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MOLLY BLAKEMORE: Hello and welcome to Free Speech with CR. I'm Molly Blakemore, your host, and I'm joined with my cohost, Dr. Keith Flamer.

KEITH FLAMER: Molly, it's great to be here with you. And our guest today is Michael Kellerman. And he's the CEO of Providence and Redwood Memorial hospitals.

MICHAEL KELEMAN: St. Joseph.

KEITH FLAMER: St. Joseph.

MICHAEL KELEMAN: Yeah.

KEITH FLAMER: OK.

MICHAEL KELEMAN: We just call it Providence Humboldt.

KEITH FLAMER: Oh, I like it. That makes it so much simpler.

MICHAEL KELEMAN: I'm trying to just make it where one system. Yeah.

MOLLY BLAKEMORE: And St. Joe's, do we still call it St. Joe's or--

MICHAEL KELEMAN: Yeah, there's still two separate hospitals, separate licenses, but when I talk about it publicly, we are Providence Humboldt, because it's the hospitals. There's a medical group. And I think at the end of the day, if you're living in this community, it's just Providence. You don't really care.

KEITH FLAMER: Here's a question for you. There's a lot of conversation about rural health care and what the answers are to the solving all the problems of the world in rural health care. So help us understand what the real problems are and what the answers from your perspective are.

MICHAEL KELEMAN: Well, let's solve it today, Keith.

KEITH FLAMER: Yeah.

[LAUGHS]

Because you know what? Everyone has an opinion. I'd like to know your opinion as the frontline CEO.

MICHAEL KELEMAN: So problems and solutions.

KEITH FLAMER: Problems and solutions from your perspective.

MICHAEL KELEMAN: I'm also going to say I think there's probably different variations of rural health care. I think that's also important to share.

KEITH FLAMER: Talk about that some more for us.

MICHAEL KELEMAN: Yeah, so there's rural health care where if you talk to some people-- well, actually recently we had our St. Joseph gala. And at that gala--

KEITH FLAMER: Which I had a very good time in, by the way.

MICHAEL KELEMAN: Thank you.

KEITH FLAMER: It was fun.

MICHAEL KELEMAN: Well, the Moras came up and they did the big auction, and one of them mentioned that they have friends in other rural communities that drive for hours just to get to the nearest emergency department.

KEITH FLAMER: Yeah.

MICHAEL KELEMAN: So that's one version of rural health. Our rural health, I think, is just defined by our population density. Massive County, about 130-ish thousand people give or take, spread across the county. So we're rural.

I'd say the biggest challenges with rural medicine, there's a few things. One, to try to bucket these. So one is physician, in terms of access, it's not that we lack subspecialty care. It's the number of subspecialists we have. And that has to do with population density.

I think two, rural environments. How do they attract people? I don't think everyone understands what it is to live here.

I don't think everyone understands that you still have a lot of modern amenities, but it's a balance where, for example, if you go to Los Angeles or the Bay area, you don't ask yourself, gosh, I wonder if they have good schools for my kids. You feel confident you'll find a good school for your kid, even though you have no idea what the schools are.

When you move to a rural community, that's a very legitimate question, because you don't actually know how many other schools in options they have.

KEITH FLAMER: Sure.

MICHAEL KELEMAN: I think the other part of it is just funding. Rural communities are interesting. When you go into a metro areas, actually per Medicare, rural communities get paid less. So a physician working in a rural environment who is billing for Medicare is actually getting paid less than they are in a metro area.

And I have to remind myself of why that was because I remember being confused and inquiring about it, and I think it had to do with the fact that they looked at it as the difficulty. And I think it was seen that, well, it's probably more difficult, you have more patients, there's more demand in a metro area than rural.

MOLLY BLAKEMORE: It could be cost of living also.

MICHAEL KELEMAN: It could be. But I think it had more to do with that. I have to remind myself, so don't fact check me on this one or please do.

KEITH FLAMER: Or someone will, but go ahead.

MICHAEL KELEMAN: Yeah, but the real challenge is in a rural environment, what I'm learning is the pathology here, meaning how sick people are. And I don't think we factor that in. And that's a challenge for a physician here.

A physician comes into this environment and you see people that are just very, very sick because they don't access care the same way people would do in the Bay Area. I think people here are very resilient.

KEITH FLAMER: Never thought of that.

MICHAEL KELEMAN: Solution to it.

KEITH FLAMER: Yep.

MICHAEL KELEMAN: I would argue the best solution we have is our community. And it's the catch-22 of what the beauty and the challenge of a rural community. So Humboldt right now, for example, it's a beautiful community. It has a lot to offer, but how do others know that?

If I bring in, let's say, a new physician and they come in and they're going to go, OK, and I put them in a hotel. What hotel did I put them in? And I mean that genuinely. Ask yourself that or people who are listening to this right now, where are hotels located?

If you had a family or a friend just moved to Humboldt and you wanted them to experience your new home, is that where you would want to house them in that hotel? That is not a good reflection of who we are.

I think the second part of trying to solve this is how you help them feel that they're going to be successful and able to grow. I think anyone who comes out of, let's say, a graduate program or anything when you're young especially, you want to make an impact. That's your motivation is that you want to make a difference.

So when you come to this community, how do I give you a sense that there is opportunity to do a lot here versus small town, not a lot of growth. How busy am I going to be? How much am I going to be able to do here?

MOLLY BLAKEMORE: Yeah, we have a lot of the similar problems with recruiting people, finding housing, suitable housing, health care is a big one for them. Schools, all of that. So we have a lot of the same problems with recruiting people.

And I definitely hear your point about where are they staying and what are they doing, especially young people. And is that another reason that we probably get-- I know when I first got my doctor here, she retired within a few years.

And so I think people maybe retire here, but they don't want to start their careers here because of what you've mentioned about opportunity. So that is a challenge.

MICHAEL KELEMAN: We're changing it though. Don't get me wrong. We're bringing on new physicians. So we have a new interventional pulmonologist, we have a new general surgeon who started. We have another one starting in the fall. We brought on about 25 physicians in the last year. So we are growing access. But it's hard. It's slow and--

MOLLY BLAKEMORE: Cost money.

MICHAEL KELEMAN: Yeah, it costs money. But even outside of that, I think the hardest part it's not even always the physician. A lot of times it's the family, the partner. And it's not even them successfully living in the community. A lot of times it has to do with their family and how isolated we are.

So oh, family live in the Bay Area, how close are you? Oh, pretty close. Well, I also have an opportunity in Sonoma. Oh, easier. And so that's sometimes the hard part.

KEITH FLAMER: You and I are part of these conversations about rural health. And how do we find an answer to those? I find that everyone I talk to has a different idea about what the problem actually is. So what's the problem in your mind that our community should focus on to solve?

Because everyone has a different interest, and they're eager to tell us what the problems from their perspectives are. What are those problems, and from your perspective as a CEO of a major health care hospital?

MICHAEL KELEMAN: The first thought that comes to my mind is care coordination to be honest with you, I could talk to you--

KEITH FLAMER: Talk about that. What does that mean?

MICHAEL KELEMAN: Yeah. And before I jump into it, I could talk all day about recruitment. I could talk all day about what we as a community can do. And I know we've talked about home in Humboldt. There's a lot of things. But if you really ask yourself what are people struggling with. It's coordination of care. So what does that mean.

Step one, how do you get established with the primary care? Find one. I know right now just in Providence Medical group, I have the capacity for about another 5,000 unique patients. That means that if there's 5,000 people in this community who are not established with the primary care, I have capacity.

Now, if you all call today, it'll take you about 90 days before you get your first appointment, before you get established. It's a process. So one part of it is in education, and the community needs to know how to lean into that and get established. But again, finding it. I'm the CEO here of these hospitals. And I can tell you right now, it's not easy.

The next part of care coordination is let's say you have your primary care. Let's say you go to the ER, whatever it is, and they say you need to see a cardiologist, you need to see a neurologist. You're now going to your specialists.

What happens is you're leaving your primary care office, and they say you need it. I'm going to put it in an order. Here's your referral. Call this number.

KEITH FLAMER: OK.

MICHAEL KELEMAN: That right there is the whoopsie.

KEITH FLAMER: Yep.

MICHAEL KELEMAN: We've given the burden for lack of better words to you. So the problem with that is, one, you are now falling back into this phone system. You're on hold. You're waiting for someone to call you back. That's one of the problems.

The other problem is in rural communities especially, everyone has different means. It's a different kind of demographic range here, and not everybody may have the time to sit on that phone to make that appointment, or the flexibility in their work to get in when you finally say you have an appointment available.

How do we ease that way? How do we ease that way that if you're in a primary care office and they go, you need to go see a cardiologist, I would love for us to be in a position to go. We're going to get you scheduled right now what's a good day and time that works for you. That's what we're trying to get to.

We're piloting that right now, actually in partnership with opendoor in the hospital. So if you're getting discharged right now from St. Joseph, and you are established with an open-door primary care physician, before you're fully discharged, we have someone who's dedicated to scheduling your appointment with your primary care before you leave. And lo and behold, 96% of those patients are showing up to the visit because it's done for you.

MOLLY BLAKEMORE: And when you give the burden back to them, also, if they've had prior bad experiences, they're less likely to follow up regardless of their level of need for care.

I had the experience with the imaging center for my mammograms. They were really on me to make an appointment, and that's really why I did it. So I think that is very-- I mean, even have the time and don't have bad experiences. And I probably would have let it go for a long time had they not been calling me. So I appreciate that. And I think that that's--

MICHAEL KELEMAN: But that's the coordination again. So there is someone looking out for you and pushing you to go, hey, gotta make sure you're doing this. And I think a lot of people get lost in that. And so a lot of times when I hear people to go, oh, we have no specialists or it's taken me six months to get in.

And like, for example, I recently had someone reach out to me because they needed to get in for a diagnostic scan. I won't give too many details, but it was a diagnostic situation, and they're like, yeah, I can't get in for over a month.

And I was like, for over a month? That seems like an urgent situation. Well, we got him in within two days. There's always the space for it, but it's the coordination of care.

MOLLY BLAKEMORE: Not everyone can call you.

MICHAEL KELEMAN: Well, it's also when our team, looked into it, the way the referral was put in, it didn't have the right signals to say that this is an emergent situation. This person needs help and care coordination. It was just put in as an order, and that's a miss.

And those are the opportunities for us as a health system. It's not a failure on the referring provider. It's not a failure on the patient. It's a failure on us as an organization, as a system to go, hey, how do we fix this? How do we ease the way of everyone that we're caring for?

MOLLY BLAKEMORE: And we have a new program coming up, health care navigator. And is that similar to what you're talking about.

MICHAEL KELEMAN: That's huge. This is the other thing that's interesting. I don't know if people realize this in California. California is one of a few states-- it's like California, Iowa, Texas. There's a few more that escape me that don't allow what's called corporate medicine.

So our physician network out here, so if you go into Providence primary care, that's actually not employed by the hospital. We don't employ them. We have a very close relationship, but we do not directly employ employee physicians. So one of the things we're talking about with our medical group partners is how do we--

MOLLY BLAKEMORE: Who does employ them? Are they independent?

MICHAEL KELEMAN: They are actually their own. They are their own medical foundation. And then they lean into Providence for back office services. So there's an administrative function that we Providence provide.

MOLLY BLAKEMORE: And they rent the spaces from you if I go to--

MICHAEL KELEMAN: No. So they have their own board. Physicians here have their own board. They have their own leadership team. They have their own tax ID and everything. And then they contract with Providence Medical group to provide them all the infrastructure.

So like the salaries, the pay, the offices, the staff, we just pay for it all. Now the hospital does do, at the end of every month, we do a transition of funds to this medical group to go, OK, help cover all the expenses associated with it.

But we don't actually directly employ the doctor. They're their own self-governing body, and that gives them the autonomy to practice medicine independently.

The navigator role, though, we're really starting to talk a lot about this with the medical group and the hospital together is what does that look like? So we have a whole team that understands how we're taking care of you in the hospital. Then we have a whole team that focuses on running clinics, and there's really no one in between.

We do it in oncology. Oncology has nurse navigators because we've realized that that's a vulnerable population. There's no room for error. And so you'll be connected with what's called a nurse navigator who will literally guide you like your mammogram situation, every stage of care.

Make sure you got your appointments. Make sure we're getting all this done. If you have any barriers, you call me. They lead you through it.

And so we're starting to talk about why can't we do that for other service lines? So for example, for cardiology. Why can't we have someone who has a lens into the ambulatory footprint, the hospital footprint?

And so imagine you get into cardiology and they go, hey, we're going to do this thing called a stress test. And then you get a positive result. You now need to get scheduled for a diagnostic Cath. There's all these steps.

Those first steps to get identified that you have a positive stress test are all happening on the ambulatory network. Then they say you need to go get a diagnostic Cath. The hospital just got involved. Now, you're going to the hospital.

Who's helping ensure that we are seeing everybody with a positive stress test, we're understanding who's more sick than whom, like a triage system, and making sure that we're transitioning them timely and appropriately. We don't have that right now. And that's the conversation we're having which is could that be a navigator.

KEITH FLAMER: So you asked the question, why can't we do this? So my question for you is, why can't we do this? What's standing in the way of doing what you're suggesting?

MICHAEL KELEMAN: We are doing it. We're heading that direction. I don't think that those conversations have been happening before. And to be candid, it's not a Providence thing. It's not a Humboldt thing. I think that's another good discussion is go to Los Angeles, go to San Francisco, go where you want and access health, it's the same.

The difference there, though, is let's say, I move back to where I grew up in the Bay Area. I have John Muir, I have dignity, I have Sutter, I have Kaiser, I have a lot of other health systems like Starbucks, basically on every single block. UCSF is in my backyard. I can get to anyone I want to.

So if one person isn't able to give me the care that I'm looking for or to meet me where I need to be met, I will find someone else to pick that up.

What we're struggling with a little bit here, I think in Humboldt County is Providence, we really are the largest player right now for health care. And so we're trying to get focused on how do we cement our position in terms of what matters most to our community.

And one of the things my team and I have been doing for the last few years is really looking at that data and asking ourselves, what's the greatest need? What do we see the greatest need being in the next 5 to 6 years?

And we need to focus all of our resources there first to make sure that we're well positioned for that. So cardiology, oncology, women's health, our trauma services for emergency care and making sure that we have a robust integrated ambulatory network that is communicating with the hospital.

The other stuff I don't want to dismiss it. It's extremely important, but it's not my primary focus. So do I need more allergists? Do I need more dermatologists? Yeah, 100%. I can't tackle them all at the same time.

KEITH FLAMER: So what are the top three things that you need?

MICHAEL KELEMAN: In terms of service line or just need--

KEITH FLAMER: Need, period. Let's talk about that because at some point, I'm going to branch off to let's zoom out to the National stage on health care.

MICHAEL KELEMAN: Top three things I need. I need more capital investment, and I know that sounds kind of silly and funny. We need to invest into our infrastructure. We have a really we have beautiful hospitals. They're very clean. They're very pretty, but they lack diagnostic tools. A lot of the tools we have are old.

There are some services where we do advanced things. We've introduced a lot of new things, but I have an MRI that's 25 years old. And sometimes patients have to leave the area, three hours or something like that, just to get an MRI so that they can come back and do a procedure that we're able to offer them here.

So they get the procedure done here, but they left for three hours just to get an MRI scan. That stuff keeps me up at night. And that's something that we're working on with Providence, because all health care is dealing with it.

And what no one really talks about is we have a lot of other costs that no one helps us with. So California, we have a seismic mandate.

KEITH FLAMER: Oh, of course, you do.

MICHAEL KELEMAN: For Providence alone.

KEITH FLAMER: Which I think we deeply understand what that means. Yeah.

MICHAEL KELEMAN: Do you guys face the seismic data in education system.

KEITH FLAMER: Gosh, yes.

MICHAEL KELEMAN: Oh, I didn't know that.

KEITH FLAMER: Significantly, yes.

MOLLY BLAKEMORE: Our whole campus is moving down the hill because of seismic activity. The possibility of--

MICHAEL KELEMAN: Yeah. So that's a $9 billion-- I think it's 9 billion is the number I heard for Providence alone.

KEITH FLAMER: Yeah.

MICHAEL KELEMAN: $9 billion. No one's funding it. No one's supporting it.

MOLLY BLAKEMORE: We do get funding from the state.

MICHAEL KELEMAN: We don't. It's just that you better do it. No one talks about that. For St. Joseph alone, we're currently working on that right now, it's like $50 million plus just to meet the 2025 requirements. Then we got to meet a 2030 requirement, and no one talks about that.

So that would be really helpful is if the state, and again, I'm not trying to say the state's not a good partner and not trying to do good things, and the intentions are probably positive, but work with us and help us figure out how we can fund that, because I think COVID proved to many of us that health is actually a lot more vulnerable than we may realize.

People talk about it like, oh, you make billions of dollars. Well, look at how many hospitals are closing their doors or closing down service lines because they can't continue to afford doing them.

MOLLY BLAKEMORE: Especially rural hospitals.

MICHAEL KELEMAN: It's hard. So that would probably be the biggest thing, is some help with that. And then just the physician landscape. I really would love for this community to really come together and not say Providence, you need to hire more physicians. Your health is the worst.

This is something we need to own as a community. I could go into the legacy and the sisters and the founding, and this is a special place for us, and we care about this community and we are trying. It's a hard lift. It's a lot of work and we've done a lot of good things, but this community can help us.

I talk again about the hotels. I talk about the way we present ourselves. How do we become an environment that when someone comes out here, they want to be here, that they realize how beautiful this place is?

KEITH FLAMER: So it's just not the beauty of the place though, right? So you want the community to partner with you.

MICHAEL KELEMAN: Yeah.

KEITH FLAMER: What else in your mind should we be partnering with Providence? How can all the partners, not just the community, but education, how can we partner with you to make sure everything--

MICHAEL KELEMAN: I think some of the work we're doing now

KEITH FLAMER: --is good.

MICHAEL KELEMAN: Well, some of the work we're doing now, launching new programs. We're looking to partner with the College of the Redwoods right now to launch the nurse navigator program, have the psych tech program.

KEITH FLAMER: Surge tech.

MOLLY BLAKEMORE: Redtech.

MICHAEL KELEMAN: Respiratory, radiology--

KEITH FLAMER: All the above.

MICHAEL KELEMAN: Those are huge programs. They're going to be able to support the hospitals in areas that the nursing program has shown. We've almost filled every single nursing position over the last two years, and that is due to the relationship we have with the nursing program. So now we can do this.

The other part of that no one talks about is County economics. How do we invest economically and grow this place economically? And I understand it's a balance. I'm new. I'm not trying to say turn this into San Francisco Bay Area. There's something we like about how rural it is here and how you can still enjoy it.

If you look at the population growth, we are projected to see growth the 55 and plus. But if you look at us from 35, right in that middle range, we're shrinking. And I don't think it's because people want to leave. I think they're leaving because they don't know how to stay. So how do we do--

KEITH FLAMER: Very good point. They don't know how to stay is important. When we talk about the future of health care in this region and how to solve that problem, people don't think about the economics part.

All they think about is, well, we need more doctors. But that's really not the answer. It's how do we solve the economic foundation of the region to be able to support rural health care.

MICHAEL KELEMAN: Yeah. And then you create an environment that these doctors are going to walk into and go, this is great.

KEITH FLAMER: Yeah.

MICHAEL KELEMAN: And I know there's people use bend Oregon as an example. I don't know if that's a good benchmark to be honest, but there are communities who have done it. And I think Humboldt is very well positioned to do it as well.

MOLLY BLAKEMORE: So we have a lot of benefits through CR that are telehealth. Do you embrace the telehealth?

MICHAEL KELEMAN: Very much.

MOLLY BLAKEMORE: Yeah. I mean, I've found that for me, if it's not a serious issue, it's so easy. I mean, it takes about 15 minutes, and I have an appointment, and I have a prescription at Costco an hour later. So that's been wonderful for me. And I'm just wondering what Providence--

MICHAEL KELEMAN: Who do you do telehealth with? And I'll tell you ours. I'm just curious, who do you do it through?

MOLLY BLAKEMORE: Well, I do Midi for women's health, and I, we have Teladoc, and we have another one, too. But Teladoc and Midi are the ones that I've been using.

KEITH FLAMER: I think big timely--

MOLLY BLAKEMORE: That's for mental health is TimelyCare.

KEITH FLAMER: TimelyCare for mental health.

MICHAEL KELEMAN: There's another one called Tia. It's also women's-focused.

KEITH FLAMER: Never heard of that.

MICHAEL KELEMAN: It's pretty cool. So we do a few. So we actually offer, for one, we offer services to our physicians like that as well. We offer services like that to our caregivers, especially around mental health. All of that's free and provided to them.

So telehealth, we use it in different ways. We use it in the hospital setting. So for example, we have neurocritical care. When I worked at John Muir, there was a team that I worked with there who are neurocritical care specialists because it's all they do is neurotrauma.

MOLLY BLAKEMORE: So what would that be?

MICHAEL KELEMAN: Stroke.

MOLLY BLAKEMORE: Stroke, OK.

MICHAEL KELEMAN: So if you go into the hospital right now, every bedside, we have a teledoc function where those neurocritical care specialists are beaming in, and they're looking at strokes and neurological deficit. And that's been a huge impact.

So in 2023, I think, to-- no, '24 to '25-- I'm trying to think of my timeline that I've been here-- we were able to keep 100 more stroke patients in our community. And that is not because the number changed, the number of people getting strokes. It's because we didn't have to ship them out, because we had a team of specialists that could actually assess it.

KEITH FLAMER: That could do that. I see.

MICHAEL KELEMAN: And they did that through a telefunction. We do the same thing for Redwood Memorial, for example. We're trying to really build up Redwood Memorial. I think people need to see that that place has a lot of opportunity and a lot of growth, and it serves the southern county of Humboldt and actually towards Mendocino. It's not just Humboldt again.

And so it hasn't happened yet, but we're going to be deploying telecardiology, telenephrology-- so that's kidneys, because a lot of times, what happens-- and this goes back to the access issue-- you're a patient at Redwood. And to be honest, you're fine at Redwood, but you might have a little bit of a cardiac thing going on.

And so the hospitalist at Redwood can't consult with a cardiologist. So they're going to transfer you to St. Joseph, even though it's just that one thing, if they could just talk to a cardiologist. So we're looking to say, hey, how do we deploy telecardiology? How do we look to deploy telenephrology? Because there's not enough demand to have a full-time person there, but to at least be able to consult and to help the physicians on staff there.

MOLLY BLAKEMORE: And this goes back to the imaging problem, then, that you have if you don't have the right imaging technology, because you would need to send accurate imaging to any telehealth doctor to look at.

MICHAEL KELEMAN: Correct, which they all are connected through through our EMRs. The other way we use tele is we use it in our clinics. We have tele options in our clinics for patients. So you don't always have to go in.

And then we also offer what's called a virtual urgent care. I should have brought it. I can send it to you guys. We actually created a business card, and it has a QR code to make it easy. And it's from, like, 7:00 AM to 8:00 PM.

I've used it for my kid, always got a weird rash or something like that. And it's exactly that. A virtual doctor comes on. Show me what's going on. Great. Here's your script. Is it at Green's Pharmacy? Wonderful. Off it goes. So we do offer those.

KEITH FLAMER: So it's a real doctor, but they're just they're virtually, not a virtual doctor like AI.

MICHAEL KELEMAN: Yeah, I'm doing it on my phone--

KEITH FLAMER: Ah.

MICHAEL KELEMAN: --talking. We use a lot of AI, too, for tools, but yeah, but not for that.

[LAUGHTER]

MOLLY BLAKEMORE: But those doctors are Providence doctors or--

MICHAEL KELEMAN: Yeah.

MOLLY BLAKEMORE: OK.

KEITH FLAMER: Oh, I see.

MICHAEL KELEMAN: Yeah, so the strength of Providence is we are a large health system, and I think that's part of why-- I get a little flustered when people say, oh, real care here is horrible. I'm like, actually, it's pretty amazing. We do neurosurgery, trauma, like the stroke, care, NICU.

And it's because we have the resources of being a part of this very large health system that we can do this. Some of our cardiology services that come up tele are actually cardiology physicians that are based in Santa Rosa.

We have endocrinology. If you need to go see an endocrinologist, maybe there's not enough patient population up here that we can have a full-time endocrinologist who lives here. But there is in Santa Rosa. And then they can do the televisits with those patients up here. So we lean into that.

KEITH FLAMER: So it sounds like it's a dual problem. One, you have-- what you've just talked about is you have a supply problem for doctors and other services. But it also sounds like we have a narrative problem, is that we don't know how to speak well about ourselves and say, we're actually not that bad, and here are the reasons.

MICHAEL KELEMAN: Yeah, and part of that, I wonder if it's because it's been over so many years that maybe COVID-- and there was a huge exodus in health during COVID, massive exodus, across the country.

And if you talk to people about the physician shortages and everything that's coming, I would say that we probably felt that more here. I wasn't here, but my guess would be you felt it more here than I felt it where I was before, because, as I mentioned, we have very good quality care.

I have a subspecialist. I have a gentleman, for example, who does robotic thoracic surgery. I have a vascular surgeon. But there's, like, one or two.

KEITH FLAMER: Oh, I see what you're saying. And so if you lose one, then you lose--

MICHAEL KELEMAN: Very detrimental.

KEITH FLAMER: Got you.

MICHAEL KELEMAN: And now we're back on the recruitment thing. So let's take vascular. I have two people in this community that can do vascular surgery, Dr. Michael Palmer and Dr. Huy Trieu. Great.

If one of them right now says, I got to go, how many thousands of lives was that person taking care of? Knowing that recruitment could take six months, a year--

KEITH FLAMER: Or more.

MICHAEL KELEMAN: Right?

KEITH FLAMER: Yeah.

MICHAEL KELEMAN: OK, but you can't recruit while they're here, because if someone comes and they go, OK, I'm a vascular specialist, I go, OK, well, you're not going to be very busy.

KEITH FLAMER: Because you already have that.

MICHAEL KELEMAN: I have enough for two full-time.

MOLLY BLAKEMORE: So the gap, yeah.

MICHAEL KELEMAN: How do I do that? And that's the challenge.

MOLLY BLAKEMORE: So we usually start with this, but I've been curious-- where did you come from, and how long have you been here, and tell us a little bit about your background and--

MICHAEL KELEMAN: Very magical place. No, so I was born in the Bay Area. That's my home. It will always be my home, although this is the second-largest bay in California, I found out. And this reminds me of home when I was a child.

KEITH FLAMER: Is that right?

MICHAEL KELEMAN: Very much so. If you think of the Bay Area back in the '80s, Eureka's Oakland. It's got that Oakland artsy vibe, very free-spirited. You're on the water.

KEITH FLAMER: OK.

MICHAEL KELEMAN: Arcata is my Berkeley. I don't know if Fortuna is, but I like Fortuna, because no one judges me in Fortuna.

[LAUGHTER]

I don't know what that is in the Bay. But anyway, so that's my home. And then I was going to go into medicine, and I decided not to, and then I studied business instead. And so I did my undergrad at UC Davis. So I spent some time up there.

And then I did my graduate at USC in Los Angeles. So I'm a fellow Trojan for anyone out there throwing a V at me right now. And I've tried to experience as much as I could.

So I've worked at Sutter Health. I've worked at Scripps, John Muir, Stanford. Tenet-- I did for-profit for a while, which was actually very educational.

KEITH FLAMER: That's interesting.

MICHAEL KELEMAN: It was really educational to understand how to really look at the business of health care. The for-profits really have that dialed in, and they're very good stewards of their resources. There's one more in there. Oh, and Kaiser. I was at Kaiser for a little while.

KEITH FLAMER: Oh, you got Kaiser.

MICHAEL KELEMAN: Yeah, and that was really interesting because that's what taught me-- that's the thing I talk about. So remember, hospitals don't employ physicians. I find in a lot of places the ambulatory network in the acute setting, the hospital setting, they have no idea what the other one does. They really don't. They think that one's more important than the other, and they don't understand the interdependency.

MOLLY BLAKEMORE: And by ambulatory, you mean when you're walking--

MICHAEL KELEMAN: The outpatient office.

KEITH FLAMER: Outpatient office.

MICHAEL KELEMAN: Yeah.

KEITH FLAMER: Got you.

MOLLY BLAKEMORE: You're walking into an office, and you have an ailment, and yeah.

MICHAEL KELEMAN: Exactly.

MOLLY BLAKEMORE: You're not going for urgent care or emergency care.

MICHAEL KELEMAN: Yeah. Kaiser. They get it because that's their model. Kaiser is a gym membership. They want you to pay the insurance and never go into the hospital. So they're very, very good at that ambulatory outpatient work.

And I learned a lot from them. I learned a lot on the interdependency of an outpatient care environment in a hospital and how they really should work together. And that's kind of what we're doing here.

The difference, though, is imagine having a network that is fully integrated, communicating, coordinating your care, but you still have a choice. That's the one shortcoming I have found with Kaiser is it is hard for you to dictate your care. You may not agree with what's being told to you. You may not appreciate your physician and talk to another physician.

You don't have that choice a lot of times in the Kaiser model. But imagine if you did. That would be really cool. You go, OK, I appreciate your opinion. I'd like to go see another neurologist.

Great. You can. We'll get that coordinated for you, and all of it's being communicated with your primary care. That'd be amazing.

MOLLY BLAKEMORE: So how does Kaiser get around the not being able to employ the doctors and the ambulatory doctors?

MICHAEL KELEMAN: I'll be careful here, but--

KEITH FLAMER: Be careful on this one, Michael.

MICHAEL KELEMAN: Kaiser is actually three different entities. They're the trifecta. They're an insurance product, they're a Permanente Medical Group, and then they're the hospitals. The relationship there is that triangle of how they all integrate, and they're all under the one umbrella parent company. That's how they're doing it.

KEITH FLAMER: I'm going to zoom out a little.

MICHAEL KELEMAN: OK.

KEITH FLAMER: Lots of conversation about health care on the national level.

MICHAEL KELEMAN: Yeah.

KEITH FLAMER: So let's say, Michael, that RFK resigns, and Trump calls you to say, hey, I need a new Secretary of Health and Human Services. And he says, OK, Michael, solve the problems of national health care. What is your answer? How do we do that? And really, what do people--

MOLLY BLAKEMORE: It's a real softball question.

KEITH FLAMER: Well--

MICHAEL KELEMAN: Just to be clear, I'm going to get a phone call from Donald Trump. That's cool. I'll record that one.

KEITH FLAMER: Because I don't know if people understand where are the real problems with national health care. Where should we be as an industrial nation that we are? What is important to us in your mind?

MICHAEL KELEMAN: So I'm going to answer this. This is my opinion only. This is not a reflection of Providence. I don't know if they agree or disagree, but I'm just going to say my opinion.

KEITH FLAMER: Absolutely, absolutely.

MICHAEL KELEMAN: So I'm not opposed to universal care. I'll just say that right out the gate. I'm not at all. And I'm going to use an analogy as an airline. And some people are going to hate me for this, but--

KEITH FLAMER: Oh, I can't wait to hear it now.

MICHAEL KELEMAN: So I think everyone deserves the right to be able to get on the plane and to get safely to the next destination. Everyone deserves the right to access care, period. I do trouble it a little bit when we talk about is that Medicare or Medicaid, because I'll tell you right now, those do not cover the costs of health care delivery in this country, which, again, people travel from foreign countries to get into the access that we have.

So again, Medicare and Medicaid is a problem that we need to talk about. How do we actually make sure that these hospitals and this health care environment is actually solvent? And there's other variables to there-- device, equipment, technology, pharmaceuticals, insurance. There's a lot of drivers around health care costs.

But back to the plane, everyone should get on. That's called economy. You might be in a patient room where you might have maybe three, maybe four partners with you in that room. But you're getting the same doctor. You're getting the same diagnostic equipment, the same surgical abilities. It's the same. It's high-quality care.

Now, let's say there's people out there that have the means, and they want to be able to pay a premium. So now you're going on to economy plus or business or first-class. You're all still getting to the same destination. You're all still getting there safely.

You might have a private room. And it might be a nice little room with Netflix, and it's streaming, and all those beautiful things to make you feel comfortable on your own.

KEITH FLAMER: Sounds fun. OK, got it.

MICHAEL KELEMAN: Here's the care part. At the end of the day, both the person in the room with four people-- and I'm not saying for sure four. I'm just throwing it out there.

[LAUGHTER]

KEITH FLAMER: It's just an example.

MOLLY BLAKEMORE: There's economy.

MICHAEL KELEMAN: No one in our hospital is sitting with four people, just to be clear. But imagine the person in the room with three other bunkmates and the person in the private room getting a glass of champagne or whatever-- same doctors, same care, same surgeon. Everything's the same.

The only difference is the amenities, the comfort. So why can't we as a country go, look, you all deserve access? You should have access to primary care. Let's be real. Outpatient care, that's not the most expensive thing.

You should be able to see your primary care provider. You should be able to see your specialists. You should be able to get all that taken care of. If you get into a hospital, though, now we got to talk about that.

Are you under the economy, where you just get the government plan that's provided to you and you're good with that? Or, no, I want something a little more special. I want more comfort. Great. Then you pay for that.

That's where I think we have the imbalance, the way the system works right now. And it's been referred to as the hidden tax. So people say, well, I'm not going to pay for someone else's health care.

But you do. And the way that happens is to cover the costs that we lose for Medicare and for Medicaid. We go to Blue Shield. We go to United. You name a commercial insurance plan.

Ask yourself why your premiums at times--

KEITH FLAMER: Keep going up.

MICHAEL KELEMAN: They spike sometimes.

KEITH FLAMER: Yeah.

MICHAEL KELEMAN: They're spiking because we're having to go back to the table and negotiate. I would also say you need to ask yourself, why do you-- when you walk into a hospital-- and I have a nice hospital, and I've experienced some that are much nicer-- walk into a hospital that has a piano, grand piano, it's beautiful, whatever aquarium type of tank with bamboo in it, and ask yourself, how does that help you get better and get healthier?

I don't know if it does, but it's beautiful. It's also extremely expensive. And so just know that when we're going to the insurance companies, we need to negotiate those rates. And that's where the commercial part is kind of that hidden tax. So it's going up.

You're also paying for-- and this is why preventative medicine is so critical. If you go to St. Joseph, and let's say you just go in because you have a cough, and you leave the ER, and you have the best experience. Everything's great. 10 minutes or less, you saw a physician. You go home.

You're going to get that bill, and you're going to be very upset because you got that bill. But you have to understand that you went to a hospital that I am paying for trauma surgeons, neurosurgeons. These people are on call, 24/7, 365, because that hospital is meant to be there to save lives.

So how do we create a robust ambulatory network that helps you live a healthier life so if you're going to the hospital, you're going to the hospital because you really need to be there?

MOLLY BLAKEMORE: I just heard a story about someone who had very good insurance through their work, but they had twins who had to be in the NICU, both of them. And the bill that she saw that she didn't have to pay was over a million dollars. So how--

MICHAEL KELEMAN: [CHUCKLES] I'm laughing for different reasons, not because-- yeah, I'll tell you why.

KEITH FLAMER: I'm just curious why you're laughing, but OK, go ahead.

MOLLY BLAKEMORE: I mean, that was outrageous to me. And no one can afford that. And I understand the costs that hospitals have to employ all of the specialists and that people are traveling here to get the best care. But that still seems outrageous to me.

MICHAEL KELEMAN: She didn't pay that, just to be clear, right?

MOLLY BLAKEMORE: No, the insurance paid it.

MICHAEL KELEMAN: Yeah. So I'll clarify that for you.

KEITH FLAMER: OK.

MICHAEL KELEMAN: Welcome to the complexity again. So you go, how do I fix it?

KEITH FLAMER: How do you fix it?

MICHAEL KELEMAN: This is why there needs to be a baseline. So it's different. Every contract negotiation is different. And I'm not the expert in this. But from a high level, this is how it works with commercial insurers.

They pay you based on a percentage of your gross charge.

KEITH FLAMER: Explain that one for us.

MICHAEL KELEMAN: So let's say I say, hey, this costs $100. They go and they say, we're going to pay you 25% of gross charges. You're capped at blah.

That means for every $100 that actually something costs, they're only going to give me $25. So guess what I got to do to make up my cost?

MOLLY BLAKEMORE: Jack up the price.

MICHAEL KELEMAN: Four times.

MOLLY BLAKEMORE: Right.

MICHAEL KELEMAN: That's why, when the government is trying to do this price transparency-- again, very well intended-- not the right model, because if I just show you what my gross charges are-- and to be completely frank, they're almost meaningless, because if you look at gross charges across hospitals all over, they're all over the place.

Why? Because the way they contract with private insurance is all over the place. It's different by every hospital, every health system. Some are we pay you a daily rate. Some are a percentage of gross charges. You don't know.