Redonda Miller 0:03
We have this playbook of physical capacity staffing policies. I’m thinking about all the thought that went into standing up a visitor policy or a masking policy or a travel policy. Now we can turn those on and off as needed.
Gary Bisbee 0:20
That was Dr. Redonda Miller. President at Johns Hopkins Hospital, speaking about the core competency of scaling up and scaling down, developed to respond to the COVID crisis. I’m Gary Bisbee. And this is Fireside Chat. Dr. Miller outlines the top three priorities of the Johns Hopkins Hospital and she speaks about the benefits and challenges of the Maryland all-payer model. Let’s listen to Dr. Miller respond to the question of how the COVID crisis changed her as a community member.
Redonda Miller 0:50
As a community member Gary, I think this was probably the most impactful and humbled every day by the incredible appreciation from the community, the number of ways they stepped up. Whether it was school kids making cards for the healthcare workers here. Whether it was the donations of homemade masks, businesses sending food to the front line. I really feel a part of the community here in Baltimore like I’ve never felt before.
Gary Bisbee 1:20
Our conversation includes Dr. Miller’s view of the need for a reliable PPE supply chain and the necessity of governmental stockpiles, how telemedicine visits grew overnight from 35 to 20,000 per week, the strategy for educating the community to return for necessary surgery and treatments, and the top characteristics of a leader in a crisis. I’m delighted to welcome Dr. Redonda Miller to the microphone. Good morning, Redonda, and welcome.
Redonda Miller 1:52
Good morning, Gary. It’s such a pleasure to be here virtually so to speak.
Gary Bisbee 1:56
Exactly. We’re pleased to have you at the microphone. Let’s begin with learning a little bit more about you – start out at the very beginning. Where did you grow up?
Redonda Miller 2:06
Well, I actually grew up in southern Ohio, very rural area near Kentucky and West Virginia, where my parents still live. And in a desperate attempt to escape, so to speak, I ended up at Ohio State for college, and then here in Baltimore for medical school at Johns Hopkins, and I’ve been here ever since.
Gary Bisbee 2:27
What have you found that you liked the most about Hopkins? What’s the culture of Hopkins like?
Redonda Miller 2:32
When I came to interview for medical school, I had this mental notion in my mind of very smart people, serious scholars, discoverers and sure, that is all true. It is. But what I found 31 years ago was this incredible warmth, and humanity and kindness and esprit de corps. And honestly, that is what has kept me here for 31 years. There is a drive toward excellence. Everyone wants to be the best. They want to be on the cutting edge, but at the same time, a sense of collegiality and family that it’s really a powerful combination.
Gary Bisbee 3:13
Let’s drop back a bit. At what point did you decide on medicine, Redonda?
Redonda Miller 3:17
It’s an interesting story. I am a lover of math and physics and economics and finance. And I started my college career, wanting to be an engineer, an aeronautical engineer. But I quickly learned that there was a human side to what I wanted to do, probably stemmed from in high school, my parents, who my dad, in particular avid gardener, they were both school teachers. But he was an avid gardener on the side. And one evening, after dinner, they became very ill very quickly and within 15-20 minutes, were both passed out. I called 911. I was a freshman in high school, the oldest of four children. I remember vividly the sight of the paramedics doing CPR on my dad as they wheeled my mom and dad out of the house to the local hospital. And I will tell you, the paramedics, the nurses, the doctors at that local rural hospital saved my parents. And it turns out they had organophosphate poisoning, which was very common, you know, it’s from insecticides that have since been banned. My parents are fine today alive and well. But I always remembered how those healthcare workers saved their lives. And it really influenced my choice later on.
Gary Bisbee 4:33
Sure. The fact that they were teachers, do you think that cultivated your sense of learning and excellence?
Redonda Miller 4:39
I do. You know, in pure teacher form they had high expectations for the children to pursue something they loved and to give it our all. So yes, and in fact, I started out my career here at Hopkins after I finished training as a clinician-educator, there’s some of that love of teaching hidden inside of me.
Gary Bisbee 4:58
At what point did you decide then to pursue your MBA?
Redonda Miller 5:01
I was probably mid-career in my 30s had been doing very well. I had a typical traditional faculty role as a clinician-educator focusing on women’s health but became frustrated with how we delivered care. This was back 15-20 years ago, and we were not as patient-centered as I thought we could be. We were not as efficient as I thought we could be. At some point, you either just whine or you become part of the solution. And it also provided this opportunity to enjoy some of the other subjects that I’d always liked, like economics and finance and math. So I decided I wanted to retool my career and work on clinical operations. I didn’t have the right tools. So it prompted me to go back to business school and pursue an MBA. So I at least had some foundational knowledge of operations and healthcare delivery that would hopefully serve me well.
Gary Bisbee 5:59
I believe you’re still practicing. Is that right?
Redonda Miller 6:01
I do. I do. I’m a general internist. And I love still practicing. Many of my patients I’ve known for 20 years. I have a clinic once a week. And that of course is all of the physicians who are listening might know your practice doesn’t end just because the clinic door closed, so I field phone calls all week long. But it has been invaluable. To live firsthand some of the initiatives we roll out as a hospital, I have to take the same epic training, I see what it’s like to care for a patient who may be PUI for COVID and wear a face mask. I also now have a cadre of secret shoppers. My patients are the first to call me with Redonda, “Did you know this happened during check-in?” or “I was in the hospital and this happened or did you realize this?” And so it’s been so valuable in many ways.
Gary Bisbee 6:54
Unintended benefit of practice. Do you find as a leader at an academic medical center that it gives you more credibility with those you’re leading that you’re still practicing?
Redonda Miller 7:06
I think it does, because once again, anything that you say we have to do, I’m going to do it as well. And so I do understand the frustrations of clicking in an electronic medical record. I can empathize more, and hopefully, it informs decision making a little better.
Gary Bisbee 7:23
In terms of leadership, what drew you to leadership?
Redonda Miller 7:28
I’m not for sure I was drawn to leadership per se. In fact, I think more what I was drawn to was this notion of fixing things. As a true general internist, I like variety, I like diagnosing, and I like trying to fix things. And so what I liked about hospital administration is those same principles applied. Your day consists of a myriad of different problems that hit your desk, and you pull the right teams together, diagnose the situation, and try to fix it. The leadership part, I think was sort of an accidental outcome of that, that perhaps my mentors hopefully acknowledged somehow that okay, I could execute on what we designed. And then that led to greater responsibility. But I didn’t necessarily go into this hospital administration route thinking I wanted to be a leader.
Gary Bisbee 8:21
Right. Sometimes it’s referred to as an accidental leader, but you’re doing a terrific job. Why don’t we turn to Johns Hopkins Hospital? You’ve been president now I believe for four years. Will you describe Johns Hopkins Hospital for us?
Redonda Miller 8:36
Sure. The Johns Hopkins Hospital is a 1,000-bed hospital, roughly, with revenue of around 2.6 billion. We have about 11,000 employees, about 2,500 medical staff, and then 1,300 residents and fellows. We have the usual typical designations level one trauma center, comprehensive transplant, NCI-Designated Cancer Center, but we’re part of a larger health system. And our larger health system is comprised of six hospitals – five in the Mid-Atlantic and one in Florida. We have a payer arm, we have a home care group, we have a community physician network. So that’s a little bit about the hospital and how we fit into the health system.
Gary Bisbee 9:17
How do you relate to these other hospitals? Do you draw from them? Or do they draw from you? How do you think about that?
Redonda Miller 9:23
Oh, it’s very commensal. And I would say that’s something we’ve struggled with over the last decade becoming a system. But over the last couple of years, and particularly with the crisis of COVID-19, we have really done wonders to become functioning more like a system. I will tell you, I learned things all the time from my community hospital colleagues, the presidents of our community hospitals. Hopefully, they would say the same thing about the academic medical center, but it’s been a great partnership.
Gary Bisbee 9:55
What are your main priorities at JHH?
Redonda Miller 9:56
I would be remiss, Gary, if I didn’t tell you COVID-19 rose to the top three months ago. And for the next year or two, it will continue to be right at the top. And it’s interesting how the focus has changed from “Oh my, how are we going to deal with that initial surge” to now the focus of how do we conduct our usual business and as an academic medical center, there are patients that we really specialize in and have expertise. So how do we care for those patients, in addition to caring for COVID-19? So that’s priority number one. I think priority number two, we had started all kinds of good work on high-value care. In the era of patients paying more out of pocket for their health care, they are going to want to choose wisely. And so we have to hold ourselves accountable to being high value. How do we deliver high-quality care, but at a price that is appropriate? So that would be our second priority. And then interestingly, we have really shifted a lot, without losing our emphasis on discovery and innovation. We at the Johns Hopkins Hospital can never lose that. But thinking more about population health and community care, and what it means to serve East Baltimore. Historically, obviously, we focused on transitions out of the hospital, care coordination, disease management, but we’ve taken that to a different level. And how do we tackle the social determinants of health? We’ve done work on jobs and hiring. More recently, we partnered with the other city hospitals, health care for the homeless and the city to house 200 individuals experiencing homelessness, and we decided we were going to build and renovate houses, but go beyond that and provide all the supportive care one needs. Job counseling, treatment for chronic diseases, help getting to and from the grocery store. So those are really our priorities high-value care, community care, and of course COVID-19.
Gary Bisbee 12:06
What percentage of patients come from Baltimore and surrounding communities?
Redonda Miller 12:10
Right now about two-thirds of our 50,000 discharges derive from Central Maryland, and about one-third from Baltimore city itself. And then of course, the final third, given some of our areas of expertise draw from states far away and internationally.
Gary Bisbee 12:28
Why don’t we go to the Maryland all-payer model for lessons learned there? Could you describe that for us, Redonda?
Redonda Miller 12:36
Oh, sure. We’ve had the all-payer model here in Maryland since 1977. And it was initially designed and still is today. It functions as all-payer in the sense that everyone pays the same for care delivered in Maryland hospitals, and by everyone I mean, commercials, Medicare, Medicaid. We love that about the model, it takes away any kind of gamesmanship or trying to attract a certain patient over another, everyone pays the same and the rates that hospitals are allowed to charge are set by a commission. In 2014, there was another unique component to our model that was added, hospitals were now going to be reimbursed via global budget revenue. So each hospital in Maryland knew its revenue for the next fiscal year out of the gate. And then year after year, that revenue would be tweaked, based upon volume shifts, market shifts, demographics, and so forth. So I know going into FY 21, what my revenue will be. That’s been our model to date. It’s highly regulated, and year to year, you’re not going to have huge operating margins as a hospital in Maryland. But I will tell you during bad times, and we’ve looked at over the last three or four months, that model can be protective. Well, because the volumes dropped so precipitously, none of us could charge up to our full GBR. We did have some increased charging authority that provided the cash flow and liquidity we needed to survive the pandemic.
Gary Bisbee 14:13
As a result of COVID, one imagines that legislators in Washington DC are going to be thinking about some kind of model like the Maryland all-payer model. So we may end up with something more like it at the national level, who knows. What’s the payer mix? If I could ask, what’s the current payer mix?
Redonda Miller 14:32
Here at the hospital, government payers are about 48%, 19% for Medicaid, about 29% for Medicare. And then commercial, we are about 49%. And then self-pay about three.
Gary Bisbee 14:46
So that would be among a lot of health systems that country pretty favorable payer mix, actually. Why don’t we turn to COVID you brought that up, and I think we all agree a crisis accelerates existing trends, but thinking about capacity, PPE and so on, how did that fare at JHH?
Redonda Miller 15:06
We did okay with PPE, but we have the luxury here in Maryland of learning from Seattle, learning from Italy and learning from New York. So we knew right away that we had to start conserving. We focused meticulous attention on PPE conservation. We also had help from partners. Local industry stepped up to help us. Sagamore Spirit made hand sanitizer. Under Armour made masks. Many volunteers went to our central distribution center, and we crafted our own face masks. So we really and then of course, other businesses donated N95s. So we were okay. But it wasn’t without a struggle. And I will tell you we’re still not where we need to be as far as PPE, but we’re working on it.
Gary Bisbee 15:53
If you formulated a point of view, Redonda, about the reliability of supply chain, do you think we need to do something nationally about that? What’s your thought?
Redonda Miller 16:03
Oh, of course, absolutely we do. I think we’ve learned about when you have a sole producer in the market or one country dominating the manufacturer of a good bet is a common good, you run into trouble. I think we saw this in the pharmaceutical industry somewhat. And we talked about the escalation in drug prices a couple of years ago, where market economics resulted in a sole source provider of certain generics that have been around forever and the ramifications. I think we see that with PPE. We need to make sure that we have the right supply chain that is diversified. I also think we need to take a look at our stockpile and rethink exactly what numbers are appropriate. And the conversation about do we do that as a nation or by individual states, we need to fine-tune that conversation and make some decisions.
Gary Bisbee 16:54
That’s definitely being discussed around the circuit. There’s no question about that. How did your ICU capacity hold up?
Redonda Miller 17:02
That was, even to this day, everyone here will tell you that is our major factor. We were incredibly lucky. When the COVID pandemic first hit, we decided as Johns Hopkins Health System that we would transfer the initial code of patients here, particularly those that were critically ill. So we were taking a lot of patients from the National Capital Region, Gumby county where they were very hard hit Howard County and bringing them to the Johns Hopkins Hospital. And we did that predominantly for two reasons one had to do with our physical capacity. We have new patient towers that we were able to flip unit by unit to negative pressure and keep staff and patient safe. We had the luxury of having a lot of ICU. So we had staff expertise who were gifted at critical care, nurses, doctors, anesthesiologist, so ICU capacity we did okay.
Gary Bisbee 18:08
It seems to lead to a new competency, maybe even a core competency to scale up and scale down quickly. Do you think about it that way?
Redonda Miller 18:19
What we do every day, we call it our playbook, our pandemic playbook. And honestly, I think it could be used for other global health crises or even any crisis. But so much of our initial time was spent trying to figure out which units could be converted. How are we going to redeploy staff and leverage expertise? We have very highly specialized staff at AMC, so retraining people to go back to their roots in their core competencies. So we have this playbook of physical capacity staffing policies are in the playbook. I’m thinking about all the thought that went into standing up a visitor policy or a masking policy or a travel policy. Now we can turn those on and off as needed. And some of the models of care. Thinking about testing, we know how to do community testing now and how to stand up tents. We know how to compile a Go team that will help go into nursing homes and do testing and risk mitigation at potential hotspots. So yes, I do think this has taught us that five years from now two years from now, who knows when the next issue hits, we will have processes in place that we can roll out much more easily.
Gary Bisbee 19:37
Terrific. What about tele-visits? Most of the health systems saw dramatic, even exponential increase in tele-visits, how about you?
Redonda Miller 19:46
I laugh because telemedicine was sort of on our three to five-year goal, of okay, we’re really going to roll this out. And then overnight, I mean, literally Gary, overnight. We went from around 35 tele-visits per week across our health system to 20,000 per week, overnight. So here at the hospital, we’re doing 5,000 telemedicine visits a day. It’s about two-thirds of our ambulatory visit volume. And I have to say it’s going well. Patients like them and you know, I can tell you that firsthand. My own practice. I have patients who will say, “I was reticent to do this, this high tech stuff Redonda. I don’t know about this.” They love telemedicine visits, they don’t have to drive into East Baltimore. They don’t have to pay for parking. They can do it from their own home. I think telemedicine is here to stay.
Gary Bisbee 20:38
Do you think that the older generation will adapt to it?
Redonda Miller 20:52
That was the first thing that went through my mind is how is the older generation going to handle this? They are fine. I have patients that are in their 90s. They’re doing just fine with it. I think the big challenge will be wrestling with the reimbursement. Here at hospital-based clinics, if we just reimburse only the profit part, I don’t think that’s going to do justice to all the infrastructure needed to conduct an efficient telemedicine visit. You still need staff to virtually room the patient and make sure that the med reconciliation has been done and all that pre-visit work, you’re still going to need staff to do the follow-up and schedule appointments and tests. So I think we have to give some serious consideration about the appropriate reimbursement model.
Gary Bisbee 21:38
The CMS waivers on payment and physician licensure across states, no doubt were important. Do you have a feel for how important they were to accelerate the visits?
Redonda Miller 21:49
Very important. We still struggle because there’s not complete reciprocity and licensing. So we still struggle with sometimes delivering out of state care, but hopefully, we’ll get there.
Gary Bisbee 22:00
How did you ramp up to 20,000 visits? I mean, did you employ just a whole bunch of your doctors and nurses, or how did that work?
Redonda Miller 22:08
We have an amazing telemedicine team and an amazing ambulatory team. You asked me, What do I like about Hopkins? Well, people just they rally and they get it done. So everyone did their virtual online training so that they would understand how to use it. We redeployed our staff, so they can handle the volume. I don’t think there was any magic bullet. I think it was just a culmination of group effort.
Gary Bisbee 22:35
Terrific. Well, why don’t we turn to elective surgery assuming that you had to lock down and discontinue that for awhile. Have you restarted?
Redonda Miller 22:43
Yes, we did restart our elective surgeries. On May 18, we opened up for our ASC. And then this past Monday, we started hospital-based elective surgery. The biggest limiting factor for us is just getting our ICUs back online. We still have a decent amount of COVID-19 patients here that are critically ill. So bed capacity is our biggest limiter.
Gary Bisbee 23:09
How have patients responded?
Redonda Miller 23:12
Initially, we were worried that people would be hesitant to come back to the hospital and I think there’s still some fear. But every time we’ve opened our schedule, we’ve been able to fill it. The pent up demand is so great that we’ve not had difficulty filling our OR schedules. Now some of this could also be due to an aggressive campaign we’ve launched encouraging patients to return to hospitals who’ve been very worried about some of the statistics in the literature about people putting off care and having heart attacks at home. And we saw it here at the Johns Hopkins Hospital. Our ED visits fell to a third of normal. We knew that patients were out there and bad things could be happening. So we did launch an aggressive campaign both here at our own institution via messaging through MyChart and Epic and text messages and articles and videos and graphics. But we also partnered with the Maryland Hospital Association, who launched a broad sweeping campaign in Maryland, billboards, TV, radio, encouraging people to really seek necessary care.
Gary Bisbee 24:19
Why don’t we turn to economics, which is not a pretty picture for any of our health systems. How was JHH affected by the whole COVID crisis in terms of your financials?
Redonda Miller 24:30
As I mentioned a bit earlier, our GBR here under the Maryland payment system did protect us to some degree, I mean, we will experience losses, and I think that’s to be expected. Anytime you lose that kind of volume, you’re going to suffer, but we’ve managed okay to be honest. Capital, we had to reduce our capital expenditure and delay some of it so we took a really close look at what our plans were for capital expenditure. And what did we absolutely have to do in the name of patient safety and quality? And then put other things on hold. We’re hoping to revisit that. And of course, a lot of our strategic capital plans we had to put on hold some of our larger projects. Hopefully, the numbers will continue to go down. I’m going to be an optimist. Gary, I am. I think we will have a surge in the fall. But hopefully, we can contain it and manage it and we can get back on track for some of our strategic priorities.
Gary Bisbee 25:28
With your optimistic hat on what are you thinking about 2021 Redonda? Will you be able to get back to “normal” by then, do you think, financially?
Redonda Miller 25:37
Our goal here is to really be able to resume all the essential care we did. I think about care here at the hospital, transplants, high-end surgeries, all of that work that really we rely on our AMCs to do as we don’t often have that kind of expertise and community hospitals. I view we owe it to the local Maryland community toet back in that business right away. And so our goal is to really figure out how we’re going to ramp up all of our usual book of business, and then still take care of COVID on top of that. That’s going to be meaning adding or renovating physical capacity that’s going to be looking at staffing plans. And can we bring on staff to do that to get us through the next year? Just like all of my colleagues across the country, we’re looking at, you know, people who’ve retired do they want to come back for a year. We have some fellows who are graduating, who are worried about the job market, and they want to spend time next year being COVID hospitalists and really take a year-long break. And so we think that’s going to help us on the provider front. But our goal is to try to get back to do all of our usual work and take exquisite care of COVID-19 patients.
Gary Bisbee 26:49
Leadership’s always important, particularly magnified, probably in a crisis. When you first became aware that the COVID crisis was gonna strike, what was your first thought?
Redonda Miller 27:00
I think that was probably like most people. Your first thought out of the gate is, oh my, we have never faced anything like this before. This is going to be a long three months. But I have to say it was quickly followed by a little notion of, we’ve got this. We had already practiced. We’re one of the regional centers for biocontainment. And we stepped up after Ebola to become a center of expertise. So we’ve already been training on a continual basis. Staff, nurses, doctors, pharmacists, respiratory therapists, you name it, who knew what it was like to step into a pandemic, and they were able to train others pretty quickly. So I figured, we’ll be okay. We will manage this. And luckily, that has been the case.
Gary Bisbee 27:46
What is one of the most important characteristics of a leader during a crisis like this, do you think?
Redonda Miller 27:51
I think some of the most important characteristics are, number one, being able to pull groups of experts together and then just trusting those experts to manage. This notion that we’re all in this together and having the right people around the table because no one has complete mastery of a pandemic like this. No one does. So it really was this getting the team together and building our plans in unison. And then I think, honestly, for leaders, you have to be the person who is positive. And explaining that, yes, we can do this. Yes, we’re going to make decisions that we will have to rethink and maybe pivot in a different direction. And that’s okay. But we will get through this. So the leader has to have some element of positivity.
Gary Bisbee 28:42
This has been a terrific interview, Redonda, I have one last question if I could, and that is how does the COVID experience change you as a leader and as a family member?
Redonda Miller 28:54
As a leader, I’m not sure it’s so much has changed me as reminded me of all that is great in health care. As a physician, I trained in crisis mode. A patient would code on the unit and you stepped into action quickly and you were the leader of a team who did the CPR and the resuscitation. And so that muscle memory came back. And what I like about it as a place like Hopkins, it reminded me how every single person on the team stepped up in just that fashion. There was no wailing and whining, and it was all about, we can do this. So I think it was very refreshing to be reminded of how incredible my colleagues are. As a family member, boy, it changed me a lot. I have two daughters. They are ages 15 and 11. My husband is a pulmonary physician, who helps take care of COVID-19 patients at a different hospital here in Baltimore. So my poor little daughters became orphans overnight. They got themselves up, made breakfast, did their online school work. So I told them it was good practice for college and being on their own. But it did change me. And I realized that my daughters are growing up and they can be self-sufficient. And then as a community member, Gary, I think this was probably the most impactful, humbled every day, by the incredible appreciation from the community, the number of ways they stepped up, whether it was school kids making cards for the healthcare workers here, whether it was the donations of homemade mass businesses sending food to the front line. I really feel a part of the community here in Baltimore like I’ve never felt before, and I think all of them for their kind gestures and donations to support our healthcare frontline.
Gary Bisbee 30:52
Well, we appreciate your thoughts, Redonda. This has been a terrific interview. Thank you very much for being with us, and good luck to you and everybody else at Johns Hopkins.
Redonda Miller 31:01
Thank you, it was a real pleasure.
Gary Bisbee 31:04
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 firstname.lastname@example.org. Thanks for listening.