month that they would show up.

People would sign up for it through the general store or whatever it happens to be, and you know, be able to, you know, in effect provide access to this. And the sad part about it is I went back, in effect, 25 years later and started talking to various people that I know in that area in rural health care, including my the medical school. And while there has been some positive changes, it's it has in many ways hasn't gotten any better. And it's actually getting worse.

And and it's so sad because these are people's lives. You got kids, you got, you know, it's really sad. Uh do you think urgent care is replacing uh primary care or filling the gap because of these shortages? I I have mixed feelings about urgent care.

Urgent care, yes, uh, immediate need, take care of it. One of the things I don't like is uh a lot of the major hospital systems are doing two things. Um by the way, when I sort of write and I have issues with the American Hospital Association or some of the urban systems, I I'm not saying because many of my students were physicians that are now physician leaders in these organizations, and many of them or others were, you know, various levels. They're good people, they want to make a difference.

The challenge is again the the the their overall mission that comes from the sector or whatever. Well, the point though is they are focused on you know trying to really push health care from a dollar and centpoint. They need to keep the mothership alive, you know, so that they can provide the other services that you know goes through. So, you know, the bottom line is as it relates to these rural areas, they just aren't getting the um the resources that they need.

Or even when a major urban system acquires uh a small rural hospital, next thing you know, services are cut and all this uh high-end stuff goes to the major urban system. But they're not really investing as much in that community, which I have a real problem with. What I found really impactful in doing research for our interview is that last year in 2025, 46% of rural hospitals had negative operating margins. And 432 rural hospitals were vulnerable to closure.

And looking at those stats and knowing that these communities don't have enough family medicine doctors, internists, pediatricians that on average are paid $80,000 a year after they do high school. They have four years of college and four years of medical school and three years of pediatrics training, and that's if they don't subspecialize. To me, that's mind-boggling. How can we make primary care more attractive and sustainable?

And on top of that, how can we make rural medical care or practicing in a rural community more attractive and sustainable? Well, two things. One going back to what I said before, I think um starting in medical school. And a number of medical schools are doing this, having sort of a rural health care track in medical school where they start getting, you know, maybe even if they're in the urban area, opportunities to have a site visit to rural America, better understanding, uh, educating them about the um the experience, you know, let's put it this way.

You come from a family of doctors, and they're not they didn't do it for the money. Yes, you know, there's different things. It really to have an impact on people's lives, to be fulfilled in that. And in many ways, in rural America, as a primary care family medicine doc versus urban America tied in with a major health system, it is so much more fulfilling in what you're doing because you don't have that big uh mega organization that's out there.

You're really the lifeline to so many people, and you know, ideally with a team of people in the primary care arena with PAs and nurse practitioners. So that's why, again, having uh you know residency programs tied in with rural America, educating them about uh and getting them to know the experiences of being a doctor in rural America and primary care versus in many ways, as I mentioned earlier, in urban America's primary care, your your job is mostly to see as many patients as possible and refer to a specialist.

Now you get to be able to have more hands-on approach. You get you're more involved with the community, and I think a much more satisfying experience. The other part of it, obviously, loan forgiveness, increased compensation, that's a big issue. Uh, one of the big challenges, bluntly, is quality of life because depending on how rural the area is, uh, from a family standpoint, you know, school systems and everything, that could be a challenge, you know, in regards to attracting people.

But there, and then you also have uh ability through uh technology, virtual care and that, to maybe have an impact, as long as there's obviously broadband or other vehicle satellite uh capabilities, be able to bring in that type of experience. And then the other thing is care in the home settings. There are different ways to be able to bring that, including in rural America. I think this is the perfect opportunity to talk about osteopathic versus allopathic medicine, because in the state of Florida, there are so many schools popping up right now and so many additional training programs.

When I was graduate when I graduated college in the 90s, and when my husband went to medical school in the 90s, there were three MD schools in Florida that I can think of offhand: the University of Florida, the University of South Florida, and the University of Miami. Now, I don't even know the number, but it's more than doubled. And the osteopathic school that I'm aware of was at and still is at Nova Southeastern Medical School. I just had Dr.

Chad Perlin on the podcast, and he is the dean of the allopathic school. Nova decided to add an allopathic school in addition to their osteopathic school. You were an associate dean of an osteopathic school. What's the difference, and why do you think there is a rise or a need to add and have two options for osteopathic and allopathic?

Another good question. Uh but you know what it comes down to is well, first of all, in some ways, the differences uh are becoming smaller over time. If you go back to um, I forget Still's first name, but you know, who started the osteopathic movement, it was very much we need to find the cause. Uh, we don't like the idea of uh drugs and medication.

There may be other ways to be able to address issues, and it had sort of uh a less invasive approach. Plus, it was very much focused holistically and open to uh different ways outside of uh the, you know, sort of the clinical, they were open to different approaches, you know, from uh different type of uh medications, you know, more natural type medications, those types of things. And um with the uh Flechner was the big uh, I think, uh was the big person that started the um medical schools overall back in the 1900s, early 1900s, you know, for uh across America and that.

He was sort of like the father of adding the credentials and credibility to medical schools. But uh there was a lot of debate during that time period. But I believe actually, tied into your question, is there is a part of me, there are advantages, but I would like to see osteopathic um medical schools primarily focus and have their mission really greatly focused on primary care almost exclusively. And I would also like to see uh sort of a melding where in that medical school there is also a PA school and nurse practitioner school where they're also they're going to school together.

They're sort of uh training together. There is a team aspect to it. And it has sort of uh, and it's almost changing the mindset of that to the focus is keeping people hot healthy and prevention. You know, that's the and then you can have uh the you know uh other schools, you know, allopathic and that having much stronger focus on specialty side.

And then hopefully you could almost have uh back in World War II with the issue of uh with Germany and Japan, they talked about the general Marshall Plan, the Marshall Plan. You know, we got to do resources and it's gotta be a priority and accelerate. Well, I would like to see a Marshall Plan for primary care, you know, both uh in regards to uh, you know, physicians, but also nurse practitioners and PAs and the team approach. And I think that medical school concept and team approach and prevention, and part of that is an educational vehicle.

How you know there should be as part of this, how do you educate and connect with patients? Because one of the, as you know, based on your background, and you know, including people that you uh interviewed, is that one of the biggest challenges in healthcare is when individuals don't get engaged in their own health care. But that should not be a cop-out by physicians saying, Well, I told them to do it, and it's they didn't take, you know, it's it's their job, not my job. You know, well, there needs to be an onus and uh and a priority by providers, too, to find ways to effectively communicate and educate their patients.

And then maybe the payer side can provide incentives as it relates to it. I mean, it really is a team effort from all the players. I want to go back to your idea of DO schools focusing on primary care and rural care. And I want to add into that family medicine.

When my dad graduated, he's a DO, by the way. When my dad finished medical school in Des Moines, Iowa, and went to the University of Miami for his residency, it was only a one-year general practice residency. And my dad did practice general medicine. I think they've done away with that one-year general practice residency at this point, but at least he didn't have so much delayed gratification and got to jumpstart his career.

And as he had a clinic, he did have MDs work for him as well as DOs. He had a whole physical therapy department and he worked more on rehabilitative medicine. Why do you think DOs are more closely aligned to primary care, family care, rural medicine? Because if I'm looking at it in 2026, I would say MDs, DOs, they're the same at this point.

They're getting to that point, and that's why, again, I would like to see that separation, because the prevention and keeping people healthy has to be the primary focus. Now, specialists, by its very nature, yes, they get involved when somebody uh has potentially a history in the family of heart issues, or they're maybe right at the beginning of a progressive disease, that they're playing a role of prevention where they don't want it to get worse. But uh but really the primary care family medicine uh nurse practitioners PA group uh is their focus primarily and where they're educated historically, is again not just educate, um both prevention and part of that education.

And it's sort of um, and they also don't necessarily, a lot of the osteopathic medical schools, including Ohio University where I was at, they when they recruited, they didn't necessarily want uh, and this might sound crazy, the person that had the highest uh grade average in college, or you know, the highest IQ, or you know, was the uh the brainiac and everything else, because part of their admission process was the individual themselves, their uh their the their passion, their ability to want to make a difference.

And a lot of that is related to, in effect, a common man or common woman. And they were they've historically also been very open to recruiting people in their mid-30s, late 30s, early 40s into medical school, which uh and a lot of the uh the baseline major medical schools uh don't do that. You know, they don't you don't cut the cry. And I think that's what you need in primary care because the average person can connect with these people.

They can understand them, they make things understandable. You go up to Washington, D.C. now.

You work with a lot of our Congress, and you're definitely focused, and I think you have, even in your past life, been an advocate for patients, been an advocate for even doctors as the associate dean. What are you trying to accomplish right now? What is your goal in creating change within our American healthcare system? Well, first of all, back to diversity.

I've been uh a Democrat, Republican, uh I've been moderate in different things, you name it. And now my political party is I'm called apolitical. Uh I I bluntly have issues with both sides, mainly because of so much of what we talked about today. You know, there's so much, and I have a narrow focus on healthcare, and uh and I just see a lack of focus and desire on all sides.

And I can point finger, they're easy, they can point fingers at each other while I'm pointing fingers at all of them. So, my role or my focus, like for an example, with the current administration in different ways, and I've done a little bit of work with Paragon Health, which is the big healthcare think tank with uh the Trump administration, and it's been minor, but I've met with them and and I've been critiqued some of their work for them. They've been open-minded to listen to my perspective.

And my view in all this is I'm not uh saying I support one side or the other politically, but if I can have a positive influence, if there is uh a perspective that I can bring to the table that's not looked at, that can ultimately have a positive impact on people's lives, I'm willing to work with whoever to get it done. And uh so I've done that with think tanks, you know, in DC, but I've also been working with, you know, including with prior groups uh under other administrations, with healthcare policy people, at um at, you know, with Democrats, Republicans, senators, uh, Congress, you know, and you know, and having an exchange, and you know, many of them get my newsletters.

Some of them are tired of getting me, hearing me coming back with my views one way or another. But I don't care, you know, uh I have something to say and I'm gonna say it. And Tom, I want to wrap this up with your expansive knowledge. 40 years within healthcare, and you've worked on the payer side, the legal side, the academic side, the consulting side, and rural community side.

Do you still think the system can be fixed? I get I got to. It's gotta, let's put it this way, it's the only thing that keeps me going. I really, you gotta have hope.

And uh, you know, there's an old analogy that I've always used, but uh it's the uh, you know, Peter Pan syndrome. One, I can't grow up, but keeping your toes on the ground and reaching for the stars. I mean, so you gotta be realistic and recognize that there isn't a silver bullet answer. But going back to what I said before, uh one thing I do know the answer is not we can't be done.

There are ways we can do it. We just gotta find a way to collaborate and work together. Sadly, the current environment in DC and other places, uh, collaboration is not necessarily uh the word of the month. For sure.

I have shared this before on the podcast. I was an intern up on Capitol Hill between my junior and senior years in college, and I worked for Senator Connie Mack from Florida back in the day. And he had two issues that he was highly personally involved in. One was the right to bear arms and our Second Amendment, and the other one was health care.

And he was actually working across aisles with at the time Diane Feinstein on the House side, and there was so much collaboration back in the mid-90s working on the Senate and the House, working with the Democrats and Republicans. There was constant communication. My maiden name is Feinstein, and I was always sent over to representative at the time, Diane Feinstein's office, to get signatures and to work on this healthcare reform. And I finally said, guys, if I was related to Diane Feinstein, would would I be in this office?

But I was the one and I made so many friends on both the Democrat side, the Republican side, the House side, the Senate side. But that's all how we work together. I mean, it's so different from what it is now. Is it possible to get back to those days 30 years ago?

Well, you gotta, you know, the analogy I use, uh, for example, I live in Ohio, you're in Florida. Uh there's different ways to get to Florida. You know, you can go I-77s, you know, you can do uh go through I-75, you can fly, you can take a bus, you know, there you take a car, you name it. Uh point is you got to be able to uh have an agreement of where you want to get to.

So there, if we can first start off with, well, what are we trying to achieve? You know, you know, and some of it at a high level, healthier society, address costs. Well, obviously you got to go down from that. But then there may be different approaches from different people and how to get there.

But if you can focus initially on, okay, guys, let's first focus on what is our goal to get to, because guess what? If the goal to get to is Miami, Florida for one person and Los Angeles for the other person, guess what? You know, you're gonna have a problem. Yeah.

So I think you need to have that open and honest communication there. And then the how to get to, there really isn't one easy answer to get there. That's where the collaboration comes in. But if you at least initially get that mindset, this is the goal that we're trying to achieve.

It's like a puzzle. You know, if you don't know what the picture is going to be, having a bunch of pieces, you don't know how to put them together. But if you have a sense of what the puzzle piece is, the end picture is supposed to look like, then when you look at the puzzle pieces, oh, then this would fit to that piece, that would fit to that piece, and ultimately you have a completed puzzle. You gotta have that type of mindset.

This was such an invigorating interview, and I appreciate your time. And thank you, Tom Campanella, for being a part of Working Healthcare. If this conversation hit home or made you think a little differently, don't keep it to yourself. Share the episode, tag a friend, or post about it on social media.

Connect with me on LinkedIn to keep the conversation going in between episodes. If you've got a question, an episode idea, or someone you think I should feature, send me a note at MeredithHirsch.com. Thank you all for the five-star reviews.

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