Rural hospital CEO talks Medicaid cuts, staffing challenges and the joys of community healthcare delivery

HealthExec: From big cities to rural America, from for-profit systems to now serving as CEO of a regional nonprofit hospital. How do the experiences differ?

Steiner: Pretty significantly. At the end of the day, it’s all the healthcare business, but working for the for-profit industry, my job was to meet a budget. I spent most of my day really thinking about the finances of the organization and how to boost profits and cut costs. Here at Phoebe, we are more community-centered, not just because we’re in rural America but because we don’t have to worry about making a profit for investors. 

We’re motivated by what's best for our community. We still have budgets—and it's still important to stay within budget. But, that’s because a surplus of money is how you give raises and how you add additional services to a community. 

Phoebe is free to add services that we know won’t make a profit, because at the end of the day it’s what the community needs. For example, a trauma center to treat people who have been in an accident. That’s not going to be profitable, but it serves the larger mission of the organization to ensure the people who drive cars here don’t have to be flown to Atlanta if they’re in an accident. They can be treated right near their home. 

I imagine staffing is challenging, because you ostensibly have to hire your patients as workers. 

Workforce is one of the biggest challenges we face as a regional nonprofit. I’m recruiting right now; literally, I just left a meeting talking to a urologist who is done with her five-year residency next summer. We start two or three years before they’re done, and she’s all in. She’s ready to come here. But she said, ‘We’ve got to get my husband to want to move here.’ I met him, but I asked her what the challenges were and she said, ‘Well, the challenges are he’s from Houston. Partly he wants to go to Houston, but partly he’s just a city guy.’

If you try to get somebody that wants to live in a city to come here, you’re going to pay more to get them to come. There’s no discount. But they learn to love it here–I did, I have no desire to go back to a big city. 

What I love about rural and smaller towns is the people. When you go to Home Depot or Lowe’s, you’re going to run into people that either work here or know you and want to talk. When you go out to a restaurant, you can't just wave, you go talk to them. It’s a beautiful thing. 

Looking at these looming cuts to Medicaid as part of the One Big, Beautiful Bill Act, how is Phoebe preparing as those roll out over the next couple of years?

The bill included $900 billion in cuts over 10 years. The effects of those cuts will be slow—we’re not feeling them yet but by 2028 we will. When governments make cuts, it tends to be the elected officials who come after them that have to deal with the reality. 

It’s not just Medicaid cuts, it’s the loss of the Affordable Care Act (ACA) subsidies that have been in place for a number of years—those have expired and it does not look like they're going to extend those. 

What we’ll see probably soon is a wave of people losing their coverage. It's estimated that 25% or more of people who have an ACA plan won’t be able to afford it. And so they will become self-paying patients. Hospitals typically collect about two cents on the dollar, of cost for patients that don't have insurance.

And so you’re expecting to have to take on more debt related to patient care?

That's probably right. It's eventually written off, and that's a challenge of our healthcare system. We provided about $70 million in true charity care last year. All hospitals do it to different levels, but 6% of our operating income is just for charity care.

But that’s our mission, that’s what Phoebe does. We’re a charitable organization—and we take that mission very seriously. People sometimes come into the hospital on the worst day of their life. Our job is to take care of human beings, and my job is to find a way for us to do that. 

With a lower-income patient population, higher rates of chronic illness, how do you continually manage patients that tend to end up in the emergency room?

For chronic disease, what you try to do is surround that patient with resources. We try to understand them, not just tell them what to do. It’s about trying to dig deeper. So we have a social worker meet with the patient to find out what support they need. We have a dietician give them a diet plan so they can still enjoy eating but do it in a healthier way. 

We have a program where we focus on patients who have a high admission rate in our emergency room—people who might come in 20, 50, or even 200 times a year. We started an intensive outpatient care program where we can manage their disease in a clinic setting. We’ve had success with that. We’ve seen a big drop in emergency room visits, and patients love it because they’re feeling better and being treated by a provider they get to know and who develops a care plan to fit their needs. 

Can you elaborate on how you use data to improve patient care delivery for this cohort? 

We are using artificial intelligence to help identify them automatically, which triggers a case manager to call these people directly. The system is constantly sifting through patient records, and every morning it spits out a report to identify patients at risk of serious health complications. The goal is to keep our clinicians one step ahead for our patients, and we are certainly doing that on the outpatient basis as well.

We try to also look at telehealth and remote monitoring as another tool we can use. But, rural America struggles with Wi-Fi and consistent high-speed Internet access. So that component is happening and we’re seeing good results, but we have to also come to terms with the fact that we’re not in a big city with reliable Internet. 

We do things a little differently here, and this is why I’m grateful Phoebe has local control over our entire health system. We don't have to worry about some headquarters in Atlanta or somewhere else giving us opinions about how our resources should be spent. Healthcare here in Albany, Georgia is a person-to-person experience, and I wouldn’t have it any other way.