This session provides a healthcare industry outlook, including environmental pressures and opportunities, measures of success, federal and state advocacy updates and an overview of some health improvement efforts underway in Missouri.
OK. So um when Brandy first contacted me about coming to do this, uh I was offered, oh, gosh, I'm an opportunity to kick off the morning with you all and I kept trying to make it sort of a shorter period of time and take some of the pressure off. So when you hear me talk, you realize that was, that was good for both of us. Um And now I'm here this morning, there are a million things I wanna talk about in about 35 minutes. So we're gonna try and go really fast. I want the opportunity to drill down a little bit. Uh But first I want to express my affinity and I'm gonna go ahead and say it even though it's a little weird uh sort of my love for each of you. Um I was a hospital administrator in my hometown for 11 years, for 11 years before that. I worked at Cerner. Um I got to do a lot of fun things at Sir Anne, I'm sorry. Right. Um And truly, um but, but here's the deal, 1998 I was, I was going through um my orientation at Cerner and Neil Patterson, the the founder chairman, Ceo of Cerner was talking to us to e as human had just come out, right. So we were sitting there focused on how we as a health care information systems company could help save lives, right? And, and we talked in that session in 1998 about the the equivalent, you know, 44 to 98,000 was the number of people who die of avoidable medical errors in, in American hospitals every year. And that a 747 flying into a mountain every day and all these things. And he's, and you know, it was a time that a lot of us, you know, Cerner had tried hard to recruit us. They've been very nice to us to get us in the door and now Neil's standing up there and he says, you know what? You're damn lucky to be here. You are damn lucky to be here. You could be starting work today at a company whose future success depends on convincing the Chinese to develop a taste for sugar, flavored carbonated beverages. And instead you're starting work at a company that's gonna save those people. Why statements are pretty important and pretty good. And man, he had me, right. I was hooked and I was at Cerner for 11 years. I got to do some really cool stuff for a little while. I was dispatched to help staff, um, a rand corporation study of what the widespread adoption of electronic medical record systems could be that ended up with a health affairs article which ended up leading to meaningful use. I'm sorry, except we had to do it right. We had to think about where we were in 1998. We had to be able to structure and store and study all of this information. We had to have work flows that would help people systems that help people do the right thing. We had to do the hard work and it was hard and it still kind of stinks. Usability is really tough. But here's why we had to do it when I was staffing that I got to work with a guy who chaired it. His name was Doctor David Lawrence. Doctor David Lawrence was the CEO of Kaiser Permanente at the time and he was the head of the steering committee that was guiding this work for the RAND Corporation. And he was also on the board of Boeing, right? So he's a medical doctor. He was on the Boeing board. You talk about manufacturing discipline, all the rest. And he says, so we flow charted this and they were in the process of designing and starting to produce the Boeing triple seven, which is really, it was a leap forward for them. It was really kind of a big deal and they flow charted all the things that go into the production of a Boeing triple seven. And he said it's roughly the equivalent of the complexity and decisions and variances of one unit of hernia surgery. Right. The simplest sort of same day surgery that we do. He said when you start talking about what has to be monitored, what you can control, what you can't control how responsive you have to be, how your systems have to work, how you detect things are going wrong. He says, yeah, producing a triple seven is about like one unit of hernia surgery. I didn't, I wasn't smart enough or bold enough to challenge him on that. It sounded kind of ridiculous to me. Uh The point is this stuff's hard and so you do have my respect and affinity and love for the work that you're doing to take care of people better. And by the way, I have no financial relationships disclosed, I, I only work for the Missouri Hospital Association which means I work for you. Um This is kind of sad. I wish I had lots of secret financial relationships to disclose this suit is four years old and I would replace it. Ok. Mh A what do we do? So, first of all, um I hope you've heard of us if you haven't, it's ok. Um Missouri Hospital Association is 100 and two years old. It exists to do this. Whoa No, that's not what it exists to do. It exists to do this, right? Produce hospitals and health care systems. Fulfill their mission. Prove health care community valued. And here's my favorite part is our mission, right? This is what if we weren't here, how would the world be different? We wanna shape an evolving environment that helps our members thrive and fulfill their current and future missions and those are two different things. Our industry is evolving. We we fight like crazy to protect your interests today to bring you programs that help you do things better today. We also wanna help you think about how you're gonna compete and take care of people forever because I say this all the time. It's not always considered politically correct. I work for the good guys. There are a lot of people in health care right now. There are a lot of people chasing the rewards that are attached to health care. And I think I work for the good guys and I'm, that's why I do this right. I, I got, I went home to my little hometown, 2000 people. Albany, Missouri, northwest corner of the state left Cerner to go home and take care of my mom, dad, aunts, uncles, cousins, all the rest in the hospital where I was born, which was really cool and I thought I was gonna stay there forever. And I was on the MH A board for seven years and my predecessor in this role retired and I was getting ready to serve on the search committee. And some people said, hey, if you would have an interest in this, you might actually be a credible candidate. Um And it turned out I was, they didn't cut me in the entire selection process and for the last 2.5 years, um I've been getting to do this and I've, I've done one of these strategic plans now since I got there. And here's what we do. Of course, we do public policy. Nobody works harder on what's happening in the state of Missouri related to health care than our crew does. Uh from a policy standpoint goal two. OK. So 2020 we switch, we switch over and, and yeah, I was ta I was working in a hospital in 24,021 before I took this role. Um We were health care heroes. The world loved us. Rewards were coming. Funding was coming. We were gearing up to do this wartime effort, which was very difficult and awful, but we were held in great esteem and from an industry like an mh a standpoint from a legislative standpoint, we were thinking, hey, everybody loves us. What can we get done? How are we gonna spend the COVID dividend? And by the time I started in October of 2021 the governor was dying to get out of COVID in the public health emergency, which he did against our advice. Two months before the Alacron wave pi peaked, which was the highest concurrent number of COVID hospitalizations in the state of Missouri throughout the pandemic is February 2022. There was no COVID dividend, there isn't a COVID dividend, right? People sort of appreciate what we did, but mostly they think we were complicit in a pandemic, which is really tough. So we're gonna keep working on engaging our members to, to build support for initiatives that strengthen all hospitals and build trust with policymakers and the public and being credible and telling the truth. Uh I is part of that, we have tremendous moral authority. I really do work for the good guys. My favorite of the three goals and I'm not just saying this because I'm sucking up to you guys because I'm here this morning. Is this one, enable a healthier Missouri by advancing health care. It's accessible, reliable, equitable of expert quality and value in safe and appropriate settings. When I was a hospital administrator, my first four years in Albany, we were an independent critical access hospital. I had 100 and 40 people running a full service hospital end to end. Um Our administrative team was six people, right? Um And we leaned heavily on mh A. So we found out that our quality wasn't very good when we started to participate in the hen the hospital engagement network and then the hen that followed it and other things we learned a lot about ourselves by engaging in statewide cohorts and taking advantage of expert resources, many of which were developed in places like this. So, thank you. This is what we do is we try to make sure we drive forward the quality of care in the state and the safety of care in the state. And then of course, we want to be good stewards of all these things we're given. Ok. So there's a little bit of background. Um, this is a big room, so I'm gonna try my best to do some interactive stuff here. I wanna set the stage on macro environment, macroeconomics of the American health care system really quickly because we got some other stuff we need to talk about and I successfully negotiated for not that much time in 2020 us health spending eclipsed $4 trillion in 2023. That number went to $4.5 trillion. How much is a trillion? All right. Does anybody here have a phone? Somebody take out your phone, please? This is the interactive part, but it's only with one of you. You're gonna be my favorite. Does somebody have raise your hand if you have a phone with a calculator function? Here we go. Type in. Yeah, I know, I, I didn't warn you about the calculator function until late. OK. Type in, in the calculator 6 million. So that's a six with a whole bunch of zeros like six of them type in two or multiply 6 million by 2024 which is what year it is right now. 2, 2024 this year times 365.25. It's a leap year. So I, I've thrown in the 0.25 as we do this today. I am super super cognizant of leap year right now. Can you tell what that number is or does it kick out like the little E 12 thing on the end? So what is that number? It's about $4.5 trillion if on the day Jesus was born and I'm not asserting the divinity of Jesus. I'm just saying the historical figure here, Jesus of Nazareth. If on the day he was born, you put $6 million in a box and every day since then you put another $6 million in that same box, you still would not have $4.5 trillion. Yeah, I like that one too. That's a lot of money. Guess what? There are. What do you think that just hang with me? This is for everybody. What do you think is the approximate gross domestic product of Germany and Japan? That number guys, the US health economy is the size of Germany's economy. Germany is pretty good at economics and producing things. The US health system is massive, 30% of that is spent on hospital services. 20% of that is spent on physician services and and other professional provider services. So half of it goes to direct provision of care by the hospital segment by docs. Ok. It's a big number. We spend, you guys know this part, right? We spend more per capita, 16,000 some dollars for every American. We spend a lot more per capita than other industrialized countries and our outcome measures aren't great. So, here's what else is going on? People don't like that. Shocking. Right. Hey, wait a minute. We're spending 2 to 3 times what they're spending in other countries. We're not getting better outcomes. We should do something different. Let's blame someone who should we blame. Let's blame the incumbents. That's us. And there are a lot of people out there from a policy standpoint and a business standpoint who sense an opportunity here and that's what we're gonna talk about. Um, sometimes our organizations like to borrow money by issuing bonds, right? People buy bonds, they buy them because they think they either have a really good chance of getting paid back, which means they might be willing to do that for a lower interest rate or they wanna speculate, they wanna buy a bond in something that's risky. That means they expect to earn a lot, a higher rate. When your bond rating gets downgraded, you have to pay more in interest to borrow money through selling bonds. Lots of us sell bonds to raise money for things. And the people who rate bonds for nonprofit health systems don't think we're a very good credit risk as an industry and this has changed it changed in the middle of COVID and it isn't rebounding very quickly. Fitch still has us at deter uh had us a deteriorating now. It's a negative. Um Moody's has gone from negative to stable this year. Congratulations on your stability and here's the big one at the bottom and you just gotta say it, investment of health care from outside of traditional competitors accelerating quickly and they're not buying hospitals. Guys, Amazon didn't buy in hospitals. Apple didn't buy in hospitals. United isn't buying hospitals, but somebody's gotta do this work that you guys do. We're the good guys and when they need us. So lots of people are betting on primary care. I'm gonna start going faster when you think about this. Ok. So who pays for care? Well, governments pay for care. They get their money from taxpayers. So we all do employers pay for care for, for insurance in this country in a way. It's very different from all those other countries and employers have to compete on a global scale and they don't like spending all this money and, and the federal government doesn't like spending all this money. So they don't, they ratchet down what they pay us. We collectively don't make money providing care to Medicare and Medicaid beneficiaries and that's a huge percentage of the people we get to care for. So we're trying to hang on, we try and make up that money somewhere else. Where do we make it? Up, we make it up on people who have private insurance that private insurance comes from. Employers, employers are competing on a global scale. Other people are doing it cheaper. Do you see the problem? And you also see the opportunity, there's 4.5 freaking trillion dollars being spent and people are coming after that and we gotta know it. One of the things that the government, the federal government has decided to do is they said, let's push people to Medicare advantage. Let's get them in Medicare managed care. And then we're gonna hand money to Medicare managed care companies and their job is gonna be to beat the hell out of hospitals and health systems with prior often and denials so that they get their money, they make 15% and we struggle to make a profit and that's the deal and guess what, Uncle Sam's taking it and you can act like he's not. But Uncle Sam's taken it 12 million people in Medicare advantage in 2011. It's now, I should have updated this slide. It's now, well, over 30 million, over half of Medicare beneficiaries now have Medicare managed care that and that's true in the state of Missouri as well. Um And if you think Congress is gonna get anything done. No, they did yesterday. They did yesterday. So we were gonna, we're gonna close the government right now. We're not gonna close until next week. How are health providers doing financially Well, what's your definition of health providers? Hospitals and health systems? Pretty good chunk, but not all right. So we're gonna go through some data from Kaufman Hall. I got this from Ruth Lew. He, no, seriously, he's really nice to us and he said, hey, we, we do business with Kaufman Hall. Maybe they would give you some slides and they did, um, I'm gonna show you some stuff here in just a minute. But before I do, United Health Group just posted its earnings for 2023. They did, ok? Um that operating cash flow of $29 billion they earned $23.86 per share. They posted a 6% operating margin. Now, when I think about who our competitors are, man Optum, right? Wholly owned by unitedhealthcare has been putting together a different sort of delivery system for the last 20 years. They haven't lied about it. They've been very straightforward. They've acquired a bunch of stuff. Ok? Here we go again. Audience participation. But I'm not making this too hard. I kind of just gave you the answer. Who's the largest employer of physicians in the United States? Boom. How many hospitals they own? Mm, no, maybe we're in the wrong business. Pharma. Whoops, I did it again. Pharma 20% is, is. And so let's do market cap, market cap is the value of all your shares times the price of your shares, right? We start thinking about who's big, you think, man HC A is a pretty big health system in this country. That's their market cap all the shares of HC A times the price. There's United, that's pretty big. There's Amazon and there's Apple. What do these guys have in common? They're all in health care. Take out your phones. If you have the Amazon app. Open it, please. I forgot to say please. I'm like a super nice guy. That's my shtick, please. Jessica, is that true? It is my stick. Yeah, Jessica works for Mh A fortunately for you, you get to listen to her very soon. Top banner of the Amazon app home page. What do you see medical care? Did you know that was there? Uh What did you learn from John Medical Care is on the Amazon app. You know what Amazon likes to do? Make money, you know what they're really good at doing, connecting with your patients before they're your patients and after they're your patients, what Amazon Clinic? That's weird. So here's the other part that's going on and this is gonna sound like whining and I'm sorry, but these are the facts operating margins. Our organizations have to generate margins. So we have money to reinvest, right? They don't have to have crazy margins, but that's where we get our money to reinvest. We also have to meet payroll, do all the other things, expenses, margins are in net income over expenses, right? Our expenses go up our net income doesn't that's bad for margins. Here's what happened. 2022 was the worst record, worst year on record for hospitals and health systems in this country. COVID stuff was going on. Cares. Act was happening then it wasn't Omicron hit here. Remember we just talked about that Omicron hit right here. What was different about that from previous waves of COVID hit the whole country at the same time, you couldn't take nurses from New York to Houston to Seattle, to Indianapolis, to Missouri over a period of four or five months, it hit everybody at the same time. What happened to wages? What happened to the demand for, um staffing? It went crazy and, and, and look, it's good for a lot of us, right. It, it elevated wage levels for the people sitting in this room. And I'm not ever gonna say that doctors and nurses don't deserve what they get paid. But this is a reality is that organizations had to figure out how to pay people more. A lot more on an hourly basis in a short period of time and then it kind of leveled out. But here's where it still is the new normal. On average hospitals and health nonprofit hospitals and health systems ticking along on average at barely positive financial results. You don't get to survive for very long like that and you sure as heck don't get to invest in the new technologies that make care safer and better. It's a problem now, it has gotten a little better and there are exceptions to this. This is an average, there are organizations that are doing better, but this is the reality that we face as an industry. Missouri Hospital Association has 100 and 39 hospital members in the state of Missouri. My old hospital is one of those members and BJH is one of those members. They have one thing in common. They both have the word hospital, right? Um So very different and very and, and mh A tries to be different things for different people. It's intentional customization, it's design. It's why when I showed up this morning and somebody had mentioned that I like diet Coke. I got a liter of it like thank you. Um Labor shortages have disrupted the industry and there's not a lot of end in sight. Um And that hurts our capacity as a segment. Um So what's happening? There's, there's just a remake of the industry and again, who did well during the pandemic while we were busting our butts to figure out how to staff and get stuff, Doctor Lynch, right? Every day we were showing up going. What are we gonna do? Pay whatever it takes, take care of these people. This is what happened to Walmart and Amazon and CV S regarding their revenue growth during those years. And hospitals were fairly flat. It's kind of a problem because our competitors got stronger they banked money and they didn't have the same societal obligations during those years that we did. So there are people bucking the trends if you wanna go be in a high growth uh, area and, and you got, you know, it's great when you can take care of a lot of people who have private insurance. That's not our lot in life. Always in the state of Missouri particularly. Um, and people are trying to make good expense management decisions. They're, they're trying to create value. They're trying to do things differently. I'm gonna fly through this but here's the other problem. Remember I talked about that COVID dividend deal. People don't love us and it's not that they don't love you because they do, they love nurses, they really appreciate doctors, they appreciate health care workers on an individual basis, but they don't think the health system in this country is doing a very good and affordable job. Now here's, here's another thing that's interesting about this. Who do they trust to fix it? What kind of nobody? But if they trust anybody, they know we're the good guys. They want us to fix this? Cool. So what are people doing? Well, one of the things they're doing is they're trying to get bigger so they can do things at scale, they can buy things cheaper, they can leverage systems, there is consolidation in the industry. Does anybody here know anything about that? Just checking. Um I will say this and, and I know not everybody in here is from BJC. I know there are folks here from SSM. I know, I hope there are folks from other places. I forgot to ask at the beginning. Is anybody here an investigative reporter? Ok. Like they would identify themselves, right? It's a Simpsons joke. It's one of my favorites. Um So lots of consolidation and I think we probably expect more and I will say to have strong Missouri based, I keep screwing up the clicker, strong Missouri based systems as a part of a national change. Um, is a really good thing for Missouri Hospital Association. I think it's a really good thing um, for, for the state and, and for you all frankly, um, there are people, I'm not one of them, there are people who think we'll get to a point where um, we follow sort of banking and retail in some other areas and you have a few national players and everybody kind of works for one of them, by the way, one of them would definitely be united. Um No, they would. Um So, so we'll see what happens, but this is what some people are doing. Ok. So there's the macro bit, the federal bit I'm gonna fly by because I'm actually not expert in it. Uh They kept the government open for a little longer. There's a lot sort of noise. Um, there's not a lot of substance going on. Everybody's waiting to see. Um, which of the really old guys that no one likes are gonna be our next president from a, from a regulatory standpoint. Um This is bad news because our costs continue to go up pretty quickly. And medpack Medicare payment Advisory commission makes recommendations to C MS about how much they should give us a raise from year to year for the work that we do and they don't want to spend much on us. So they look at us and they say, hey, you're too expensive. Do better. United, here's some money, you know, it, it's, it's really interesting. Uh, but this is what the recommendations are for, for moving forward. So we have to live within these means. We have to buy the things we need, do the work we do. We're already at low margins. We know our costs are going up and this is what we can expect in regard to reimbursement. I'm gonna skip through some of the rest of this because I'm not even halfway through my slides and I've got 10 minutes and I thought, I, um, ok, what's happening in Missouri? Missouri is a mess at the moment from a, a sort of civility and process standpoint. You know, we have a house, we have a senate, um, leadership was consistent from year to year. All these people came in with good intentions. They were gonna have more civility and then the freedom caucus showed up and decided, um, we're gonna kind of wreck stuff a little bit. So there have been a lot of Filibusters. There's been very little substantive legislation. We don't even have a budget yet out of the House to go to the Senate, which we usually would. Um, it, it, it's a lot of infighting because it's an election year and almost everybody's running for a statewide office and, and there's just, and so no investigative reporters, no senators in the room. Ok. So here's the really interesting part. And if I don't get some of my slides, it's ok because you got this part, we've seen this thing at the national level and now the state level where traditional norms and mores the kinds of things that the culture, right? How we do what we do, which is what you have to manage if you want to improve patient safety and care quality. It's a really hard thing to change. We've seen an erosion of what was sort of traditional statesmanship, civility and we've seen at the national level and we've seen at the state level and you got two houses, you got the Senate and you got the House of Representatives and the House is a much larger body. I'm starting to get the hang of this clicker. The Senate is a much smaller body. The house is more sort of the passions of the people and, and, and the Senate is this body that's supposed to be very deliberative and it has rules about things like the Filibuster where one person can stand up and say no, I oppose this bill and nothing's gonna happen until we work through this and either compromise or lay it aside. It's hard to get stuff done by design. What I am worried is happening right now in the state of Missouri is the House application of the Missouri Senate and this is not, this doesn't mean I don't like the house. I love the house. They're, they're very functional. They're a little more orderly. They get stuff done, but there's supposed to be two bodies that do things very differently and you're supposed to have to compromise. You're supposed to have to listen. It's not just who has more votes today and what's happening in the Missouri Senate right now is you have a faction that just wants to say this is what I want. Damn, the torpedoes. I'm a fighter and we lose this idea of statesmanship and civility and relationships and compromise that we all love, but we don't vote for, we get what we deserve and you and I are not electing people who care about civility and decency. And until we start, we're gonna, if you, if you do what you've always done, you're gonna get what you've always gotten. There are primary elections coming up in Missouri in August, you would have told me if I remember to do this crowd participation part that election day is in November and you're not wrong, but in a highly gerrymandered and right leaning state, all of these things actually get decided in the primaries in August and you know what, we collectively don't show up and vote in those and you better start or we're gonna get what we've always gotten. Now, there are some issues. We are working really hard. Budget environment is good enough in Missouri, there was a whole bunch of COVID money. We've got money in the bank. The budget has historically high levels that's gonna change because we did a lot of tax cuts. Revenues are not gonna continue growing in the state of Missouri. And so there is a sense of scarcity, but right now there's plenty of money. But you see general revenue collections during the pandemic when there was a lot of federal money were way up and now they're leveling out. So we got a $50 billion budget. There's still money in the bank to go do things we need to do. One of the things we need to do is spend money on the Medicaid program that lives in the Department of Social Services. So Medicaid is a pretty big part of what the state of Missouri buys in its budget. Education is the other really big part. Total state Medicaid budget has gone up right now. We're going through this thing called red determination. Nobody got, nobody left the Medicaid rolls during the pandemic. Now people are having to prove that they're eligible again. So the number of people on Medicaid are going down, that's by design. Some of those folks are eligible for other care. What we don't want to do is have people who should be on Medicaid leave Medicaid and we're in the middle of this fight right now and, and all of you, I hope in some way are working to make sure that people who are eligible for Medicaid are getting it when they come into your, into your care settings if they don't already have it. But that, so enrollment's gonna go down and the spend is gonna go down and the state can afford it. That's on the money side. Um, again, written close to time. Wait five minutes, boom. Ok. We're gonna talk about a couple of things. Pharmacy is, is kind of our top legislative priority, particularly the 340 B program. There are lots of hospitals who are eligible for this who share in those benefits. It doesn't cost the government anything. We're fighting with insurers and Pharma. Um, things are moving pretty well on that front. We've had really favorable hearings in both houses and they're both noticed up for a vote next week and if we get this done, it'll be our home run for the year. Um, if you can help with that advocacy, we appreciate it. It also included in that is a prohibition on mandatory white bagging if you know what that is. Um, you know, that it's dangerous and it's purely a financial move, uh, by insurers to keep more of the money that we should be getting for mixing drugs and taking care of patients. And so we're trying to prohibit mandatory white bagging again if we get that done. Um, my team will have had a good year. There's a lot of other good stuff going on and what I really wanna get to in my last five minutes and I had some other good slides, but they don't matter as much. Um I really wanna talk to you while I'm here gathering information. One of the things that we're opposing and this is gonna sound counterintuitive is a bill that has come from a Saint Louis area representative related to assisting with workplace violence issues. OK, so Representative Justin Hicks has put forward legislation and it has a lot of parts. Um but essentially what it would say is any nurse who feels like a patient poses them a threat can refuse to care for that patient. It would say that organizations cannot mandate training in restraints and holds and de escalation techniques. It would do a lot of things that are designed to put nurses much more in the driver's seat in regard to workplace violence of patient safety. And I understand it. I understand it logically. I also understand it because my oldest daughter, um one of the loves of my life is a junior in college who started clinicals last month. She's working in a, she, her first assignment was in a pediatric um behavioral health facility where she got to spend time on the inpatient and then in the crisis ward. And then on Monday, she's really smart guys, good nurse. Um She was one of two people in her cohort who got to work her first shift in the emergency department on Monday at an urban hospital in Florida. I love my, my whole job is take care of people who take care of people. I was a hospital administrator in my hometown for 11 years who absolutely rejected the doctrine that a nurse is a nurse, is a nurse. I love, love, love individuals who dedicate their lives to caring for people. I don't know what to do about this. From a legislative standpoint, we already have enhanced penalties in the state of Missouri for violence against a health care worker. We probably need to try to ratchet that up. We already are able to get some funding for grants and other programs to harden your environments, but we still wanna help you have loving caring environments, right? People don't need to feel like they're walking into a prison when they go somewhere for care, but we have to keep folks safe. So what I'm searching for is the unified theory on workplace violence. What can we be for? Because I'm against this bill. It would, it would cause impala problems, it would be a, a lawyer's dream and, and we can't have that. But what can we have, what would you like to see from your government? And I'm your advocate there or what would you like us to teach and spread around Missouri hospitals? Their best practices related to workplace violence? And we've got about two minutes. Somebody help me please. Civility. Of course, I'm preaching it. But, but how do we enforce it? Yeah. So, is that signage, is that training for staff? Is it, is it um more people to enforce proper behavior? And I mean, like these are real things. What can we do? What do you want us to do? So you cool. Live in save Illinois. Yeah, its that we have in our region outside the house. These patients are coming to us, they get, get the love, they need the resources they need and the minute they need right back into the same. Yep. What is this best? Awesome. So I was on a slide here, increase in reimbursement for developmentally disabled patients or clients of D mh. But also other asks for other parts, nonhospital parts of the, of the state. Um When we get a new governor in 2025 our current governor is termed out the case that we're building is a revised investment and in public health and also in behavioral health infrastructure in the state of Missouri, the state of Missouri got out of the uh behavioral health business. They privatized for a while. Things were being funded to build up community providers. Times got cut, times got tough that funding went away. The bank shot that I want from N mh A standpoint is we make things better for hospitals and health systems by getting the government to give money to somebody else and then we have relationships. So the Department of Social Services Department of Mental Health, which includes children's division in here And then health and Senior services Public Health Agency are all working collectively on a plan that gets funded to try and build more capacity outside of us. And I want the new governor to have that as something he talks about in 2025. That's it. That's our answer and it's tough. But that's, that's what we're trying to do, right? I don't want your money. I want you to give it to the people who should be caring for these folks so that there are places for us to send them. And in the meantime, I need some money to help reimburse hospitals for what they're doing to care for them today. I think I'm at time I would have, I would have loved to. I, I was a bad negotiator who was a good negotiator. You will like the next presentation more.
