Steve Markovich 0:03
Part of the culture of OhioHealth is that it’s a very team-based culture. We tend to solve all of our problems in multidisciplinary teams. And how do you do that and still have the same chemistry and dynamic while you’re making social distancing or working from home?
Gary Bisbee 0:16
That was Dr. Steve Markovich, President and CEO of OhioHealth as he works through changes brought by the COVID outbreak. I’m Gary Bisbee. And this is Fireside Chat. OhioHealth has the largest health system in its region, with 12 hospitals and 400 ambulatory sites. Dr. Markovich and his executive team are focused on using lessons learned from COVID-19 to accelerate to the next level of convenience for consumers. Recovery is a top priority for the health system, and for patients needing surgery or treatments. The OhioHealth executive team is working to solve a key barrier to patients returning, which is the restrictions to limit or exclude visitors and family members from accompanying patients. One of the learnings from the COVID crisis is that the state and local governments have an expanded view of OhioHealth actual delivery network. Let’s listen.
Steve Markovich 1:12
I think the government views us, in fact, as a system that is more comprehensive and more integrated than it really is. I was being asked questions by the governor’s office about well, how are we coordinating with all the nursing homes to use nursing home beds as overflows we need them. And they frankly didn’t understand that. OhioHealth doesn’t own a network of nursing homes.
Gary Bisbee 1:32
As a result of the crisis, OhioHealth will be addressing more completely the integration of disease management and public health. I’m delighted to welcome Dr. Steve Markovich to the microphone.
Well, good morning, Steve and welcome.
Steve Markovich 1:49
Gary Bisbee 1:49
We’re pleased to have you at the microphone. We’ve been leading off our conversations the last eight or 10 weeks with the discussion of COVID. What’s the state of the surge in OhioHealth’s primary service areas, Steve?
Steve Markovich 2:02
So we’re in central Ohio central and southern Ohio, very stable right now we compared to some of our colleagues across the country, and our governor acted very quickly and aggressively. And that blunted when I think most people would think of as the surge. So we are averaging about 1100 patients in the hospital across the entire state, of which we have 80 to 100 at any given time at OhioHealth, which is a 12 hospital system. So it is relatively flat. For the last few days, we’ve seen declining volumes at a state level. So this may take you straight to see the backside of the curve, that the big exponential peaks and a lot of people have predicted it really was born in Ohio.
Gary Bisbee 2:45
Good news there compared to some of the other hotspots. Why don’t we move to OhioHealth? Many of us are generally familiar with OhioHealth but Steve, could you give us an update on OhioHealth as it is today?
Steve Markovich 2:58
Sure. As I mentioned, we’re headquartered out of Columbus, Ohio at the center of the state. We’re the largest system in the region with 12 hospitals 400 ambulatory sites about 1000 employees, physicians, and about four and a half billion in revenue. 30,000 Associates. So it’s a medium-sized regional player, we are only within the state of Ohio and don’t venture up to Cleveland or down to Cincinnati. So to that center part of the Midwest, Columbus is a unique community in the state capitol. It’s not a manufacturing center. It’s really very much a business center. It’s the Ohio State University. So you’ve got a lot of the economic base here is very, very stable. It’s actually a great place to have a health system.
Gary Bisbee 3:39
What’s been the policy on remote working due to the COVID outbreak?
Steve Markovich 3:43
As soon as the Governor declared a state of emergency we effectively sent anyone who wasn’t a frontline caregiver home. And we are still working from home yet the typical administrative challenges up front are making sure everybody had access to the right software and the remote capability, but we’re making it work. It’s great when you can see people are just doing a session. Today, one of the things we got back is the associates that are working remotely while they’re able to do their jobs, that connectivity to their teams, and the connectivity to their manager, something that is challenged. So we’re trying to work out ways to work through that. We’ve had board meetings, we’ve managed to work through it. And so we are right now we’re working on a plan to hopefully bring everyone back. You know, you look across the community. I know folks that aren’t even planning to come back in Columbus, some folks in other industries are coming back in September. So we’re trying to figure out what makes sense, let’s say for our associates, where there might be some increased operating efficiencies. Now let’s prove to people can work from home. While it was a challenge, I think it’s one of those things that in the long run, we’re going to find that it creates opportunities for us.
Gary Bisbee 4:49
Can you focus a little bit more on the opportunity side? Will this translate into people permanently working from home in certain cases?
Steve Markovich 4:58
For example, revenue cycles, Our revenue cycle prior to COVID was largely campus-based at one of our administrative centers. We’ve got 1000 people working from home now. And the intention is not to bring them back. So I think especially folks that are working transactionally will benefit from working at home. I think for a lot of individuals, we’re going to end up at a hybrid model, where people will be able to as needed work from home, one of the things we have to do is we have to look at our physical plant and say, okay, at the administrator spaces that were designed in the past, with large group operating spaces, can we still have space, social distancing, we’ve got signs up in the elevators. Now, at work, you can only have two people in an elevator, there are things we’re going to have to rethink how we do part of the culture of OhioHealth is that it’s a very team-based culture we try we tend to solve all of our problems in multidisciplinary teams, and how do you do that and still have the same chemistry and dynamic while you’re maintaining social distancing or working from home?
Gary Bisbee 5:54
It’s a big project. You mentioned earlier that you have teams working on thinking about how to get back to whatever normal is going to be. How’s that working out? Steve?
Steve Markovich 6:05
We got two teams. We knew the day this all started, we started what was called back to business. We knew that there was going to be a wave of patients on the backside as well. I think yesterday we had 4000 prepped up imaging studies that needed to be done for patients. So we knew that there was this way that was going to have to happen. And so how do we come back to business? How do we make sure we’ve got the staffing, the supplies, the clinical protocols that allow us to function in the new world, as the governor relaxes some of the restrictions that he has in Ohio. We can do surgery, we can do elective surgery. We just can’t keep people overnight. Emergencies are still a “go”, treating pain, treating cancer, those things are still good, but you can’t do an elective procedure. We have to stay overnight. So we know there’s going to be this wave of people that need care. So we start thinking about that the day that the Cova crisis started. At the same time, we have another team that’s looking at what we call COVID plus one, which is what they learn from COVID. And how do we not go back to the way we were meant, like most of the systems across the country, our er volumes fell 50%. So people come through the front door 50% of baseline. Do we want to take it back to what it used to be? Or can we create new models of care and new delivery models where we can hopefully save some economic impact? Because we all know that there are a lot of folks that end up in different levels of care that really don’t need that, that level of support. How can we further leverage ambulatory surgery centers rather, for elective surgery, rather than bring people to the big hospital? Because prior to COVID, it was really a lot of physician input and physician preference. But really, we have to think about it differently now, as opposed to just saying, we want to bring everybody we can’t do our big institutions. So we’ve got two separate teams working on those things.
Gary Bisbee 7:56
Makes good sense. What’s your feeling about the way that your community is looking at coming back. Is there any way to judge how much concern there will be with coming back to your surgery facilities or the hospitals?
Steve Markovich 8:13
It’s anecdotal at this point, we had heard some concerns and started to make some plans, thinking I’d hear from other system leaders across the country that there was a significant number of folks that were hesitant to come back out of fear. We are working both through our physicians, some of our physicians are our best advocates for the safety of the healthcare system. Our government officials have stepped up. The mayor did a public service spot where he was talking about how safe the hospitals are. And then we’re going digital and print media to let people know how safe things are, that we have adequate PPE and that we will take great care of them. One of the big concerns we heard was really not so much around patients being concerned about infection or more COVID as much as the severe restrictions that were put in place around visitors. Family members, people who are willing to come to the hospital. But if they ask if their wife can’t come with them or their, their caregiver or partner, that creates an issue. So one of the things we’re really looking at is what’s the policy on folks coming? If folks are coming in for surgery? How far do we let support folks come with?
Gary Bisbee 9:18
Just follow up on that you’ve been mentioning, communicating with the community with your caregivers. What has been your communication strategy, Steve?
Steve Markovich 9:27
We’ve had multiple channels. We communicate internally with associates and physicians every day. My chief medical officer is on point for daily communication. I communicate to the organization with a video once a week. I communicate to my board once a week, and then every two weeks or so I do a communication video to the medical staff. We’ve done some things that I think are a little unique, and I’m very proud it covers from several aspects of the crisis. The four system CEOs we got together, and we said, “Listen, this is bigger than any one of us.” And so when it comes to the safety of the healthcare environment, our policies around visitation support for an alternative site of care, you know, standing up the convention center as 1000, better 1500 bed hospital in Columbus, for mass casualty management, we did that together. And so there’s been a lot of communication to try to reinforce across the community, that it’s not just about a house, it’s about the network. It’s about the system of care that exists, and that people should have confidence in that all four CEOs. We wrote a big letter to the editor. In some communities, hospital systems don’t collaborate but we’re really proud of Columbus. We have a way of doing things that are above us at that level. We all agreed to be one team.
Gary Bisbee 10:43
Excellent. What’s the morale been of your caregivers? It doesn’t sound like you’ve been swamped, like some of the hotspots but nonetheless, treating patients on a continuous spaces. What’s the morale been?
Steve Markovich 10:56
It’s really been pretty good. We’ve been very transparent with where we are, what we’re doing, we created some really solid channels for feedback as well, as we got into this. We had some physicians from the front lines that jumped in to help us work on the teams to set policies and procedures and help us as things evolve. We recognize, right upfront, there are eight principles that we set out at the beginning. And one of them was taking care of our associates, economically, physically, and psychologically. And when I say associates, I include the physicians with that. And so we created physician associates resilience teams. So every day there’s an incident command center report out and resilience and burnout is actually an agenda item. So we’ve been working hard to take that into effect. The good news is because we didn’t have the volumes that you might have seen in other parts of the country, we’ve been able to manage the workload, and frankly, when the volumes went down, we sent a lot of people home to keep them safe and keep them ready for a recovery period. So we’ve been able to rotate people through to make sure that people are feeling refreshed as best they can.
Gary Bisbee 11:57
Just thinking about leadership for a moment. What have been your takeaways from this crisis in terms of your leadership style? What have you had to do differently or think about differently?
Steve Markovich 12:10
It’s interesting. I’ve gotten a lot of feedback on that because I’m a relatively new CEO. Having only been in the job now about seven months when this thing kicked off. Historically, I would have been the guy that was probably running Incident Command, and I needed to stay about it. And so we put together and I essentially kept the senior team out of incident command, we put together a structure where we had clear channels, we had clear roles and responsibilities. We empowered those people, we gave them as broad of decision making authority as we could. And we basically said, “Listen, job one is to take care of the people, and that could be the patients or the associates.” We got to do this safely. And we’ll figure out the processes and the finances on the back end. But we got to make sure we got the right PPE, we’ve got to make sure we’re managing this appropriately. We got to collaborate with our government officials. The biggest thing is that my leadership change was really elevating. And then letting those people that are really experts at the job, just turn it loose, and they have really done a great job and it has been great to see some of those young leaders mature and grow into the roles.
Gary Bisbee 13:10
So you mentioned PPE, how’s the supply chain been holding up for PPE for OhioHealth?
Steve Markovich 13:17
It was really challenging at first, like most places, we have GPO relationships. And we had gone to a lot of relatively limited inventory. And so there were a lot of challenges up front. We ended up working back channels and alternative producers. And so we are in a pretty good place right now. We were super fortunate. And you may have seen it on Today Show and I think it was on Time Magazine. There’s a large think tank in a town called named Patel. There’s a lot of government work and research and we work with them to actually come up with a decontamination system. And so at one point, you can reuse a mask 20 times and so we started decontaminating them long before we had the alternatives PPE or from a supplier perspective, we were recycling PPE to the tune of 10,000 masks today at one point. It was great to see that innovation come up. That was one of our family physicians who in partnership with Mattel, started thinking about how can we fix this thing. And it was great to see that level of cooperation. But we’re in a pretty good place right now. We are tracking it very closely in Ohio. The governor has a perspective that really the healthcare system is in fact a system where you’ve got small hospitals, big hospitals, nursing homes, the independent silos and bureaucracies, and the different legal entities. I think he takes a perspective that, listen, it’s one system, we all got to take care of each other. And so you’ll have a hospital association stepped up and helps us track who’s deep in PPE who’s not who can help somebody else out. So some of that does go on, but we’re in a pretty fortunate place right now.
Gary Bisbee 14:52
Many of your colleagues are talking about the fact that we should have a more reliable supply chain for PPE And perhaps thinking about how much of the supply chain is outsourced globally? How would you think about that?
Steve Markovich 15:07
I think that’s spot on, I think we’re going to have to rethink for critical items, whether it’s in 95, or facials, there are certain surgeries. And we’ve seen even before COVID, we saw the problem with one of the major GPOs with the problem of production in China, and sterility. So this idea that we’re dependent on relatively few channels, and those channels are offshore, it creates challenges. So I think we’re going to need to look at that. I think whether it’s local sourcing, or creating deeper bench deeper stockpiles, I think those are all the things we’re gonna have to look at.
Gary Bisbee 15:39
So you were a command pilot in the Ohio National Guard for a number of years. How does the military handle its secure, reliable supply chain? Are there any lessons learned there for us and healthcare?
Steve Markovich 15:51
The military focus, you know, has some of the same issues. You’ve got some relatively specific items that may be sourced from a single vendor and they have to do another on a worldwide basis, so you end up with inventory management. And there’s a logistics tail to just getting things moved, that the military is really, really good at. I think inventory management awareness of where you are things that you can learn that I took away from the Air Force, clearly a strong sense of supply chain management, people that understand that business and just making sure you go through your contingency planning to where if you’re dependent on a single supplier or one or two suppliers, that is a risk that we’re not talking about at the board level. In today’s world, it’s not sustainable.
Gary Bisbee 16:31
Yeah. Well, and the question is who’s really going to pay for this excess capacity that we all think we need now that we’ve drummed out of the system before? So I’m sure you’re talking about that with your board too.
Steve Markovich 16:45
Yep. We had a tremendous response and I’m sure most communities did. We had a tremendous response from the business community for folks that have in their particular businesses. They may have used masks or protective equipment. We had over a million items donated in a relatively short time, we actually had to get a separate warehouse just to take care of what was being donated. Again, that was another place where all the systems in Columbus came together. And so it doesn’t make any sense for each one of us to be looking for help from different businesses. We ought to look at this together. And then if there are issues we got to supply that we can draw from. Yeah, that’s just terrific.
Gary Bisbee 17:20
Turning to telemedicine, have you seen a marked increase in telemedicine visits?
Steve Markovich 17:25
Huge. I think through the last report that I saw, we’ve done 75,000 telemedicine visits, ie visits, video visits, mobile chat with a patient so that was a relatively immature space for us. We knew we were gonna have to get better at it, but there just had been that catalyst to make it all happen. And COVID really pushed it. And so we’ve got 900 providers now that have all been trained, and the office staff and we’re actually encouraging folks, especially for routine follow-ups, things like that telemedicine is going to be huge. He’s been using it for a while. tele-consults for things like urology, counsel to the Are things like that, but pushing it down to primary care? we’re operating at a whole new level now. And I don’t see that going back.
Gary Bisbee 18:07
Well, it helped the CMS and the insurance companies are paying for the tele-visits to I suppose that was an important part of it.
Steve Markovich 18:13
Absolutely. I think in this case, just because of patients not wanting to go into their doctor, there’s pressure to solve that problem no matter what. But the fact that they’ve now created a way to make the economic model work is a good thing.
Gary Bisbee 18:26
Have your providers your caregivers responded to this? Have they been innovative in terms of how they’re thinking about and using telemedicine?
Steve Markovich 18:36
They’ve been superpartners. Most of them are very engaged, they see and they’re thinking about it from a safety perspective and a patient care perspective. They don’t want to bring people into the office that don’t need to come into an office. It’s really been remarkable to watch the collaboration. It is challenging in a community-based hospital system like Ohio Health. Our providers are all on epic. But you’ve got independent folks that aren’t and so it was interesting, there were a lot of requests for help to help create a telemedicine solution for them something that they could connect with their patients or that was secure and appropriate. So we’ve been trying to help them as much as we can stand up that capability.
Gary Bisbee 19:12
Well, let’s turn to the all-important economics piece. How will OhioHealth end of the fiscal year? I think you’re a June 30 fiscal? How will you end up your 2020 fiscal year Steve?
Steve Markovich 19:25
We are going to weather this better than some. So we did take advantage of a number of government programs as well as the Medicare advance payment. So from a cash flow perspective, we’re in a good place. We did curtail capital. And we did discretionary spending. We put a lot of constraints on the organization, new capital projects were stopped and we actually lowered the threshold, the authority matrix for what people could do to really try to make sure that we have things clamped down on things. Our fiscal year ends June 30, essentially the last third of the year. We’re what we’ll probably watch about the first two-thirds of the year. But overall, I think we’re going to end up in a pretty good place moving forward, we did make the strategic decision, we have a pandemic PPE program. So even though I’ve got associates at home, we’ve released June 1, we’re keeping them whole economically, we’re going to need those associates, we are modeling as quickly as we can, what the bounce back is going to look like both the short term pent up demand as long as what as well as what is the new normal look like. And so rather than put associates in a conundrum or an economic hardship, we leveraged our economic stability to keep them whole. And our board was very supportive of that. And we’ve gotten a lot of positive feedback about that. Just the fact we had the ability to do it, we chose to do it. But this next few months will be those are going to be the benchmark that we use to look at how the next quarter looks and we’ll probably end up in a quarter to quarter budgeting or management situation for a little while.
Gary Bisbee 20:50
Well, that makes good sense. What about cap x? How are you thinking about budgeting next year for cap x?
Steve Markovich 20:56
We will still have capital available. It’ll be a little more emphasis on routine capital. And then some of the big projects with long term bricks and mortar type things that would have had a much longer-term financial payback. We’re really looking at those. Clearly cash is important right now. And so we’re trying to be very, very selective of what we need to do. There will still be regular routine infrastructure that has to be managed, and some strategic thinking, but some of the major projects right now, I was on a capital meeting yesterday, and everything is being relooked at because we just don’t know the volume assumptions that went along with some of those strategic projects. Those are actually in flux. So we got to figure that out.
Gary Bisbee 21:32
Sounds like, in addition to your cap x plans, your strategic plans for the next several years may need to be adjusted as well.
Steve Markovich 21:39
Absolutely. I was talking to our population health team this morning on a call, they’re gonna have to help drive what the new normal looks like and how we deliver the care and what level of care is going to be appropriate in the new home. I’m not gonna say the whole strategy has changed, but I think that demand on the system is going to change just because of the nature of people going to the doctor or going to the house. Go to the surgery center. People are rethinking those things as how bad they need it. Or where else can they get it?
Gary Bisbee 22:05
Let’s turn to the Board of Directors, which you mentioned meeting with previously, how have you communicated with your board during the crisis?
Steve Markovich 22:14
I do a letter to the board every Friday that summarizes how the week is gone and what the issues are dealing with. I think I mentioned earlier, I do an all-staff video once a week on Tuesday, I attach that video to the mailing to the board. So the entire board gets that I’ve gotten a lot of very positive feedback on that. I have had a couple of private board calls with my executive committee in my chair, just to inform them of anything major that was covered down or what we were, whether it was the plan for reopening of elective surgeries, things like that. So the communication with the board has been good. We have had one full board meeting. We’ve had several committee meetings, but the full board actually had one fully electronic remote meeting, which was great.
Gary Bisbee 22:55
Well now I’m asking everybody any tips for smooth virtual board meetings.
Steve Markovich 23:00
Give ya a couple that worked well for us. One thing is we literally because you know, most of us use PowerPoint or something like PowerPoint, one of my concerns was keeping everybody on the same slide, you got to make sure everything is numbered, even the agenda, each topic of the agenda. It’s had its own separate slides. So if you just went page by page by page, you knew where to go. We also put whoever each slide was assigned a staff member. And that name was put on the slide so that if a board member had a question because some of the board members had visuals, and they were using an AV tool that had visual capability, and some board members were calling in. So sometimes when you’re calling in, you can’t tell over the phone who’s actually talking. And so I wanted to make it crystal clear if you had a question on slide 17. Here’s what you should ask. And so there was no ambiguity as to where to direct your question as you went through the meeting. Because it’s not unusual to have a person meeting you could have three or four people talking and I could appreciate on the phone, you might not be able to I understand we need to direct the question to it went really well.
Gary Bisbee 24:03
Yeah, that’s a terrific idea. I had not heard that before. So well done. Let’s move back to a higher strategic level, it seems evident that public health is now part of the national security, not sure that we thought about it that way before. How do you think about that? Steve?
Steve Markovich 24:20
I think this has been a real eye-opener. Frankly, there’s a lack of integration of public health, both at the state level and at the federal level. I think this is going to be the catalyst that makes us rethink that I mentioned a little bit ago, I think, in the health systems. I think the government views us in fact, as a system that is more comprehensive and more integrated than it really is. I was being asked questions by the governor’s office about how are we coordinating with all the nursing homes to use nursing home beds as overflow as we need them. And they frankly, didn’t understand that. Ohio health doesn’t own a network of nursing homes. They’re independent, very high-quality nursing homes in the region. But it’s not like we’re networked on a giant computer database. Well, we know what each other census is and what the demand is for beds or TV or anything. So when we say public health, it’s not just about testing and disease management. It’s how do you in situations like this? How do you create a system that truly is integrated and leverages everyone’s capabilities? Like most hospitals, we’ve been through a lot of mass casualty exercises, and contingent outbreak exercises. We’ve never exercised the system to this level. New York during 9/11 would be the closest thing having come from the military. I’ve got this vision of Sunday, there’s gonna be an exercise, where there’s a Blackhawk helicopter from the National Guard landing on one of our hospital helipads. When we start thinking about it at that level, we will be on the right track.
Gary Bisbee 25:45
Does this kind of add to our focus on social determinants of health?
Steve Markovich 25:50
I think the data is showing for patients who are struggling with social determinants of health and this particular disease outbreak is or having worse outcomes. It’s just another case where folks, folks that are either socioeconomically challenged or medically challenged, their prognosis is poor. We have to figure out ways to address that. You’ve got cultural barriers to testing. There’s actually I sat on a committee that was looking at how do we get greater penetration of testing into minority communities where there is a fear of government and fear of gig systems, because they don’t trust they don’t know where the data goes, they don’t know how to be used. So this is a multifactorial problem of how do we address not just social determinants, but deeper penetration of the healthcare system and to all the patients that we serve?
Gary Bisbee 26:36
Yeah. Well said, this has been a terrific interview. Steve, if I could wrap up with one question. We’ve had a number of people at this microphone talking about a “new normal.” What do you think will be changing going forward as a result of the COVID crisis?
Steve Markovich 26:54
Could there be so many things I think the just how we approach our interaction with each other you know, whether it’s the need for physical distancing or the desire to do things in a way, that is like, if I can do it from my family room, if I can find my groceries that I can find my paper towel, I can I see my doctor and get what I need. So I think there’s going to be a whole new, and I’m a family physician by training, you know, I was trained with the idea that you know, your patients and you understand your patients, and you have these deep relationships, that whole model is going to be challenged. And I think that’s probably one of the biggest things we’ll see. I think, too. How do we continue to deliver high-quality care in smaller communities, this clearly shows us the economics of health care are going to have to be addressed. If you look at the hospitals that are dealing with hundreds and hundreds and hundreds, if not thousands of COVID patients in the larger urban centers, or the small community hospitals that were living on elective surgeries and we shut that off. I think that’s a wake-up call that we’re going to lose. County hospitals are smaller community-based hospitals if we don’t do something.
Gary Bisbee 27:57
Well said, Steve, this has been terrific. Thanks. So much for your time and good luck to all of you in Ohio and OhioHealth.
Steve Markovich 28:05
It’s a pleasure. Thanks for doing for this.
Gary Bisbee 28:08
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