Episode 41:
You Can Only Connect the Dots Backwards
Dr. James Linder, CEO, Nebraska Medicine
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In this episode of Fireside Chat, we sit down with Dr. James Linder, CEO, Nebraska Medicine to talk about his storied career at the University of Nebraska, a leader’s most important characteristic in times of crisis, and the role of the Nebraska Biocontainment Unit and National Quarantine Unit in treating some of the first COVID patients from the Diamond Princess cruise ship.

James (Jim) Linder, MD, is the chief executive officer for Nebraska Medicine and professor of pathology for the University of Nebraska Medical Center (UNMC). After earning his medical degree from UNMC in Omaha, Nebraska, and subsequent training in pathology at Duke University in Durham, North Carolina, he joined the UNMC faculty in 1983. Dr. Linder has authored more than 150 publications and five textbooks while filling diverse roles in academic medicine and business. Read more

Transcription

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James Linder 0:03
Every health system is looking at their labor stack if you will. Who does what work? How is work getting done? How’s the care provided? So I do believe we will get to a different care delivery model than we had in December of 2019. And hopefully, that will be better for the patients and be more efficient economically.

Gary Bisbee 0:23
That was Dr. James Linder, CEO of Nebraska Medicine, discussing how the COVID crisis will lead to a new delivery model to provide more convenient and efficient care for the patient. I’m Gary Bisbee. And this is Fireside Chat. Dr. Linder has a storied career at the University of Nebraska, including being interim president, a long term faculty appointment as Professor of pathology and microbiology, and his current appointment as CEO of Nebraska Medicine. Dr. Linder is a long-standing entrepreneur with a broad range of interests. Let’s listen to Dr. Linder respond to a question about the public health infrastructure and its importance to national security.

James Linder 1:05
The pandemic has illustrated the fact that robust public health infrastructure is essential for not only the health of individuals but the health of the economy. It’s not nice to have, you really need a strong public health infrastructure. And I think every city-state and the federal government has underfunded that for many years because it’s not a glamorous activity. Hopefully, people have learned from this pandemic that proper investments and public health are essential.

Gary Bisbee 1:37
Our conversation includes Dr. Linder discussing a leader’s most important characteristic in times of crisis, Nebraska medicine, economics, what he likes most about Nebraska, and the role of the Nebraska medicine biocontainment unit that received early COVID patients from the west coast. I’m delighted to welcome Dr. James Linder to the microphone.

Well, good afternoon, Jim, and welcome.

James Linder 2:03
Thank you very much, Gary, I’m delighted to be with you on this podcast.

Gary Bisbee 2:06
We’re pleased to have you at the microphone for sure. It’s always interesting to learn about our guests. You’re Midwesterner born in Nebraska and have been at the University of Nebraska in one form or another for quite a while. What do you like best about the Midwest?

James Linder 2:21
As you say, I was born and raised here. And I guess I could say I like the seasons to some extent, and I certainly like working with the people. I’ve had just great professional interactions since I joined the faculty here in Nebraska in 1983.

Gary Bisbee 2:37
For those of us that aren’t familiar with Nebraska, how would you describe Nebraskans?

James Linder 2:43
Well, I would say we’re the well-deserved brunt of many jokes. You know, it’s like a study, in contrast, it’s a very agricultural state with expanses of land with very few people. So we’ve been practicing social distancing since 1869. Then we also some major metropolitan areas with huge businesses with Fortune 500 companies. So it’s a nice contrast that appeals to many people.

Gary Bisbee 3:12
What would be the distinctive feature of Omaha as a city other than there are these four companies and Nebraska medicine and so on, but how would you describe Omaha to somebody that was not familiar with it?

James Linder 3:25
I’d probably still describe it as a big town as opposed to a city, which is a little unfair since the metropolitan area has close to seven or 800,000 people, but it’s a community I think, where people do still know each other, they interact a lot of farmers markets, cultural events, and everything is accessible. And I lived in the Boston area for a while for work. It was very hard to go to a show because of just the logistics of traveling and parking, whereas in Omaha, you can still enjoy those things.

Gary Bisbee 3:57
Now our listeners wouldn’t forgive me if I didn’t ask the obvious question. Do you know Warren Buffet? And do you run into him at all?

James Linder 4:05
I do know, Mr. Buffett. We have run into each other on a few social events. And he’s a very private individual. And I think everyone in Omaha respects that. I’ve been in restaurants where he’s been at a table and no other people walk up to him to start conversations. They’re very grateful for what he’s done for the community and for all the investors in Berkshire Hathaway, but he enjoys his private life. And a favorite story about Mr. Buffett, I actually when I was a younger person, saw him in a hardware store looking for a part on his own, and walked around some aisle and there’s Warren Buffett. I didn’t have the foresight then to ask him for investment. My wife Karen actually did write a book on the women executives who served Berkshire Hathaway for many years. And in doing that, we learned quite a bit about the company and its success.

Gary Bisbee 4:59
That sounds like a must-read and maybe the next podcast interview would be with Karen, but on to you. When did you decide on medicine?

James Linder 5:07
Well, I was an undergraduate biochemistry major Iowa State and was actually pursuing a PhD program in the 1970s. And unfortunately, that time, getting a PhD in biochemistry was a ticket to the unemployment line. And I decided that I could be a very good researcher with a MD degree, as well as a PhD degree. So that really drove my choice of medicine. And some of you may know that I’m a pathologist by training. And pathology is more of basic science. So that was kind of in line with my research interests.

Gary Bisbee 5:40
You’ve held a variety of positions at Nebraska, including interim president in the university and certainly been a professor of pathology microbiology for quite a while and currently CEO in Nebraska medicine. What were the circumstances that resulted in your being appointed interim president?

James Linder 5:58
I was working in the university prior to that time leading to technology development. And that was because I had worked in industry for about 12 years. And so I had a good sense of tech transfer. And when the president of the university took a position at the City University of New York, he recommends that I’d be one of the candidates for that consideration, simply because we had worked together at the system level. The University of Nebraska has four different campuses. So it has quite an expanse throughout the state.

Gary Bisbee 6:31
How long were you interim President, then?

James Linder 6:33
So luckily, I had to get out of jail free card. My agreement specified that I could not be a candidate. The search concluded after one year, and so I had a full year of all the things that you would have as a university president, including an occasional athletic department, controversy or two, but then when the year ended, they had a good candidate who followed me who was dedicated to being a university president. He took that job on.

Gary Bisbee 6:58
If you could focus on one thing that you learned as President of the University of Nebraska during that year, what would it be?

James Linder 7:05
I would say that it is a learning that I’ve tried to carry all my life is that if you have people who are working for you or with you, let them do their jobs, don’t try and do their jobs. Because the reason that they are a dean or department chair or Chancellor is to lead their faculty and their employees. And I think that’s always been a valuable lesson. I’ve applied in different roles. I was the Dean of medicine for a while and I left the chairs to do their job. And as CEO, I let my chiefs and divisional leaders do their jobs, that’s why they’re there to do the best job possible.

Gary Bisbee 7:43
That’s a good transition to the current role you’re holding, which is CEO of Nebraska Medicine. What were the circumstances, Jim, to your being appointed to Nebraska medicine? You were sitting on the Nebraska medicine board at the time. But what were the circumstances underlying your appointment?

James Linder 8:01
I was on the Nebraska medicine board and clearly had no aspiration or even concept that I was qualified to be the CEO of the health system. But the board asked me to assume that leadership role and I talked to my wife and she thought I was being a little underutilized at that time since I had finished the university presidency. And I thought it’d be a good experience.

Gary Bisbee 8:26
So you agreed to do it. And you’ve been CEO now for about two years. What have you learned as CEO that you didn’t realize when you were sitting on the board of Nebraska medicine?

James Linder 8:39
I think the greatest thing I came to realize both as a board member and as a physician practice at this hospital for decades, was how incredibly complex it is to deliver patient care at a high level. It’s really, as all the other CEOs listening know, you’re running basically a hotel, restaurant, Critical Care Service and emergency room. It’s a very complex business. And each day when we have our daily shout out here 30 different departments report. And if anyone of them has a problem, say pharmacy, it dramatically impacts the rest of the health system.

Gary Bisbee 9:17
Most people don’t realize that you’re also a highly successful entrepreneur. When did that interest develop?

James Linder 9:25
It probably grew mostly out of my experience in the industry. I began working for a company part-time, and in the mid-90s. That was based on some of the academic work I’d done. And at the same time, I retained my faculty employment. But in doing that, we were forced to innovate new products, we had the opportunity to look at partner companies for either acquisition or other relationships. And it really gave me direct exposure to business and business development. So when I came back to Nebraska. I was actually leading the technology transfer office at the Medical Center for a while. And in doing that was active and trying to build commercial activities out of some of our intellectual property.

Gary Bisbee 10:14
So what are your current entrepreneurial interests, Jim?

James Linder 10:17
Well, for 10 years my wife and I have operated an angel investment fund called Linseed capital. And I think we invested in about 30 companies. And all of those have been great experiences because we live vicariously through the founders. Clearly, not all of them have been successful. But we’ve had great learnings from dealing with those people. And then for about the last five years, my wife and I have been operating, she more than me, a company that does ceramic 3d printing. And we were attracted to that because of potential medical applications. And that’s been true, but then there are also great uses for ceramics and other industries.

Gary Bisbee 10:59
A very Interesting life you live, Dr. Linder. Why don’t we move to Nebraska Medicine? Can you describe Nebraska medicine?

James Linder 11:07
Well, at Nebraska medicine we are the primary teaching hospital for the University of Nebraska Medical Center. We are a free-standing entity that has its own governing board. We don’t report directly to the state of Nebraska. We operate to hospitals, approximately 800 licensed beds. And during the course of a typical year, we’ll have around 34,000 visits, 95,000 emergency room visits, and 74 clinics that accommodate probably a million clinic visits. So we’re small compared to many larger academic medical centers and health systems, but really ethically share some of the same opportunities and problems.

Gary Bisbee 11:47
What about the culture? How would you describe the culture of Nebraska Medicine?

James Linder 11:51
I would say it is targeted toward getting things done doing the right thing. Innovation, teamwork, the pursuit of excellence. wants courage and healing which are embodied in our values. People work really well together.

Gary Bisbee 12:05
Nebraska medicine received one of the early COVID patients, as I recall, share with us why Nebraska medicine would have received those early patients?

James Linder 12:15
It’s a very good question. And it underscores a comment that Steve Jobs made and a commencement address at Stanford, that you can only connect the dots backward. And if you look back to 2004, a decision was made to establish and biocontainment unit at the University Nebraska Medical Center. It sat unused for 10 years, but every month, the staff in that unit practiced donning and doffing and taking care of highly infectious patients. Then in 2014, we had of course, the Ebola crisis that led to people receiving care in the US, and Nebraska medicine took care of the majority of those patients. After that, experience it was recognized that the country in the world needed training and dealing with highly infectious diseases. So over the next five years, we participated in training thousands of military and civilian personnel in the country and actually established the global center for infectious disease on our campus. And it was that center that was activated when the patients from the diamond princess cruise ship, were returned to the US who were COVID positive. And we monitored some of those who are not too ill in isolation and then provided care for the others.

Gary Bisbee 13:35
Definitely an interesting story. Let’s move to COVID a little bit more in a moment. There’s been obviously social unrest around the country. Sounds like Omaha has had its share. How would you describe that Jim and how has it affected Nebraska Medicine?

James Linder 13:53
Omaha has had a share of an appropriate share, I would add of concern over the disparities that exist both economically for people of color and in healthcare access. And our physicians and nurses have stood with those individuals. There was an event just on Friday, where hundreds of healthcare professionals knelt in a moment of silence to recognize the problems that our country is now dealing with. When I communicate to our staff, I emphasize that we cannot solve problems on a national level. But locally, we can do a lot to impact in a positive way the lives of people who would like education and healthcare, would like to add this as a career. And certainly dealing with the healthcare disparities, making sure that everybody has access to screening and care in the state.

Gary Bisbee 14:47
Well said let’s turn if we could to the COVID crisis, how has the surge progressed in Nebraska and particularly for Nebraska Medicine?

James Linder 14:57
if I had to use a term, I would say a Rising Tide as opposed to a tidal wave. We began preparing for a surge, probably in February, maybe March. And that was based on some of the modelings we had seen, that could affect our estate. And either because of social distancing or other factors, we didn’t see that spike in impatience. But we’ve seen a steady climb and the number of COVID-19 patients we’re caring for, typically 10% to 15% of our inpatient census, I pointed out to people that during this entire preparation for the surge, more than 90% of patients that we care for either in our ambulatory clinics or the hospital are the routine issues of heart attacks and cancer and neurologic disease that require our attention. So you’re ramping up to do something totally different taking care of patients, while at the same time you have to deliver excellent care for everyone else.

Gary Bisbee 15:55
Shortage of PPE has been all around the country, particularly those in the midst of the surges, how has PPE been for Nebraska medicine?

James Linder 16:07
In general, we had adequate supplies. And that is partly because of the position we sat in the country of being prepared to take care of large numbers of patients who might be ill with an infectious disease. We did pioneer early on the UV decontamination of N95 masks, which allowed an individual to use his or her mask over say three times. We also thought a lot about innovation. Our teams put together ways for droplets that might arise from having nasal canula in place, using shields that could protect anesthesiologists and a lot of environmental controls to make sure that health care workers are not affected.

Gary Bisbee 16:52
There’s been a lot of discussion about the role that the federal government ought to play for stockpiling PPE. How do you think about that, Jim?

James Linder 17:02
Well, it’s a question of when you’re doing it. If you’re doing it prior to a pandemic, it’s a wonderful thing. That way, health systems can equitably access those resources. Yes, the federal government is competing against health systems to buy PPE during a time where you’re trying to secure for your own patient care needs, and there isn’t a system to equitably distributed and that can cause problems

Gary Bisbee 17:29
How about the state of Nebraska? Is the state of Nebraska have any stockpiling of PPE?

James Linder 17:35
The state of Nebraska has been a very good partner for Nebraska medicine from the onset of the pandemic. Our staff here at UMC have worked with the six different regions in the state to try and make sure that people were educated on protocols and as much PP was available as possible. So we did have some state resources we drew on some of the resources that existed at Nebraska Medicine to make sure that the hospitals and nursing homes could actually deliver the care in a safe way. pp is just an amazing tool for controlling the pandemic. We have had no health care workers that have become infected when properly using PPE that’s since January of this year. Now I’m knocking on wood here because we could always have a mistake tomorrow. But we made use of PPE extenders to make sure that our individuals were in the care setting or properly putting on and taking off their PPE so that did not accidentally contaminate cells.

Gary Bisbee 18:39
Jim, how about telemedicine? It has exploded in virtually every health system in the country. How about Nebraska Medicine?

James Linder 18:47
It has likewise seen a dramatic increase. In the last month, we had some days where there were more telemedicine visits than there were in-person visits. And so if there is ever a silver lining from this pandemic It is illustrated that patients like telemedicine. Physicians can practice high-quality telehealth remotely. And it is a real plus for healthcare Also consider the fact in a rural state like Nebraska, it can enable care to populations that otherwise may not get it. So I think that organized medicine should work hard with the federal government and insurance carriers to make sure that the reimbursement for telehealth services is appropriate.

Gary Bisbee 19:29
If the reimbursement is appropriate, do you think that this increased usage will continue or even grow?

James Linder 19:35
I think it will continue. I think it will require our health systems to rethink how they engage patients. So we may have diagnostic centers where blood draws could happen. And imaging studies could be done here, before or after the telehealth visit. So all that information is there. And then I think you’ll see some services that have not been adequately served in the country such as in-cancer screening, that will grow tremendously because the paucity of dermatologists and many communities has led to a deficit in screening for skin cancer. And I think that can be resolved by telehealth. So the CMS and the states issued waivers pretty early on. Was that particularly helpful? I think that the waivers that were issued were helpful, and I think that we should look carefully at how that has impacted care. And when it’s improved care, we should look for those waivers to be made permanent so that it is part of the ongoing provision of care. how do you think about social distancing with let’s say your amatory care,

Gary Bisbee 20:40
How do you think about social distancing with let’s say your ambulatory care, waiting areas will there need to be new planning to accommodate social distancing?

James Linder 20:51
The point you bring up is very important. A lot of the ambulatory care areas if you think of how they were historically patients would come in, they would be given a clipboard and they’d fill out several pages of answering questions. And that does not lend itself to good social distancing. So with the digital front door, if you will, that we’ve developed with our Nebraska medicine app, which is similar to what many other health systems use, those questions can be answered before the patient comes in. So literally, they show up for their 10 o’clock appointment can be seen immediately in the exam room where they’re scheduled to be seen. We’ve taken the position that all of our providers in the ambulatory setting do wear masks. We provide masks to patients when they come in if they don’t have their own. We think that the physical barrier the mask is essential for limiting the spread of the virus.

Gary Bisbee 21:45
How about rebooting surgeries Have you begun to institute surgeries now?

James Linder 21:52
We began doing “elective surgeries” when it was permitted by the state surgeries that were required for life and limb, even during the onset of the pandemic we did. The things that could be postponed for four to six weeks were postponed. And we began doing those largely limited by the availability of staff as opposed to our time. Then we found, as I’m sure many other CEOs have taken care of patients who have COVID-19 infections as a significant burden on your critical care, faculty, and staff, whether they’re anesthesiologists or pulmonologists and that has limited our ability to staff some of those procedural areas. But we’re gradually getting back up to the neighborhood of 80%.

Gary Bisbee 22:42
COVID has accelerated the timeline for discovery in many cases, vaccines, drugs, devices, as you’ve pointed out innovations that Nebraska medicine will that accelerate to provider delivery cycles in a commencer Why do you think Jim?

James Linder 22:59
I think every health system is looking at their labor stack if you will. Who does what work? How is work getting done, how’s the care provided? So I do believe we will get to a different care delivery model than we had in December of 2019. And hopefully, that will be better for the patients and be more efficient economically.

Gary Bisbee 23:20
Let’s go to the economics of this, which is not a pretty picture for any of our health systems. How will this COVID outbreak affect and Nebraska medicines finances in 2020?

James Linder 23:33
Well, for fiscal year 20, we will incur probably a modest financial loss. We were in a fairly strong position, coming into say April this year, but April, May, and June will all be actual negative, if you will. We made the decision early on to not furlough any of our employees. And we had the luxury of doing that because we had sufficient days of cash on hand that we felt we could absorb that law. We also thought that those colleagues would be essential for the recovery of our activities in June, July, and August. But still, it’s going to be a difficult year. And it will require some innovation and work on part of everyone to make sure that we can deliver care in an efficient way and make sure patients feel comfortable coming back to the clinics in the hospital.

Gary Bisbee 24:23
There’s a lot of fear out there. Probably 40% of individuals are reluctant to come into a healthcare setting. How are you dealing with that? Are you trying to communicate with the community about that, Jim?

James Linder 24:35
I believe that the most effective way is direct conversations with the individuals who normally would schedule those patients, making sure that they are aware of the safety precautions in place for their well being. And I make the point that Nebraska medicine was one of the most advanced facilities in the country or the world in dealing with the patient who had an infection. Likewise, the safety protocols we put in place, I think are strong, supportive, and safe for the patient. Fear is fear though. And it does take repeating that message many times over.

Gary Bisbee 25:11
Yeah, I’m sure. Well, let’s hope we don’t have another wave in the fall as some are predicting. How are you expecting the payer mix to change?

James Linder 25:19
Well, I think the payer mix will change in a couple of different ways. In Nebraska, we’re finally getting to a point of Medicaid expansion. So we will be reimbursed for Medicaid from sources we did not have access to before. And then I think on the national scene, there will probably be the ongoing juggling of different payers. They probably had a very strong third and fourth quarter because of the fact that many elective procedures were postponed, but there’ll be rethinking about how they want to support healthcare and there could be federal legislation as well that affects the payment of services.

Gary Bisbee 26:00
Turning to leadership. I think we all agree leadership is always important, particularly in times of crisis. What characteristics do you think a top leader ought to have during a crisis?

Jim Linder 26:12
Calm. That answer may be too brief, but I think it’s essential. I think you have to analyze the situation you’re in, get input from people who are at the front line and be calm as you’d help guide people through the decision making.

Gary Bisbee 26:25
Yep. As I’ve asked other CEOs, that’s a frequent answer. So you all have that experience. Let’s go to the health infrastructure, it seems clear that public health is more part of the national security than we might have thought in the past. How do you think about that, Jim?

James Linder 26:45
I think that the pandemic has illustrated the fact that a robust public health infrastructure is essential for not only the health of individuals but the health of the economy. It’s not nice to have. You really need a strong public health infrastructure. And I think every city, state and federal government has underfunded that for many years because it’s not a glamorous activity. Hopefully, people have learned from this pandemic that proper investments and public health are essential.

Gary Bisbee 27:17
I totally agree with that. And it seems like it’s up to us to continue to push that ball forward, or it runs a risk of being forgotten. Again, Jim, this has been a terrific interview. I’d like to ask one last question if I could. We’ve been talking about the new normal, off and on now for a couple of months. What do you think would characterize a new normal?

James Linder 27:40
I think we have to acknowledge the fact that the diseases that plague people before the pandemic continue to exist. And we have to figure out a way to deliver care to those individuals in a way that’s safe, while at the same time meeting our challenging requirement of providing care for Cova 19 patients for at least the next year. We think that probably 10% of our hospital occupancy will be of that realm. Then, relative to your public health question, I think the more that we are engaged in communities, making sure people are healthy, making sure that there are not health disparities and access and care. I will have a healthier community overall, and just make the country a better place.

Gary Bisbee 28:25
Jim, excellent interview. Thanks so much for your time today much appreciated.

James Linder 28:29
My pleasure.

Gary Bisbee 28:31
This episode of Fireside Chat is produced by Strafire. Please subscribe to Fireside Chat on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review fireside chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating, we have found that podcasts are known through word of mouth. We appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capital in Washington DC, where we explore the intersection of healthcare politics, financing, and delivery. For additional perspectives on health policy and leadership. Read my weekly blog Bisbee’s Brief. For questions and suggestions about Fireside Chat, contact me through our website, firesidechatpodcast.com, or gary@hmacademy.com. Thanks for listening.