E21 - From Treatment Table To Corner Office

Brad is joined by APTA NE President Nick Weber and two rural hospital CEOs, Robert Dyer and Chris Nichols, who began as physical therapists share how mentorship, risk, and relentless networking moved them from the clinic to the role of CEO in rural hospitals. We unpack the realities of running critical access hospitals, from Medicare Advantage pressures to building student pipelines and modernizing direct access rules.

• Clinician to executive transitions rooted in mentorship
• Why rural hospitals enable faster innovation
• Strengths PTs bring to leadership and culture
• Financial literacy, cost reports, and 340B pressure
• Medicaid redeterminations and access to care
• Coalition advocacy across health associations
• Workforce development through student rotations
• Private practice collaboration that drives policy wins
• Barriers to hospital-based direct access in Nebraska
• Building relationships with lawmakers that matter
• Community pride in Geneva and Cozad

Show Links:

APTA NE Annual Conference Registration April 10-11th: Nebraska Physical Therapy Association - Meeting/Event Information

Show Guests:
Cozad Community Health System CEO: Robert Dyer

Fillmore County Hospital CEO: Chris Nichols

Transcript

Welcome And Guest Introductions

SPEAKER_03 0:01

Welcome to the APTA Nebraska podcast, where we dive into the stories, challenges, and innovations shaping physical therapy in our state. We're here to advance, promote, and protect the practice of physical therapy, optimizing the health and quality of life for all Nebraskans. Join us as we connect with experts, share insights, and build community throughout our profession. Welcome back to the APTA Nebraska podcast. My name is Brad Dexter, and I'm joined by Nick Weber today. Nick, how's it going?

SPEAKER_00 0:32

Good. Hi Brad, how are you?

SPEAKER_03 0:34

I'm doing well. And we have a couple guests with us. Chris Nichols is the CEO of Fillmore County Hospital in Geneva, Nebraska. And Robert Dyer is the CEO of Kozad Community Hospital in Kozad, Nebraska. Gentlemen, how are you? Doing great.

SPEAKER_01 0:50

Doing good. Thank you for having us.

SPEAKER_03 0:52

Yeah, thanks for cutting some time out of your day to join us and to chat with us. Hey, as is typical, uh, when we have people join the podcast, we'd love to hear a little bit about you guys, what your story is. Um I just mentioned you guys have CEO titles at your respective organizations. And so if you wouldn't mind for our listeners, could you just share your own personal stories? So you're you both have backgrounds as physical therapists, um, but certainly have kind of moved through the ranks into the current positions that you're in. So um, Chris, why don't we start with you and I'll have you just share your story uh from PT, the CEO, uh, and you can talk about that process and we'll probably ask some questions as we go, okay?

Chris’s Path From PT To CEO

SPEAKER_01 1:34

Sounds good. Yeah, so I'm originally from Grand Island. I grew up there, went to um PT school, I graduated in 1998 from the UNMC program, and uh went back home and um met my wife on the job, and so she's also a PT. And so we had roots in Grand Island. And um, after four years or so, I um I suppose I you could say I was handed or was um um given a management job, and and it wasn't real competitive, but it was kind of the job nobody wanted, and so it was a hospital-based management PT department, small, but it was that's where I started, and it just kind of um grew from there. I I uh ended up gravitating towards the hospital management, you know, um made good friends with some of the folks that ran the hospital in Grand Island and just um got interested in that's where uh got into an education program through my master's program at the University of Minnesota. So I went and got my degree before I got the job. And but really the the key for me was when I um started and ran inpatient rehab facilities. So I ran two of those, one in uh Maryland and one at in Grand Island at St. Francis. And that was truly an administrative, my first 100% administrative job. Did that for eight years, and what a training ground that was for learning how a hospital works and how to work with physicians and build programs and interdisciplinary team and be responsible for um this program that was separate from the hospital in terms of the how the billing worked and everything, and a distinct part unit, if you will. And so, you know, you were creating your own revenue for the hospital, and so that um it was exciting and was fun, but it ran its course for me. And I think that um I was looking for something new, and uh about 2013 I came home from work one day and I asked my wife, would you like to move to Iowa? And so she thought I was crazy, but we ended up relocating, our kids were much younger, and we uh little town called Ida Grove, Iowa, Northwest Iowa, and uh great little critical access hospital. They hired me to be their CEO, definitely not for experience, but for um a track record of kind of building up building programs and working with physicians and being clinical. I mean, they they wanted somebody clinical. And so that um was my ticket in. Um great that I landed somewhere there where the team was experienced. You know, I didn't have to come in and be the finance guru or be the HR executive. They let me be who I was, and so it was great. And so I got the degree before I got the job. That's not always the case, but I we ended up moving, and I and an important lesson for me is if you want to do this work, you probably have to move to where the job is. And so that move we made back in 2013 was a big move for our family, um, uprooted from a lot of comfort with both sets of parents fairly nearby, another family, but probably the best thing we ever did as a family, just getting closer and um professionally the challenge that I was looking for, be careful what you ask for, but I think it's a lot, but um, it's also been a lot of fun to do this work. I'm in my 14th year of being a rural hospital CEO. We moved back to Central Nebraska, Geneva, Nebraska, this hospital here in 2017. And it's been awesome being back, and we our family loves it here. Um to the point where I don't know what else I would do. Um, been doing this for a while, and yeah, and that's that's a little about my story, and it for whatever reason, that's how it worked out. Yeah.

SPEAKER_03 5:40

Yeah, there's uh I'm I I was listening to you tell that story, and I was just thinking that's a that's a lot before you said it, that's a lot to uproot your family and and move um probably four four hours away, five hours away.

Why Rural Hospitals And Community Fit

SPEAKER_01 5:52

It was four, yeah. For us it was a big deal. Some people do it all the time, but you know, we're homebodies. And well, when I had that experience for four or five years, then I had choices to come back to Nebraska. So I really that was I was very selective and chose to come here because of the progressive nature of the hospital and strong orthopedics program, which is right in my wheelhouse. You know, we're known for orthopedics here, and um I love that. We've grown that here. And so I speak that language with the two orthopedic docs that we employ. And so it's been really fun to be here and doing this work.

SPEAKER_03 6:30

Is is there something about what you're doing um in a rural health center? Like, is that important to you as well?

SPEAKER_01 6:38

Yeah, I've you know, I worked for years at in Grand Island and Hastings was my training ground in management. But like in two 2013 it changed, and I've been in small communities, and I don't know if I'd change it. I love the small hospital setting, the family atmosphere, the sense of ownership that seems to be stronger than a large corporate um you know, or just a larger facility. You know, it's just people know each other, they they want to take good care of each other, and I I gravitate towards that. Um it's really relationship driven and I love that. And um, you know, it so that's probably where I belong, you know, and then and I I didn't realize that until I had that, but now you don't want to go back.

SPEAKER_03 7:27

So and and if I heard you right, you uh when you graduated from PT school, you weren't planning on becoming a CEO of a rural health system, correct?

SPEAKER_01 7:37

Probably not. I I had an itch to scratch with management and I I probably expressed interest in the role that nobody wanted, but um when it was presented, I was excited to get it because I kind of knew this could be uh an opportunity for me, but didn't realize that um that would be that would be the what I would be doing, you know. So the I I think that it boils down to some mentors, some great mentors encouraged me and they were hospital executives, and then and that is the key. Um I was looking for that, and when I had that, it was like I was hungry for it, and I just um was encouraged to to do what I'm doing, and one thing led to another, but you know, you really had to realize that oh, this opportunity is big. You you should move to where they want you because might still be doing something, but um I don't know what, you know, I don't think those opportunities really existed where I was. It didn't seem and it was it just in all hospitals are different. The one that I was with was very corporate and it wasn't um didn't look like there would be much opportunity for growth for somebody like me who wanted to be a hospital executive.

SPEAKER_00 8:50

So Chris, you mentioned uh like when you made the transition from clinician to administrative role that there was some unknowns, maybe a little fear around what those unknowns were. I'm curious where you've where you feel like your PT education kind of set you up well and where you feel like you needed to get some additional education or or grow.

Skills PTs Bring To Leadership

SPEAKER_01 9:10

Yeah, so I didn't great question. I didn't know anything about a cost report or uh about how a critical access hospital was was financed, you know, and I was very green, but you know, you learn over time. I think the the mindset of knowing what clinicians are going through, so you you kind of have the ability to talk with them and hear what they need. When I say clinicians, I mean physicians, mid-level providers, therapists, nurses. Um you talk that language a little bit. And so being able to relate to them, that's that was really my only advantage when I started. And uh use that to help divide develop trust and hear what the organization needed and um grew programs through that. You know, once you have trust, you can do a lot. You can do you can do a lot of uh innovative things with growth, start programs that are innovative. That's another thing about rural hospitals, is you can do a lot of innovative things. Whereas um maybe some larger corporate settings, it's pretty restrictive. But we do some things out here that I don't know that you could do elsewhere. You know, the way we do our orthopedics program. Um we also are big into behavioral health here, and it's because we don't have a mothership telling us we can't. And so we we uh we we kind of are one of those places that want to try things and respond and and do what's right. But yeah, you don't know what you don't know. But my advantage was the clinical and just knowing how clinicians think and act and being able to relate to them.

SPEAKER_03 10:52

Um so that's no that's great. Um hey, thanks for sharing your story with us, and um it was very interesting to hear that. And I'm I'm curious to see how many parallels there are in Robert's story here, too. Um Robert, would you mind just kind of telling us what your path has been like?

Robert’s Origin Story And Mentors

SPEAKER_02 11:11

Yeah, of course. Um, you know, certainly there's some parallels, but there's also you know quite a few differences, you know, just like his hospital is different than than my hospital. Um, everybody takes a different path. And, you know, I think if if you're really looking at, you know, my path, you you have to go to to where I came from, which was Hyannis, Nebraska. 200, you know, 200 people in the middle of the sand hills, you know, we had to drive an hour to get to to basic medical care. It was two hours to get to an orthopedic surgeon. And so, you know, that kind of sets the stage for you know, a lot of the decisions I make. And when we're when we're looking at say advocacy down the line, when we when we talk about that, I really don't always look at things as just from how it affects COSAD or the lens through COSAD. Um, because we're on the interstate, we're we're still, you know, kind of in west central Nebraska. Um so when I'm thinking about legislative things and advocacy things, I really consider myself a rural advocate because of those real roots. And, you know, how would how would this decision, this law, this regulation impact Binkelman or Kimball or Gordon, you know, um, you know, the satellite clinic at the private practice at Mullen. How would how would that affect what I would call real rural? You know, because our lawmakers in Omaha and Lincoln think anything outside of Omaha and Lincoln is rural, and it and it kind of is, but there's also like that true frontier rural, you know. And so, yeah, like a lot of people, um, you know, I had some sports injuries in in high school and was exposed to a very limited amount of therapy because it was an hour away. So I was given a home exercise program and I I went home and did it on my own, right? And then I enjoyed science and and math and and then kind of started thinking about you know physical therapy and and you know, went through that track in undergrad, uh graduated from uh UNMC in 2001, and then went out to the panhandle and worked in a wonderful private practice out there for a year, absolutely loved it. It was an incredible place. Um, and when Chris talks about mentorship, Karen Brown out there, I couldn't have had a better first boss. She she was incredible. Um, you know, she also kind of uh got me thinking about professional development in terms of you know what we can do for say the association. Um at that time, she was on our state board and then was also doing some stuff for FSBPT. And um she she had me apply for a for a position on the Pass Point Committee. So I got to go out to uh Virginia and participate in um, you know, termining determining that cut fail line for the for the board's exam, going through that process. Very interesting process. And and then, you know, I I participated in uh writing the first uh tutorial questions for that jurisprudence exam um when it when it went online. Um so kind of got involved there, but but ultimately I left what was an incredible job to come to COSAD because there wasn't an insurance plan there, you know, and everybody that that worked in that clinic had a had a spouse who's um worked at the school or the railroad, and I needed a hip replacement and it was going to be out of pocket. And so I came to COSAD and I've and I've been there ever since. So I so I joined there in the summer of 2005. And really at that point, my goal was just to to run a rehab department. That was that was the only career goal I ever had. Um, I wanted to become an orthopedic clinical specialist, and I did that. And so over time, um, we had kind of built a wound care program at COSAD that had become real successful. And and I got a board certification in that one before APTA offered offered their version of it. I ended up getting my WSCC. But um, and then kind of over time, you know, Chris talks about mentors. I certainly had a lot of different conversations with our administrator at the time at the hospital. And he would start bringing me in for conversations and and um mentoring me kind of, and then one day he made me part of a conversation and and he said, and it kind of caught me off guard. He said, the reason I'm having you be part of this now is because someday you're going to be sitting in this chair. And I thought, what are you talking about? You know, um, and I just kind of blew it off. Um, and then in 2017, he asked me to start overseeing cardiac and pulmonary rehab, um, in addition to PTOT, speech, and wind care, and then the specialty clinic, and then um then we and then also respiratory therapy. Um, and then during that time we built uh diabetic education program. We we started that. And then he had retired, and then in 2020, right before COVID hit, we we got a new administrator, and then she's like, Hey, I'm gonna have you oversee uh you know facilities management and EVS as well. And so I was I was doing all that and then also running a full caseload too. Um and so I I gained some management experience.

SPEAKER_03 17:02

Um hold on. I I just need to pause for a moment because I think a lot of a lot of us can get overwhelmed by a full caseload, right? And you you were doing a lot, sir.

Imposter Syndrome And Switching Gears

Legislative Shifts And Reimbursement Reality

SPEAKER_02 17:15

There you were. Yeah, that was a lot. So I mean, Chris and I both have really long days now. I mean, my days right now averaged about 12 hour days, um, and then another probably four to six on the weekend. Um, but I I was doing 60 hour weeks um as a clinician uh all that time um with those extra duties anyway. So I was I was kind of used to it. So I've I had kind of grown along that path and and learned a lot of things on the way. Um, but again, I never had a structured education program in terms of you know, Chris went to go do do his master's. I never had that. Again, that wasn't my goal, that wasn't something I was interested in. Um I was just stepping up and doing what somebody asked me to do. They asked me to do it, like, yep, I can help out, I can do that, you know. And so kind of went through that. Well, then um, after two years, we were without an administrator and the board needed um an interim. So they asked me to step into that role. And I was not interested in applying at that time, you know, and and they kept asking if there were any internal candidates, and I kept saying nope, I'm not aware of any, you know, and uh then then applications started coming in, and I started seeing that, you know, none of the applicants that had applied for the position at our facility had any experience um beyond a department head. They had all been a department head, one was a director of radiology, another guy um ran the supply management uh for their facility, um, but they had had their master's degrees, you know. And so um I thought, you know, and we don't know a lot about these guys applying. I mean, maybe they could do worse than me. And so um after a lot of urging from members of medical staff, um, department heads, people in the facility, they they sort of gave me enough confidence to to go ahead and apply for that position. Um but you know, oftentimes we talk about imposter syndrome. There's definitely a ton of imposter syndrome, like, do I belong? Should I be doing this? You know, I don't have the initials behind my name that Chris does. Um, so there's there's all those things that go go through your head. Um, but went through the process, the board did hire me. Um I I certainly think that having 20 years of clinical care at that point in time and developing trust from the community, from our medical staff, from the rest of the staff in the health system kind of probably gave me an extra leash leash during my learning curve, you know. Um and so yeah, I mean, Chris and I kind of kind of took two two totally different paths there. Um in that meantime, as I was kind of growing my skill set though, I don't think we can overlook um, you know, what the APTA and APTA Nebraska did for me. Uh because in 2010, I think it was somewhere around there, I became our central district chair and and learned some things there. Um, you know, that networking component of when you're when you're the dumbest person in the room, you know, you learn a lot, you know. And then then it became a delegate and then became our chief delegate. And then when you're going to those national meetings, then you're really in the room with a ton of bright people and you're learning so much more. And I can remember back um in physical therapy school, Pat Hageman, the director at the time, you know, it was you were being voluntole to go to the state meetings, right? I mean, it was basically a requirement. Um, and she would talk about the importance of networking. And I always thought, what's first of all, what's networking? You know, second of all, when I found out what it was, I thought, oh, that's stupid. That's small talk. I'm not in, you know, this is worthless. Like, why do we care about that, right? Let's just go learn about the clinical stuff, you know. Um, the number one thing that has helped me in my position now is networking. It's picking up the phone, it's asking questions, it's coming to visit Chris and his facility, learning what he's doing, developing those relationships. The networking part cannot be. You know, undersold. It is so, so important. Um, going to those state meetings. Yeah, you learn some stuff during the curriculum they have during the day. You learn 98% of what you need to know after hours when you're networking and talking with people. Um, so boy, was Pat Hageman right. I mean, that that was just so so so important. And so that's really helped accelerate accelerate my learning curve. Um and without it, I there's no way I could could you know function right now as a as a CEO. So it's it's been really good. But yeah, I just think, yeah, a APTA has been been good. It helped bring me along that path. Um, you know, but certainly switching from clinician to full-time administration, there was a grieving process that I had to go through. Um and it was pretty intense. Uh, and I still kind of get a little bit choked up about it because um making the decision to do that first of all. Um the family I grew up in is very conservative, we're um very risk averse. And this is taking 21 years of clinical practice and going away from that and putting yourself in a position that I've had many people tell me we're always just one board meeting away, you know. And uh and that scared the heck out of me, you know. So it's like, what did I do? This was foolish, you know. I threw away the security, you know, and Chris talked about being comfortable as a therapist, right? You know, yeah, you can you can stay in your comfort zone, but when we get outside of our comfort zone is when we grow and develop and learn, you know, and it's no different than than when we're training our patients, you know. If we want to make gains, we've got to get outside of our comfort zone, you know. Um if if we're not stressing those tissues, those tissues aren't gonna get stronger, you know, and so um an organization is the same thing, a hospital is the same way, you know. We've we've got to to push and stress, but we can't stress so far that we get catastrophic failure in our organization, just like you can't stress a tissue so far that you get catastrophic failure, right? You know, it's staying in that optimal loading zone that allows us to grow. Um, so yeah, using your organization in physical therapy terms kind of there analogously, but um yeah, so that that was kind of kind of my path. Um, you know, and and I I told Chris the very first day I met him, the very first networking event I went to, I met Chris. Yeah, you know, and Chris is like, oh, I'm a therapist too. I'm like, really? That's awesome, you know. And so I found a confidant right away, you know. And um I asked him, I'm like, do you still have your license? And he's like, Yeah. And I'm like, I'm never, I'm never gonna let mine lapse. In fact, tomorrow I'm going to a Con Ed event, you know, it it took too much work to get that. I'm never, I'm never gonna let it go away.

SPEAKER_01 25:17

Well, and you're still taking care of people, yeah. It's just in a different way. And so and I don't, and I've grown to not feel bad about that just because it's a different focus. It's not patients, it's the staff, it's the patients, it is the patients indirectly. Yep, it is. Um, it's but it's also uh the various boards in the community, yeah. Uh for the hospital. You have to, it's just switching gears. And I feel PTs are kind of well suited for this work because we are we understand relationships, we understand reading people, we understand give and take. And so that's just you know, you you get used to talking to people and as a therapist, and so that can carry over to this work.

SPEAKER_02 26:01

Yeah, and I I would agree with Chris so much. Um, and in fact, right about four years ago, this time, um, HTA did some kind of a panel discussion where they had PTs that had become administrators and and facilities. And I'm like, oh, I gotta listen to this one, you know. Um, but they talked about exactly what Chris talked about is our our ability to be relational um and not just be numbers-focused individuals to create relationships and and build on those, understand clinically thinking. Um, you know, we have to do a lot of multitasking as physical therapists, you have to do a ton of multitasking as as administrators. And so it all kind of ties together. And and I was just thinking back not too long ago, there was at one point where you know, the administrator up at Ainsworth several years back was a was a PT. A guy that um had served as an administrator for 30 years at Valentine was was a PT. Um the uh the former administrator at uh Carney Regional Medical Center was an OT. Um Patrick that was at Central City there, Brad, he he was a PT. He ended up going back to Missouri. Um uh Stephanie Bolt at Preet is a PTA at Brian, or she's at Brian now. Um, and then you look at from COZED, Caleb and Luke Poor, both CEOs at at uh Albion and Ben respectively. The uh when I was a chief delegate, the president of the Kansas Um PT Association was the CEO at uh Rooks County Hospital in Plainview. And so um there are people out there that are that are filling that role that have gone from therapist to administrator and have have seemed to find some success.

SPEAKER_03 27:54

So uh Matt, thank thank you guys just for kind of sharing your your own paths, your own journeys. Um one, I guess it's just it's fun to kind of get to know that on a more of a personal level and and to hear what that's looked like for you guys. And even though those paths have been a little bit different, right? I hear those themes of mentorship. You've each really had some solid quality mentors that have, as you put it, Robert, pushed you outside of your comfort zone or asked you to do things that you didn't think that you could do. Um but I also hear from both of you, just I I guess this is maybe an overused term now too, but that growth mindset, um just a desire to grow and a humility behind that of um the way you put it, Robert, was you know, if you're the dumbest guy in the room, you're gonna you're gonna probably learn the most too at the same time. And I I think it takes a lot of humility to to learn and to grow in some of those uh situations. So that's it's really kind of cool to to hear that for you guys. And then you're both you both seem to be looking for it. You seem to be looking for those opportunities to grow over time. Is that accurate?

SPEAKER_01 29:04

Yes. I mean, I think we were looking for uh something more than maybe what just being a therapist alone and so kind of taking advantage of the opportunities when they presented and and sometimes you know for me it was realizing that um gonna have to move for it. But again, that ended up being the best thing for us.

SPEAKER_03 29:28

Yeah. No, it's really good. Hard hard during the time, hard, hard when you're making those moves. Yeah, very much, yeah.

SPEAKER_01 29:38

But you learned too, it's in these roles, you can't do any, you can't do everything yourself. You need a team. And like I'm comfortable saying that I'm not the expert, and I need smart people around me, smart people around me that that I can rely on to find answers and delegate things and to but ultimately, yeah, you are it's kind of scary what you are in charge of in these roles.

SPEAKER_03 30:01

Yeah.

SPEAKER_01 30:02

Um be careful what you wish for. But um, I think there's also a reason that you get there. You know, you definitely was a journey. And and you need good people in these roles, not just the CEO role, but gosh, there's other executive roles in hospitals that are prime for PTs, like your several department leaders, you know, your COO role, clinical management in any way, multi-departmental management. PTs can do that. And I think that um we're well suited to do that for all the reasons I said.

SPEAKER_03 30:35

So and neither of you uh neither of you seem to like have it all figured out when you were getting that role. You you very much talked about growing into the role uh after you after you got it too.

SPEAKER_01 30:50

Oh yeah.

SPEAKER_03 30:51

And which is incredibly uncomfortable.

SPEAKER_01 30:53

Yeah, well, and when I've I've applied for other jobs too, just to get here. You know, I haven't applied since I've been here, but to get here, I was looking at other jobs in Nebraska, and you're like, just up front, you're telling them like this is who I am. I'm not gonna come in and give you great insight on the cost report, but I can give you great insight on maybe the culture of the organization, the um some of the clinical and quality strengths and weaknesses, and how we might grow services. And so that's what you hang your hat on, is what you know.

Collaboration, Cooperatives, And Advocacy

SPEAKER_02 31:27

So when you look at, yeah, our I mean, certainly financials was by far my weakest point, you know, understanding hospital financials. And so I've learned a ton about that, you know, and I still have a ton more to learn. And I remember my high school coach always, he always told us, you know, the things you hate to do the most are the things you need to do the most, right? Because you're gonna find time to do the things that you like, you know. And and so, you know, just to spend time, you know, pouring through those financials, working on my weak points, um, and actually in, you know, and that's one great thing about physical therapists, right? We're usually lifelong learners, like we want to learn more, you know? And so, yeah, I've got a clinical con ed course tomorrow in in Carney. Um, but the following, I think it's two weeks from from then, then I'm going to take uh a one-day course to learn about the cost report, you know, how how to maximize that, because that really is the financial bread and butter of of how your critical access hospital operates.

SPEAKER_03 32:36

There's so much to learn, and you're willing to go do the work. That's that was awesome. Uh, can I can I shift gears on you guys a little bit? So um let's maybe shift into um you know there have been a lot of changes from a legislative standpoint. Um, how is some of that current legislation starting to impact access to care where you guys are at, payment, uh maybe workforce development in rural settings? Can you guys talk to us about that? And Chris, maybe we'll start with you.

SPEAKER_01 33:08

Well, I think currently every year is its own story. The the story of this year, I feel, with the big beautiful bill, is with some of the the cuts, is I I think we feel that maybe people aren't accessing healthcare like they were in years past. And um that's unfortunate. Um, but it's reality. And so um so I think we have to either um do do a little more marketing to and and then to the extent that you know some places are really good at um chronic care management and health coaching. If you if you own a rural health clinic, you might be doing that, but getting people in, you know, you really have to take the lead and make people understand that they need to come to their appointments, marketing the services are available in your community because we're just electively you're not seeing the the foot traffic, maybe that you were in years past with some of those changes, and it is what it is. And so we are always um watching also like the reimbursement landscape and how that affects us, and you know, the rise of Medicare Advantage is a real problem for critical access hospitals in particular, because there's no cost report settlement for those. But um, so we take a proactive approach with that in our community of trying to educate the public and working really close with our um senior services department, which they help navigate people through those decisions. Should I do Medicare traditional or or Medicare Advantage? We actually this last year saw our Medicare Advantage percentage decrease here, which is not the norm, but um that's benefited us a little bit um just to see it drop a couple percentage points, and um we feel that traditional Medicare is much better. Um, you know, in terms of patients that need care can just go seek it and get it, and it's not questioned, you know, and so pre-authorization is way less, the ongoing utilization review is way less. It's really up to the clinician or the therapist. I'm thinking of therapy visits, you know, it's really up to the therapist sometimes how long to see that patient, which is ideal. And so, but um, that's just a little bit of how I see it right now. I'll turn it over to Robert.

Workforce Development And Student Pipelines

SPEAKER_02 35:35

Well, and it's you know, the political landscape is always just so interesting because it can change so quickly, you know. Um, you know, an example of that would just be, you know, PTs not being listed as professionals, the student loan reimbursement amount. I mean, we're graduating people at the doctorate level with the DPT. How how ridiculous to be classified in that lower level, you know. And obviously, I would I would have some disagreements with you know some people that are on our list, that list compared to to us. We we should be on that list as as well, you know. Yeah, when when you know the Medicare Advantage is a big thing, three the 340B um drug program is uh is a lifeline for a lot of critical access hospitals, and Big Pharmacy is constantly attacking that program and and they've been very successful over time. And um Nebraska did get a win. We have a group of rural hospitals that that Chris and I are both part of that we work cooperatively, um, and we've been very good at advocating for for uh changes that have been very positive for rural health. And last year we were able to get a big advocacy win on the on the 340B program, which really did help um improve the financial viability of our facilities. Um at one point, 58% of the rural hospitals in Nebraska were um losing money on operations. And and that's improved slightly. I think we're around um 40% are in that category now. Um but rural health care is a grind, and it's not going to get easier. And when you look at the one big beautiful bill, it had all those cuts to Medicaid, and then Nebraska decided to be proactive in terms of how it how early it implemented the structural changes in terms of um Medicaid eligibility, and uh people have to re-enroll twice as often as they used to. So it the insurance industry is difficult enough to navigate. And then when you look at a lot of the challenges that individuals that have socioeconomic challenges have, it's I I think we're gonna see a big lapse in in care for coverage for those individuals. And unfortunately, then we end up giving away free care in our in our facilities as public not-for-profits. Um and and those numbers can add up and be pretty staggering, quite honestly. And so, you know, those Medicaid changes alone are pretty big. And when you look at the projected decrease in Medicaid reimbursement that's going to be occurring, you know, the solution for that for the rural hospitals was the rural health transformation program. Well, if every single penny from the rural health transformation program went to rural hospitals, it would only cover 37% of the losses total from the one big beautiful bill. Um, but when you look at Nebraska's application, only a fraction of the$218 million we're scheduled to get, which is a huge number. Um, only a fraction of that is is actually available to hospitals. Very small. You know, there's there's um you know, school lunches benefits a ton from it. Um, but I also question the way some of these, some of these plans have been put together because they're supposed to be sustainable and it's supposed to be a transformal, you know, innovative approach to healthcare that's going to help um, you know, ensure the long-term viability of of rural facilities, and it has to be a sustainable program. And when I'm looking at at some of the things that um our governor and DHHS has lined out, to yield the results of that would take everyone to implement those, and we would have to implement them for 30 years to be able to get a return in terms of the effects that it would have on overall health and wellness for our community.

SPEAKER_00 40:10

So um Robert, that makes me um want to share something and then also turn this into a question for you. So you know, as these challenges have come um that I've heard about, you know, through my role with APTA Nebraska, it has also, I think, led to better communication and more collaboration amongst the different healthcare associations throughout the state. Um, I have more communication with like the Nebraska Hospital Association, that's the Nebraska Medical Association, oral health group, uh, which has been honestly fantastic because a lot of these issues, we have a shared interest. Uh, and so it's been really nice to collaborate more and more on these things. And as you mentioned, you know, small victories here and there, um, but mostly just kind of reeling right now and trying to kind of find our way. But I'm curious in your guys' roles, you know, obviously you guys have been involved in APT and Nebraska, but now in your your new roles, how you've kind of found your way, maybe networked in some of these other groups uh that are relevant to your roles.

SPEAKER_01 41:18

So I'll take that one. I think for us, it's a means to survival. Like you were both um CEOs of independent rural hospitals, and so that's very unique. We're not part of a health system, we're not managed or owned, and so we um we we formed um some cooperative um interests with other independent hospitals, and we're part of a a group of about what is it, 29 hospitals that are part of this rural med cooperative. That's awesome. We we are sharing problem solving, we're sharing um some resources that are clinical, we're sharing education, um, and so that so but that's not the only one. There's there's about three others that we're both a part of that um, and some are through some of Nebraska's health systems, like through Brian Health. Uh, we're part of the Heartland Health Alliance, which is awesome, we're part of the NHA, which gives us a lot, but but we it's necessary just for survival, and you just find that that's where we learn and that's where we um in our roles, that's where we have to spend a lot of our time because that's where change happens with policy. Um, that's where we get our voices heard on the issues we're facing. So I again I go back to that's that's where PTs are really well suited for that because we we're able to see um multiple perspectives. It's not just our perspective, it's like you know you learn that as a therapist. Like, what's the what's this patient thinking? You know, you gotta think uh in order to understand these issues, you know, walking in other in another person's shoes and understanding what how they might be experiencing it is so important. And so for us, you know, to answer your original question, it's kind of like a means of survival of um being involved in these um different groups that share information. And I'm glad that you say that it's opened up doors, you know, the APTA with other entities, because I we're gonna need to do more and more of that as the as the landscape gets difficult. Because I think that we're all pulling, most of us are all pulling for the same wins.

SPEAKER_03 43:35

Maybe just a follow-up question to that, guys, uh, because we can identify some of the the other issues that are going on too. But uh what what else what else can we do as APT in Nebraska to support some of the things that you guys have going on or the things that you're seeing?

Direct Access Barriers In Hospitals

SPEAKER_02 43:52

Certainly, I mean Chris kind of mentioned this earlier the workforce development piece of it. If if you're looking at facilities. That are farther and farther away from our urban areas. Um, it's hard to recruit if you're not able to recruit somebody that has say ties to the land. And we always kind of joke a little bit. It's like we get an employee, and well, maybe they're from three hours away, and it's like, hey, we need to find them a local farmer to marry, right? So they're so they're tied to the tied to the land, you know. Um, but yeah, workforce development is is a big thing. But I I think one reason we've been successful in our facility in terms of maintaining um a viable staffing model is, and again, it goes back to to the APTA, you know. I think being involved in the APTA um on that state level, you're you're interacting with students, you know, the faculty at the schools, you know, if you've got the opportunity to do some teaching assignments in in lab at at Creighton or Nebraska, you know, and then taking those students into your clinic, you know, getting students rotating through your clinic is such a such a huge part of your future staffing model. Because I I may have a a student from Minneapolis in my clinic, and I know he's never coming back here and he's going to practice in in Denver, wants to be in Denver. Um, but he's got classmates that might want to go rural, you know, or she's got classmates that may want to go rural. And so just having those connections. And if somebody looks then, oh, there's a job posting at at Fillmore County, or there's a job posting at KOZAD, oh, George went there on clinical. Hey, George, what did you think of that? It was awesome. You know, it was one of my best spots. I got to do this, this, this, and this. And and I think that, you know, from the academic perspective, the rural clinics typically allow the students um uh greater opportunities with their patients to get to do um more more often. And so um it's a it's a great spot, uh, especially when you're looking at, I always say that your first clinical and your last clinical should be at a at a critical access hospital because you get exposure to everything. So then as you're working through your specialized clinical curriculum, you can reflect on some of those experiences you had. And then at the very end, you can tie that whole educational package together and get ready for taking boards and going out into the real world. And so um, yeah, workforce development, I think is is something that that we can always uh work on together because I think that's not so much as a competitive endeavor. I do think that if you look at, you know, say 30 years ago, the the old MPTA, which I always want to say that instead of APTA in Nebraska, that's been a struggle today, gentlemen. Um you've done a great job. The uh, you know, we had two state meetings a year, right? And there was nothing online, you know, nothing online for education. You know, there may be a few courses here or there that were out of state that were available, but really your your educational content was coming through the state association at those state meetings. And it was kind of like a class reunion two times a year, like everybody would get back together. Um, and when you look at, say, the rural facilities, I really think it created like this rural brotherhood, you know, this rural camaraderie. Um and I think we've really lost some of that interconnectedness now with so many different opportunities online, um, and even just the competitive nature of PT now, um, between all the different private practices and the hospital outpatient groups, especially in in larger communities. And so I I visited with I and you guys probably know, probably would remember. I think it was uh it was uh Mills, I think was his last name. He might at the time been vice president of the private practice section in in at APA National. Daniel Mills, I think was his name. And I said, Hey, this is what's happened in Nebraska. We were losing some of attendance at our state meetings, there's all this competition, people don't want to go learn the same thing, you know. And I said, How how do you get how do you get past that? You know, um, because he was talking about the competitive environment in in California. And he said, you know, we we look at it as, you know, the rising tide raises all ships, right? You know, so what's what's good for one is good for us all. We don't have to compete, you know. Let's let's work together to build the profession as a whole, not just our individual clinic status, you know. And so what can we do as a state to raise the profession of physical therapy as a whole, you know? Um, and and I will say, you know, I'll I'll be a little bit critical of the House of Delegates. At times I think there's some resolutions that we look at that are are political in nature and maybe don't focus on specifically rising, you know, the profession itself. I think maybe indirectly, but I think maybe we get kind of bogged down on some things. Um and and I think we can we can work at you know that collaborative approach across the profession. What can we do to elevate the presence of physical therapy in Nebraska? Um and I know Nick's been working on some things, um, and and I think we we need to kind of go down that path um to elevate the the presence of physical therapy in Nebraska because other professions are doing it and and and we need to be right there too. We're well-educated individuals and well-educated profession. Um what we need to elevate.

SPEAKER_00 50:29

I I'll share too, you know, in just really in recent months, uh we've been able ABT Nebraska has been able to uh bring together a large uh private practice uh collaborative uh amongst all the different owners in our state. And in my experience here in Nebraska, that's a group that has always been uh a little bit more independent, you know, maybe to your point about competitiveness and not always willing to work together. But again, we're all facing the same challenges. And it's been it's been a breath of fresh air to see that group work together. Um I I I feel very confidently we might have a pretty important legislative win at the state house this year, really, because that group came together. Um, so I I do think there is some like there's one, some light at the end of the tunnel, and also like some of these challenges that we're all facing are are really doing us some good in a sense by just getting us to to collaborate and work together. I agree.

Building Relationships With Lawmakers

SPEAKER_02 51:34

Yeah. And and I would love to, um, and this is something that I talked about from time to time, and at one point it and it's probably been boy now, probably close to 10 years ago, maybe even 15 years ago, because the rules and regs for hospitals in Nebraska, you know, require that all outpatient physical therapy services require a physician script. You know, so we've got a practice act that that says we're okay to have direct access, but as an outpatient department of a critical access hospital or any hospital, you know, we have to have a physician script. And I do think that that puts the um the hospital facilities as a little bit of a disadvantage compared to the the private practices. Um, but also if we're looking down the line, you know, and if you're looking at this the statistics of physicians in um rural communities, 50% of them are scheduled to retire in the next two to four years. And so you're going to be losing a lot of MD experience in rural communities. That's going to be backfilled by mid-level practitioners, nurse practitioners, and PAs. Um, certainly if you look at some of those studies in the in the mid-2000s, 2005-ish, I think it was, um, you know, that study that was put out that showed, you know, there was no statistically significant difference between the uh diagnostic accuracy of a of a PT in an orthopedic surgeon? They did have a slight edge, but on the percentage points, but statistically they said there wasn't a difference. But then you looked at and the diagnostic accuracy of a family practice provider was half of what of what we were, right? In absence of MDs that's coming down the line, can PTs fill more of that true direct access role? Um, but in those rural communities, oftentimes that's going to be through the through the critical access hospital facility. And and we need that those rules and rigs and and statutes to change so we don't have to have a physician script to provide services. Now, going down the insurance line, it's a different thing. You know, we still have to have a signature for insurance payment, but to at least get that regulatory hurdle out of the way is is one step towards progressing.

SPEAKER_00 54:14

Yeah, I mean, you bring up great points and show how they're all tied together, right? And I think, you know, one of the things that I've really encouraged our membership to do more of is just advocate, right? Like some of these issues uh maybe seem like they're in their own separate silo, but they're all tied together, as you just pointed out. And and so part of us practicing at the top of our scope is also demonstrating really our worth to the community, and and that very well might be in the future in more of that primary care role. And I think that's something that's that's gaining ground nationally, and and we need to need to absolutely look at that opportunity here in the state of Nebraska.

SPEAKER_01 54:51

Well, and whether you're the role of the APTA and advocacy, you know, whether it's a state level issue or federal issue, it does all boil down to relationships with those representatives. So like you need to work that. That's one thing that we've learned in these roles is the to the extent that we have a relationship with our state senator or the federal delegation for Nebraska often determines if we can get their attention on something.

SPEAKER_02 55:21

Yeah.

SPEAKER_01 55:22

And so that don't lose sight of um, that's what they're there for, and that and it and it work those relationships, check in with them and um just do it, even if there's nothing that's burning on your plate, just checking in with them to um make sure you're hurt when you do have something, you can go to them. And you've got an existing relationship where you can talk about a serious issue and get their attention on it. So that's just essential, I think.

SPEAKER_02 55:51

I couldn't say it better, Chris. Yep.

Community Pride In Kozad And Geneva

SPEAKER_03 55:55

Uh Nick, I I think I I've got a good landing the plane question, but before I ask it, do you have any other questions that you would like to ask Chris or Robert?

SPEAKER_00 56:06

I have an abundance, but maybe that would be uh appropriate for a part two.

SPEAKER_03 56:12

We might have to do a part two. We might have to like this one in the. I think one one of the things I just heard from us was um just the the power of strength and numbers, right? The the collaboration that exists. Um I think specific, you know, this is the APTA Nebraska podcast. And so um specific to our organization, you know, it's um it's important uh to be a member, right? So sometimes that just means paying your dues and you're supporting the organization in that way. But it's also important to show up, and we will have a number of people that decide to show up, right? Whether that's for events that are going on or it's the CE day that's happening, um, or the state conference, or or showing up when we need people to um uh to share their stories in front of the legislature or in front of committees, like it's it's showing up in those things. And and then it's also uh maybe a third level is is um getting involved at a deeper level, right? Robert, you've been a chief, you've been a delegate. Um Nick, you're the president of our organization. Uh I'm the membership chair. There are lots of different ways to uh get involved at a deeper level and to start to lead a little bit more too. And so I just have to acknowledge that you know that that strength in numbers has a few different faces to it, a few different ways to be engaged. And I realize not everyone can be in leadership, but man, just being a member and and uh showing up to events goes a long way as well. So I just wanted to say that. Um, and my my landing the plane question for you guys is can you just briefly talk about Robert? Why do you love COZAD? What do you love about COZAD? Um, the community there, uh, what you're doing. Chris, why do you love Geneva? Um, just talk about your communities for a moment.

SPEAKER_02 58:09

I mean, honestly, I like Kozad for all the reasons I like a lot of role places. You know, it's you you get to know a lot of different people, you know, your your patients, you really do get a good personal connection with them. Um you you see them in at ball games, you see them at church, you see them at the grocery store, you know. So it it really is kind of that just that cliche small town um feel. And there's such a community pride and interconnectedness and everybody trying to work work together for the same common goal. Um I really feel as a community right now we're we're being progressive. Um we've we've got great administrators at our in our school system, our local school system. Um they just we did a$28 million upgrade in addition to to all of our schools. Um the hospitals recently doing renovations that are that are giving it a new fresh, fresh look. Um we've added a four-plex ball field. Um we actually have for a small town, we've got a three million dollar museum that houses the um greatest collection of Robert Henry art in the world. Um and Robert Henry had had lived, his dad was John J. Kozad, who was the town founder, founder. And so um, but just it's it's just that community. So it it means a lot.

SPEAKER_01 59:40

For me, you know, we we chose to come here from my job into Geneva, and it'll end up being the place where all three of our kids graduated high school. And the you go through those things together with other parents and the sports, the teams that we've been on. There's pretty awesome relationships that we've developed. And so yeah, it's home for us right now. And but but beyond that, what attracted us here was just the um well, it's a couple things. It was the progressive nature of this small town hospital, the sense of family that oozes out of here, like even over the phone, you know, made me want to come visit. Um, but it's also this uh the ease of small town life, you know, that um the fact that you can take care of so many things quickly, when I and I really literally mean that dentist, eye doctor, groceries. I could knock that out and I could knock that out in 30 minutes, maybe, you know, it's just um maybe not quite that much, but um it's very, very efficient. And that we we really like that, but um that's really the same as many small towns, but um ultimately that's why we think that we're probably gonna stay in a in a in a small town and stay in Geneva.

SPEAKER_02 1:00:56

So and I think when you look at like your your work, you know, a good share of our waking hours are at work every day, right? And you, you know, your your staffs are small enough that you get to know your entire staff well, you know. Um and I can see it when Chris is touring touring me around here today, he knows his staff well, you know. And so just just those connections you have at work, connections you have in the community, it's that that relationalist, you know, component that that makes rural Nebraska great. And and it's and it's visible by people outside. We we did recently hire a um director of nursing whose her her son became a uh pastor at a church in North Platte, and so she followed him um there, and she came to work for us, and she said, you know, in Kentucky, everybody thinks everybody in the south is the nicest. And she's like, This place, there's no comparison. She's like, Nebraska is so nice compared to every other place she's ever been. Um, so that says just a lot for Nebraska. And then I did let her know that at one point in time the Nebraska slogan was Nebraska nice, right? So there we go.

Closing Thanks And Member Engagement

SPEAKER_03 1:02:18

I was gonna say, you you you haven't known Nebraska nice then yet, right? Uh now. That's great. Well, hey guys, thank you so much for your time. I appreciate you joining the podcast and and answering our questions. Thank you for the work that you're doing, for the ways that you're um, you know, supporting the physical therapist, but many other uh professions within your hospital organizations and your community as well. Um we appreciate you guys uh joining us for the conversation. And listeners, I hope that this was uh a fun topic and fun conversation for you guys to listen to as well. And we'll look forward to the next one.

SPEAKER_00 1:02:55

All right, thank you. See you guys later.

SPEAKER_03 1:02:58

Thanks for tuning in to the APTA Nebraska podcast. Stay connected with us for more conversations that elevate our profession and improve the lives of Nebraskans. Don't forget to subscribe, share, and join the discussion. Because together, we're driving the future of physical therapy forward.