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Good afternoon and welcome to the City Club of Cleveland, where we are devoted to conversations of consequence that help democracy thrive.

It's Friday, April 24th, and I'm Eric Fiala, chief corporate responsibility officer at KeyBank and CEO of the KeyBank Foundation.

It's my honor to introduce today's forum, which is part of the City Club's Health Innovation Series.

This moment is especially meaningful to me as a board member of the MetroHealth Foundation.

I've had the chance to see up close what MetroHealth means to our neighbors and neighborhoods.

I'm also proud that the KeyBank Foundation has partnered with MetroHealth to create Opportunity Centers at both the main campus and at the Buckeye Health Center.

Just this week, KeyBank announced a $1.5 million investment to help MetroHealth and its partners continue to deliver wraparound services.

This investment is important because we all know that the support people need doesn't end when the appointment ends.

It is a privilege to be here today and welcome Doctor Christine Alexander-Rager president and CEO of the MetroHealth system.

As a young girl, Doctor Alexander had dreams of becoming a doctor and since then has been on call.

See what I did there?

Been on call for our communities, she would end up serving as a physician with MetroHealth for nearly three decades.

And founded MetroHealth's nationally recognized school Health program.

This groundbreaking program partners with the Cleveland Metropolitan School District and other school systems to bring in school clinics, mobile units, and other services to students and their families.

She also sparked the creation of MetroHealth's medical outreach to people experiencing homelessness, starting in October 2024.

Doctor Alexander stepped into the role as the system's president and CEO.

Today, we will hear more about MetroHealth's progress, challenges, and vision for the future.

Also joining us on stage and as moderator for today's conversation is Emily Campbell, president and CEO of the center for Community Solutions, a nonpartisan, nonprofit policy and research think tank focused on health, social and economic conditions.

Before we begin, a quick reminder for our live stream and radio audience.

If you have a question during the Q&A portion of the forum, you can text it to (330)541-5794, and City Club staff will try to work it into the program now.

Members and friends of the City Club of Cleveland, please join me in welcoming Doctor Christine Alexander-Rager and Emily Campbell.

Thank you.

Well, good afternoon everyone.

And to the audience listening at home and out in our community.

I'm Emily Campbell and delighted to be here sharing the stage today with one of the true leaders in our community.

So, Doctor Alexander, you have spent much of your career at MetroHealth, serving in a number of different roles, some of just a very small slice were touched on in that introduction.

But since stepping into this role, some of us have gotten to know you or got to know you a little bit better.

Tell us a bit about your journey to CEO and the things that influenced you along the way.

Sure.

So thank you.

First of all, Emily, thank you for being up here with me.

Being my partner in crime today, but also just for all of the great work that your organization does for the health of not just Northeast Ohio, but all Ohioans.

So thank you for that.

My journey really started when I was a little tight and, my, my parents, we grew up in a house of faith where we were really, taught to believe in the blessings that we received.

But that those blessings came with that a sense of responsibility to make the world a better place for everyone around us.

And and my, my parents and my extended family.

They lived that every single day.

And I just was blessed to have an uncle, who delivered me, actually, quite by accident.

My my mom said I was just in a big hurry to get going with life already.

And you haven't studied, and I've been in a hurry since, and, And so I feel like medicine just became this very obvious way for me to kind of fulfill that mission that that I was blessed with by my family.

And, and so, you know, kind of all throughout school, it just really stuck with me.

And I kept the focus on that.

And, so picked family medicine is a specialty.

I, I'm a Buckeye, by training.

I'm also a shoe penguin.

So shout out to both.

And and family medicine was really that way that I could take care of all members of the family.

But also, just as you heard in the introduction.

So much of what impacts someone's health happens outside of the office.

And family medicine kind of opened my eyes to how you have to think about the whole person.

The whole family, the whole culture, the whole community.

And so that was the path.

And so went through my training and came to Metro as part of that training.

And it really became obvious that Metro was my home.

This is where I needed to be for the rest of my career.

And so just, you know, became a leader with residency and then a chair of the department and president of the medical staff.

So kind of some of the typical things that you'll see moving up in medical leadership, it just wasn't ever with the idea that the C-suite would be the end game.

That was that was it.

But it is a game which we can talk about a little bit more in a minute.

So, you know, this community in Greater Cleveland is blessed with a multitude of first tier top health systems.

But MetroHealth is different.

MetroHealth is our public hospit How how does that influence what MetroHealth does as a health system?

How you, as a leader of Metro, see the world and how it makes Metro a little different from some of the other health systems in our community?

I really appreciate that question because we are distinctly different, and I'm not sure that the community really fully understands that or engages with the concept of what it means to be the public hospital, right?

You'll often hear Metro described as the county hospital, but being the public hospital brings with it a responsibility to really think about the public.

We think about every member of our community, whether or not they ever set foot in the four walls, that is the hospital or any of our other hospitals or clinics, because we are constantly thinking about the health and safety of the community.

Where are the gaps in the care?

How do we close those gaps?

How do we address the things that we know impact the health of our patients?

And so that big comprehensive picture is really our true north.

How do we impact the health of the community, knowing what we want to create for the community and then back?

Step two now what do we need to do as an institution?

What programs do we need to create?

How do we need to partner with others?

How do we help?

Really transform the health of all those who live in our community?

So they're not just surviving.

They're able to thrive and live their best lives, and then also contribute to the community.

So that's a very unique focus and role.

I try to say that that all the health systems have their focus and have their purpose.

And the best that we can do is to make sure that that we are fulfilling those promises that we make to our community.

So what are the some of the ways that Metro is doing that?

What are some of the things that you're excited about happening at Metro?

So many things.

I think when you think about Metro, you probably think about our trauma program.

You probably think about our nationally renowned rehabilitation program.

You heard a little bit about the school health program that that was one of the things that we realized kids weren't coming in to get their shots, to get their well-child checkups, to have their chronic diseases.

Children do have chronic diseases to get those things managed.

And they were starting to access the air more.

So we said, okay, well, where are our children most at the time they're in school.

Let's get to them.

Right.

Similarly with the patients who live on the street, if we lift up the health of everyone in the community, everyone else benefits from it.

And you may not ever realize that maybe if you have insurance and you have a doctor you've been connected to for a long time, and you enjoy good health by us taking care of folks who live on the street and improve their health.

We improve your health because if you happen to come into an emergency room with a heart attack or a stroke, you'll be able to be cared for quickly and effectively.

But if you have somebody coming in who really had a primary care need, or you have now a lot of people who have primary care needs, they're coming to the emergency room.

They're waiting until something gets to to a crisis level and coming in.

So that has an impact on the ecosystem, right?

So, so just thinking about all of the different ways that we can reach out to the community, we provide care in the jail.

That's a critical piece of the care that we provide.

Because again, when folks come into the jail, they're not coming in because they're having the best day of their life, or right, because they know all their health problems or they know all of their meds.

Right.

It's critical that we provide great care there.

And we also think about where the gaps in the community.

We are opening up a new outpatient health center.

We're very excited about this.

It's on our main campus.

And this again grew out of the Covid crisis.

We were planning to build a building, to really just replace some of our legacy buildings.

And then Covid hit and we had to hit the pause button and say, okay, hold on.

What does our community need now?

A lot more is moving into the outpatient space.

Patients are telling us they want to get care at main campus.

We now need to pivot.

We need to make this a 300,000 square foot outpatient health center that has a 24 hour, seven day a week drive through pharmacy.

Because that's the other thing that patients need.

Pharmacies are closing in neighborhoods.

People can't access their medicines.

We know if we provide prescriptions, even if you are not our patient and we prescribe, we provide the medicines that are prescribed.

The adherence rate and disease control of your chronic diseases improves.

It improves because of the way our pharmacy approaches it, the way they reach out, the way they ask questions and the way they remind you, the way they interact with your doctors and your prescribers.

Right.

It's a comprehensive service.

So I'm very excited about that because I know the community needs that.

If people go without their medications, diseases flare, end up in places you don't want to be.

So there are lots of exciting things happening.

We have our Institute for Hope that does address a lot of the social determinants of health, because again, back to the idea that 80% of what impacts our health, all of us happens outside of the office, visit outside of the hospital, outside of the emergency room.

So we really want to leverage a lot of those wraparound services to say, okay, what's going on that you can't get access to food?

Let's help you figure that out.

You can't get transportation to your appointments.

Let's figure that out.

You have unstable housing.

Let's figure that out.

You need help with job training programs.

Let's figure that out.

You need help in managing your finances.

A lot of young adults, we're finding, as well as middle aged folks, were never taught how to manage their finances.

So how do we lean in and help teach you how to manage your finances?

So those are all the sorts of things that we address through our Institute for Hope, that really, again, we're trying to chip away at that 80% that really prevents people from attaining their health goals.

And you brought up the work, the trauma center and the word trauma.

So let's go there.

I had a feeling we might go there.

Let's go there.

There is discussion.

I will call it kindly call it discussion in our community about, the possibility of another level one trauma trauma center opening up here in Cleveland.

You've been outspoken about it.

Tell us a little bit about your perspective, a MetroHealth perspective on that issue.

And I think this really probably drives home the point that we are the guardians of our community, right?

We are the ones wrapping our arms around the community and saying, how do we make certain that we are protecting your health and your safety?

When you think about medicine in general, you think that competition is good, right?

I mean, doesn't competition push all of us to do better?

Right?

Trauma is the exception to that rule, because it truly is an ecosystem that starts when the person is injured and the emergency medical system kicks in, and they do their triage and evaluation and the way in which they then interact with the trauma centers.

And there are different levels.

I mean, you hear level one a lot, and that means the most complex patients, level two also takes care of the same complex patients, but they don't do the same work around research and prevention and those sorts of things.

And then level three takes care of injuries that are not as severe, not as many body systems, if you will.

Right.

So this ecosystem is very fragile because you need people specially trained to do this care.

Right.

In the emergency room, the emergency room staff, the trauma staff, but the nursing staff, the therapy staff, all of those staff members need to be specially trained and they function like a formula One pit crew.

Right?

If you ever watch them, it is the most incredible thing you will ever see because they will do this work with barely speaking to each other but fully communicating because I know what Emily's going to do and Emily knows what Justin's going to do, and Justin knows what my sister's going to do, right?

Like, everybody knows their roles.

They anticipate it.

They do it boom, boom, boom.

Because seconds and minutes can matter in those situations.

But now if you start to dilute their experience, you open up another center.

Less volume goes to the centers.

We have less opportunity to refine those skills to keep that communication going so effectively.

Right.

And then you start to dilute the talent because maybe talent gets pulled away to other places.

Now, instead of maybe replacing a team member who retires.

Right.

Or somebody who decides, I don't want to do this kind of nursing.

I want to go up to the ICU.

You're replacing a person here, a person there.

The team can rebound easily.

You start replacing a lot of people.

The team can't rebound.

So now you have less experience to work together and you have newer people to the team.

And now you've added in another center that EMS has to figure out.

Okay, wait, what's their protocol?

What's their protocol?

What's their protocol?

I have this person who's critically injured.

How do I communicate?

What do I do?

Right?

It is the ecosystem.

And and so when we're thinking about that and thinking about a new center opening up, there actually are evaluation tools to say whether or not it's needed.

And that's what I've been outspoken about when we need the evaluation to decide, is this needed or not?

Because the population in a community is what drives how much trauma you can expect, and therefore how many centers, you need to be really effective at meeting that need.

Okay, so all about what are the needs of the community and making sure that it's all right sized for for what what we are facing here.

You know, the the other thing that has been in the news a lot and a big conversation is the financial health of Metro You know, it is a business.

You are a CEO is a business.

It is.

And lots of uncompensated care that MetroHealth, is having to address.

And the probability I'll call it a probability that make it worse, not better, is some of the changes to Medicaid go into effect, from federal policy change.

Unpack for us a bit what the uncompensated care means for MetroHealth, what challenge it presents and what you all are doing given those current realities.

Yeah.

So I think this is something not unique to us, but as a safety net hospital, we feel the impact a lot more than other hospitals or health systems that have a large portion of commercially insured patients.

And the reason for that is when patients come in that have no coverage, often the buffer for that is you increase the rates of commercially insured patients.

So you see it gets more expensive, so it gets more expensive for everyone.

So someone who loses their health care coverage, you think maybe it doesn't impact you, but you might have noticed your rates went up for your insurance when you signed up this fall, so that that really is the offset.

When you're in a safety net hospital.

There isn't isn't there aren't as many commercially insured patients, right.

Because we are here to serve the community and by and large, to serve the community that is the most vulnerable.

And those folks tend to either have very limited coverage or no coverage at all.

And so we are blessed to have county support, and we count on that county support to help offset the cost of care for the patients.

But just to give you a sense, last year, our uncompensated care totaled around $360 million, $1 million a day, $1 million a day in uncompensated care.

So just like, let that sink in for a minute.

$1 million a day in uncompensated care.

And the challenge around that was that we weren't fully prepared for it because we had more patients that had Medicaid coverage.

But there was an abrupt change that led to fewer people qualifying for Medicaid, and that has continued, and we will see more even using the predictions from last year.

I just looked at first quarter data.

We had 12% more uncompensated care than what we predicted we would have, which we predicted more than we had last year.

So just to give you a sense of the scope, right.

So an acceleration.

So it's an acceleration of people losing their coverage.

Or perhaps they were signing up for the ACA, but they're no longer has the subsidy.

They can't afford it.

So they opt to drop their coverage.

So there's multiple ways in which this happens.

Now we also have the opportunity to get supplemental payment programs through the government.

And we have had very good success in demonstrating the need for that.

We've had support at the local level, at the state level, at the federal level.

And because of that advocacy work, we have been successful in securing supplemental payments that help to offset those costs.

Now, for us, what we do is we demonstrate the need not just in numbers, but we also demonstrate the quality of care that we provide and how we are taking a very vulnerable population and helping them achieve better health, so that we can say, when you invest in us to provide this care, here's the return.

Right?

And that, I think, helps tell the story in very meaningful ways.

But then we also have other ways that that we look for revenue.

You know, we have a very active foundation that has been very successful in securing dollars to support programs.

You know, just back to the school health program, we started on foundation dollars that that, you know, donors believed in us, and that's how we established it.

And we launched that program.

So we do have lots of of revenue streams that we look to to help us.

But it is an ever growing struggle as more people either can't afford the ACA any longer or don't qualify for Medicaid any longer, and so fall into the bucket of uncompensated care.

A tough time to step into this time stepped into this role.

So let me let me ask you a little bit about that.

I mean, October 2024.

So we're 18 months, 18 months and 18 months in, MetroHealth went through a series of leadership transitions before you stepped in and you were first interim and coming from inside the system rather than coming from outside.

What kind of challenges has that presented for you, and what kind of opportunities do you think that presents for you?

And taking the helm at Metro?

Yeah, I think that, first of all, I don't know how anybody does it.

That wasn't a part of the health system.

I really have such a deep appreciation of how challenging it is to come from outside an organization and to really learn the culture, especially a place like Metro Health, that has such a strong culture, so mission focused, so focused on do the right thing for the patient in the community.

And for me, understanding that mission was so easy because I came here right out of training.

So while I, you know, had had been fully trained through residency and fellowship, I still was a young attending.

And so I think I kind of cut my teeth.

If you if you are well on seeing patients, on getting to know the community, but also as a family doc, I, I work in the inpatient setting.

I work in the outpatient setting, I deliver babies, so I work on labor and delivery and then I immerse myself in the community through all of the other programs that we have established that we've been talking about.

So I had the benefit of having relationships that were both wide and deep across the organization.

And I love that.

I love MetroHealth like every ounce of my being.

Right.

Like, this is this is my place.

This is my home.

And so.

Well, if anybody had said to the 1997 Christy Alexander, do you think you'll be the CEO one day?

Absolutely not.

Would have been the answer.

Right.

But I think that, you know, coming up through leadership and where there was a need in MetroHealth, I was willing to step in and and I am so blessed because of that.

I mean, when you think about people who have the kind of career trajectory that I have had that I have been blessed to enjoy, you never get that in one institution.

You usually have to bounce around, right?

You have to relocate your family.

You have to go to new cities and state.

And I have been blessed to have it all in the place that I have called home for almost 30 years.

And so when I was asked to step into that role, yes, I was going to be the answer, right?

Even though I didn't know anything about compliance and internal audit and code sourcing audit.

And it's not a good idea, I don't know.

So there was a huge learning curve in many areas, right?

With medicine, with operations, with relationships, with nursing, with partnering on all that.

That's good.

I'm good there.

That's been my swim lane for a long time.

And so I think part of the challenge for me has been I now have to operate in a world that's not just rooted there, okay?

Because that's my soft spot, right?

Where am I most comfortable?

Let me go back and see some patients.

Let me deliver, baby.

Let me get out in the community.

Let me go to the jail and see patients right.

So so being willing to say okay, that now is somebody else's responsibility.

And my responsibility involves all of this and everything outside the walls of the hospital.

And so making that transition is still something that I feel like is in progress for me.

As I dig in and I learned so much about finance and how we make financial decisions and forecasting and all those sorts of things, somebody said to me, like, you're getting an MBA on the go.

And I think that's probably true, you know, because I'm, I'm somebody who loves to learn.

So if there's something put in front of me that I don't know, I'm going to want to dig in and learn it, you know?

So that's been a real learning opportunity for me.

But then also, I think just that transition and, and for the staff to no longer have the person that, you know, I'm used to the person being the person that they call on the phone and say, hey, Christie, I'm really struggling with this.

Like, what do I do with this?

Who do I reach out to, who do I?

I'm not that person anymore.

Somebody else is that person.

And now I'm the person who's figuring out other things and figuring out who to call about different things.

So that's been, I think, the challenge as well as that great opportunity to stretch myself in a new way.

And 18 months you've had to make a lot of hard decisions.

You and the team, you know, you don't do it alone, obviously.

No, no.

What's one that really sits with you?

What was a tough one?

Yeah, there been a couple doozies.

But I think, the reduction in force I mean, I think the parallel to that was closing some of the offices that were smaller offices where we could merge them into larger offices and have economies of scale of our staff.

Right.

And that allowed us to expand hours for patients to get in.

That was important, but very hard to close offices where, quite frankly, I recruited the people who worked there.

Right.

And to be like, yep, go ahead, close that one, merge it.

And then the reduction in force that the people whose jobs were eliminated, they believed in the mission every bit as much as I do.

They worked hard every bit as much as I do.

They were not let go because they were bad employees or they didn't perform well.

They were let go because we had skyrocketing uncompensated care and we had to save the institution.

And so still that haunts me because I knew a lot of those people.

I worked side by side with a lot of those people over the years.

And so that one will always be hard.

And yet I know we did the right thing, right?

Because we of course, corrected, right.

We landed 20, 25 in a stable place.

So I know equally it was the right choice.

But it's a hard choice.

Yeah.

Just because it's right doesn't make it.

It doesn't make it easy.

Right?

I, I heard this somewhere and I think it is so true.

Like if you spend your time waiting for something to get easy, it's never going to happen.

You just have to learn to be one with making the hard decisions and doing it hard.

Sure.

Let's talk about the future.

So when we were talking beforehand, you had shared a little bit about your vision for health care.

I'm going to put you on the spot here.

Okay.

And this is, you know, and you said you said, you know, this is whatever you're sort of in for you or something like that.

I don't believe that.

But share with everybody else what you shared with me about transforming health care.

And where do you think the answers really lie?

So, so I'm a primary care physician, I'm a family doctor.

And so I really believe that no matter what the question is about the US health care system, the answer lies in primary care.

And and for as much as I love Metro with every ounce of my being, I believe that primary care is the answer with every ounce of my being.

And not that we don't need inpatient care or specialty care.

ICU care, of course we need that, but we need to shift into a robust, primary care driven system where everyone has access to primary care, because that is where this has been proven in in family medicine data.

I don't know that it's been studied in all primary care specialties, but in family medicine this has been well studied.

When you add family medicine to a community that has limited health care, the quality goes up and the cost goes down.

I'm going to say that again, quality goes up, so the health of the community goes up and the cost of health care goes down.

Right?

Because if you're screening for illnesses early and you're catching them, you can, number one, prevent a lot of illnesses just by doing that.

And if you're not preventing it, but you're catching it early and you're aggressively managing it now, you're preventing complications.

And if you prevent complications, you prevent things like strokes, heart attacks, dialysis, all of the things that really debilitate our community members and cost a lot of money.

And we in the U.S.

are so good at all of those things.

And I'm very proud of the US health care system that we're so good at that.

But we need to be equally good at the other parts.

I think we've done it.

Just as health care has shifted.

We went from all generalist a few specialists to lots more hospitalists and specialists, and we just need to rebalance that, because we now have a lot of people who are in dire need of primary care, and we have this many people in primary care and this much need in the community.

Right.

And if we don't get to that and get to it quickly and effectively, we're just going to keep putting more people into high cost specialty care.

And by the way, we don't have enough people going into medicine as is.

So where we have these shortage of primary care folks, we're developing shortages in other areas.

We just we need to rightsize the system and that's when I want to get after.

And I think at MetroHealth we can start innovating, we can innovate primary care, we can start creating these solutions, and we can be the example that others can follow of how we can create that robust system that is high quality, low cost, that delves into that.

Primary care uses specialty care when it's appropriate, and be the example that the US health care system can be, we can be there.

So what what is something that people might not know about that MetroHealth is leading the way in or that is getting credit.

And I'll say one of the things that I notice here in Cleveland and when I go to other parts of the country, is that we don't always realize in what high esteem we are held in the rest of the country and what innovation we have right in our own backyard.

Yeah.

What's something that you would like everybody in our community to realize is happening right here at home?

So we have an incredible research institute, okay.

Like I think people probably don't know this, but our physical medicine and rehabilitation.

So that's often called p m and R those are the doctors and therapists that help you when you've had a stroke, when you've had an injury.

Number one, in the country.

We have more NIH grants to do this research than anyone else in the country.

And and we often toggle between 1 and 2.

But we're number one and I'm.

Yeah, we'll take it right.

Taking it.

We're taking it.

Right.

But because of that we now have incredible devices that, in partnership with case and with others that we have developed.

And I wish we could show, I mean, the head of research right here, I wish we could show the picture of how we can use some of these non paralyzed hand and arm to get the paralyzed one to work, like the the incredible things that are happening as a result of this, that when I say, you know, people then become very debilitated because of injuries or because of strokes and so forth, we're working to push that so that we can say, okay, maybe you might not be able to work, but you'll be able to feed yourself, you'll be able to dress yourself, you'll be able to be more independent than what you are today.

And if you can see the video of a young man who had a horrific accident that could then start feeding himself, I'm telling you, move you to tears.

So those are things that are happening that that probably, you know, we don't shine the light on because we tend to be pretty humble people.

That's what draws you to to the work at the Safety Net Hospital.

We also are doing incredibly brilliant work in what's called gene targeted therapy, where we really now are changing the care.

And this is really popular in cancer care, gaining in popularity in cancer care, where instead of taking chemotherapy to blast at it, we're saying, where's the gene defect?

How do we match now the therapy to target that.

Right.

And this has applications for so many other diseases, so many other ways.

Rheumatology like I could spend the whole day listing those for you.

But this is exciting and cutting edge.

And we have the national expert at MetroHealth.

Well, I could spend the whole day asking you questions, but that's not my job yet.

Oh darn it, I'm going to ask you one more before we turn to audience Q&A.

And it is what brings you hope?

I think I think the obvious answer is my faith.

Every day, like, I wake up with a meditation around what God has intended for me.

And this can get me teary and give me the tools I need to do that work.

My family.

And then any time I can see a patient, any time I can.

And not just like I drive by.

Hi.

I'm the CEO, but, like, be in it with them, right?

Be the person taking care of them.

Being the person walking the difficult walk, making the difficult decision.

Being immersed with our incredible teams are incredibly talented and dedicated health care professionals at Metro.

Any time I can be in that space, that's help.

That's that's the sweet spot.

I mean, really on call for our collectively on you only on call.

Right.

Well thank you.

We're about to begin the audience Q&A.

For those just tuning in VR, live stream or radio audience, I am Emily Campbell, president and CEO of the center for Community Solutions and moderator for today's conversation.

Joining me on stage is Doctor Christine Alexander Rager, president and CEO of the MetroHe We are discussing the progress, challenges and future vision of the Metro health system and health in general in our community.

We welcome questions from everyone City Club members, guests, students and those joining our live stream at City club.org or live radio broadcast at 89.7 KSU stream Public media.

It's a mouthful.

If you would like to text a question, please do so at (330)541-5794.

That's (330)541-5794, and city club staff will try to work it into the program.

Let's have the first question, please.

Hello.

Jeff Brown, Cleveland Clinic.

regarding primary care, how do we change public's perception?

We need specialists.

Absolutely.

Unfortunately, the standard story is the PCP takes someone through their whole life diagnosis of their breast cancer.

Then they see the specialist and they remember the specialist in their estate.

How do we get people, I didn't expect you to go there.

Okay.

How do we get people to say I want to support this family health center?

I want to support the pediatricians.

I want to support prevention, because, as you mentioned, that's what really improves population health.

Yeah.

Thank you so much.

And it's so good to see you.

I almost was going to jump in and say before you were of of the Cleveland Clinic, you were of the MetroHealth.

So, so I remember many, many times being in clinic with you.

So it's great to see you.

I really think that what draws people to primary care is, is a humility.

And a desire to take care of patients and communities and not necessarily fanfare.

And we got to get over that.

We have to get out there and tell the stories and advocate, advocate, advocate.

And it has to be widespread.

It has to be every family doc, every pediatrician, every internist, every med PS, every every primary care professional has to get out there and tell the story.

Jump in and tell the story.

Tell your patient stories.

Tell it to every single stakeholder.

You have a vote.

Therefore, the people that get voted into office work for you.

And and they say this to me when I meet to advocate, but they need to hear from you all because they feel beholden to the community that voted them into office.

They feel the sense of responsibility to the community.

So it has to be all of you talking about it to your elected officials.

Because if you can tell the story, your personal story of of how your primary care physician found your breast cancer or found your high cholesterol or diagnosed, you know this disease early and helped connect you to treatment.

We have to tell our stories so that the people who are making the decisions come to understand the importance of it.

So advocate, advocate, advocate, share the stories.

But then also, I think that we will start to hear more about it, because the government is very interested in the quality of care that we're providing.

So we now have quality indicators that that we report out.

And I'm really proud to tell you how we've rocked our ambulatory quality outcomes.

I mean, we're killing it.

And so we need to talk about that because that's the primary care space, right?

There are other things that we all get evaluated on for hospital care and all that.

And it's important to tell those stories, too.

But if we want a good primary care base in this country, we have to talk about why the hard work of driving down some of these A1 see, that tells us how well controlled their diabetes is.

Is important and it matters.

And this is why we also need to make sure they have good nutrition and ability to exercise and all those sorts of things.

Right.

That primary care goes into.

Tell the story, be relentless.

That's how change happens.

Next question.

My question is about how, as a leader, you balance innovation and sustainability.

As an example, over 20 years ago, Legal Aid and MetroHealth partnered to create one of the first medical legal partnerships in the country.

Very innovative, working together to remove barriers to health that lawyers could address.

And we have stuck with it over 20 years, which is pretty remarkable in today's world.

But as leaders, we always have that new shiny thing, the new innovation.

So how do you go about balancing that, sustaining important programs while continuing to innovate?

Yeah, that's such a great question.

Thank you.

And thanks for all of the great work over the years.

It's an incredible partnership.

I like seeing to folks that I work at MetroHealth, so I get $0.13 out of every dime.

And and the way in which I do that is, is through partnership.

And I think that that's where you balance, you can balance out the sustainability with the innovation.

When we wanted to start the school health program, right, we were blessed to have a funder that believed in us, but we also had a school system that knew that their kids weren't going to get this health care if if they didn't figure out a way to partner.

And so by bringing together and collaborating, sharing resources, ideas, sharing staff and uniting around that vision, that's where innovation was allowed to happen.

And we've been able to figure out ways to make it sustainable.

And and there were, you know, bumps along the way to be sure.

Right.

Because there's still has to be philanthropy.

There has to be billings and the health system has to contribute to it.

But once you realize the good you're doing for the community and you start to see people get healthier than it's worth it.

So I really think it is figuring out the partnerships and how you can pull your resources together to create what the community needs and to to move those levers in health.

So for me, I love innovation.

That's my sweet spot.

But it also has to be paired with who could potentially partner and help in this space.

And and how do we do that in a way that's a win win.

That that pulls together the resources.

My question, doctor Alexander, is what's your ask of the community?

How does the community get more involved to support and drive the mission of Metro?

What can we do here in the room?

What can I do?

What can the community do?

If there's one to ask of the community, what would what would that be?

Tell us about that.

Thank you.

Thank you for the question.

Nice to see you.

I probably have a laundry list of 25 things.

I would say, if you're not already a MetroHealth patient, consider becoming a MetroHealth patient.

I think so many times the the image people have at MetroHealth, especially if you don't live close by to to our hospital systems, you think it's the county hospital and it's not intended for me.

But it is intended for everyone.

And so think about becoming a MetroHealth patient number one, if you're if you're really happy with your health care, I don't want to interrupt that because those relationships matter.

But we have a pharmacy that's open to the entire community.

So utilize our pharmacy services.

We deliver to your door like we don't just have mail order, we bring it right to where you are.

Right?

So I can't imagine anything more convenient.

You're at work and you know you can get it delivered there.

You're at home, you can get it delivered there.

You can have mail order, you can have a consult with our pharmacy.

Like there's so many different ways in which the pharmacy provides incredible care.

So if you're not a patient, just ask your doctor, your medical professional.

Can you send that prescription to MetroHealth?

You don't even have to come and find the closest MetroHealth pharmacy because we're going to find you.

Okay.

I would say also advocate for the parts of our story that resonate with you, right?

In whatever way you find the most comfortable, whether that is with elected officials, whether that is with donors, whether that is with other community members, whether it is somebody who's relatively new to the community that's looking for health care, advocate for us.

You know, speak up, tell our story, share it in your circles, because you just never know where you share it with someone that that might lead to something.

That's the key to some innovation that we're working on that could help create the partnerships.

So I think I'm off the top of my head.

Those would be the things.

Next question.

Im listening to you talk about community collaboration and the importance of primary care and I know Metro has their toe in the water with being a federally Qualified Health Center lookalike.

How do you think about their relationship and the possible collaboration with the health centers in Cleveland, who are also as devoted to primary care as you are?

Yes.

That's such a great question.

It's great to see you Gene.

So funny enough, I was, on a call this morning with the now CEO of Neighborhood Family Practice and we were talking a lot about collaboration, and in fact, there was actually somebody else on the call with us, that that really is, is a believer in what can we do to promote community health.

And so we are talking about how how do we lock arms and how do we do this.

And, and I think for me, when I think about collaborations, I think they, they are so critical, not just at the primary care level, but also at the specialty level.

And how do we say, gosh, do we really need ten of this specialty?

Do we need ten of this specialty?

Or really do we need five and five.

And we need to share and then send patients.

Right.

Like how do we do those things.

But know that that's part of the discussions that we're starting to have.

How do we collaborate.

You know, how do we take something that we maybe have a lot of in our system and share it more readily?

And then our patients will send to another area where they, you know, have the specialty.

So, so know that that's part of what I'm dedicated to.

And honest to God, just this morning, and I sent out an email saying, hey, here are a few other people I think we need to include and bring into the discussion.

Because I really do think that's what it's going to take.

It's going to take us coming together in the community, not pulling apart, you know, at the seams.

Good afternoon.

First of all, thank you so much for having this critical conversation, particularly in this time.

The question I have is you spoke very clearly around the need for preventative care and the wraparound model.

How should we, think about the integration of mental health services as an organization that connects with the autism community, with the disabled community, and with the mental health community?

How should we integrate mental health delivery into that, as you see it, with the work that you do with marginalized populations?

Funny you should mention that.

So one of the one of the first things I was able to accomplish when I was chair of family medicine was integrating behavioral health into our primary care offices.

And when I think of primary care, mental health as primary care, I get is there is no better prevention than addressing behavioral health concerns.

Like quickly, identify them quickly and get access to care.

So to me, the model of behavioral as with primary care makes perfect sense.

And and not that I was the first one to do it at MetroHealth, because we had it in our pediatric department for years and years and years and decades, and actually had the national expert in that.

And she has since retired.

But but this has been a longstanding focus for us.

And I do think if we want to destigmatize behavioral health and mental health, having it readily available in that integrated fashion, right in the primary care offices is critical.

So I can't say that we have it in every single one of our primary care offices.

But but we're gaining on it.

We have several training programs that, allow us to bring learners in.

And there's many steps to to becoming a fully fledged, you know, psychologist and all that.

But but we have learning programs to create that pipeline.

So, so we're we're gaining on it.

We're not fully there yet, but I think that is absolutely essential and critical.

And for the patients, what we found and we did this study I'm so sorry.

I know there's other questions, but we did this study around.

If you just referred someone, to a behavioral list versus seeing them in our office, if we referred them somewhere between 40 and 50% of the time, they actually made it to the appointment.

However, if we provided it in the office 70% of the time, they made it to the first appointment.

So we knew we were on to something.

And I think there's still a role for freestanding offices, but I think there's really a critical role for the integration.

Ladies, it's a pleasure to be here and it's my honor to be here with you.

I'm glad mental health was brought up because my question, relates to the people who are struggling with mental illness here in Cuyahoga County.

I know for a fact I worked 15 years with Mount Taylor with the most severely mentally ill.

And as you referenced, going to the jails, lot of them in they are struggling with mental illness as well.

So I have a three pronged question.

What is that robust push for primary care doing to ensure that there are clinically trained and skilled employees to get out here to address some of these major concerns that we have this.

Secondly, we have children and elementary school young children that are putting being put on a cycle of meds because they're hungry, they're not getting anything to eat.

So they're acting out, quote unquote.

They're acting out.

And the answer is put them on Ritalin or put them on some medication that they absolutely do not need.

And then finally, we have a growing crisis where more and more people are being labeled mentally ill, that are going around shooting folks.

That includes adolescents as well as young adults.

Thank you.

I'm going to try and tackle them all in one one fell swoop.

So when you enter a primary care specialty, you have a couple different choices in family medicine.

I can speak to it specifically that that there is behavioral health training in family medicine, so that you come out much more confident in diagnosing and treating.

And then, you know, if the patient has something beyond the skill set referring.

And we actually are now sharing that training with some of the other specialties at I can speak to MetroHealth at MetroHealth and making sure that if you're going into primary care, you're getting some of this behavioral training.

It's a little tough because every specialty has their regulations that they have to follow, right?

But we really are working on doing that shared learning for our learners so that when they graduate, they have this comfort level.

I agree with you that the kids like we we need more intervention for children to be able to cope with their stressful lives.

And I know that might seem like something like, wow, aren't all kids just delightful and happy?

Our children live in poverty and poverty is stressful.

And and through our school health program that once we got into the schools, I thought I'd seen a lot already because I worked at Metro and I've always trained in safety net systems.

And I was like, I think I got a good grip on what's happening.

And then we started seeing the kids that couldn't get to us and we're like, whoa, hold on.

And so I'm going to give a shout out.

I don't know if Linda Jackson, I think I see Doctor Lisa Ramirez, that that worked together to develop programs called Students are Free to Express, that gives children some of the skills of expressing their stress that they're dealing with through the arts.

And it's incredible.

And hearing this, like when they present their work and it like it is one of the most moving things you will ever experience in your lifetime.

So I think every child, every school needs a Student are Free to Express program, every single one of them.

Because if we can help the children cope better, we decreased chronic illness as adults, right?

Because those are the adverse childhood events that we need to be addressing.

And now we we know here's the path, here's the program.

We can help.

But but we need it to be readily available.

And if we can start addressing those childhood events and helping those kids have coping skills, I think you will see less mental illness down the line and less of the bad outcomes from mental illness.

Right?

But again, it's a very broad program and so how how do you eat elephant?

You gotta eat the elephant one bite at a time.

Right.

So can we can we get a safe program in another school then can we get in another school.

Can we get in another district?

What else do we need?

How do we get connected to care right.

The children have seen a lot.

And they that's Covid right?

I would not have wanted to be in kindergarten during Covid, you know.

So I mean there's there's a lot we have to help them cope with, not just poverty, but there's a lot.

But we know we have a path forward and we need to embrace it.

Well, we could we could continue the conversation, but we have a we have a time frame here.

So thank you, Doctor Alexander, for joining us at the City Club today.

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You can learn more about how to become a guardian of free speech at cityclub.org Next Friday, May 1st, the City Club will mark Law Day in partnership with the Cleveland Metro Bar Association.

The CMBA's CEO, Chris Schmidt, will sit down in conversation with Deborah Archer, president of the National ACLU.

They will discuss the urgency of protecting the rule of law and defending the rights of all people nationwide.

You can learn more about this forum and others at cityclub.org If you haven't been in a while, there are a lot of new forums listed on their website.

Thank you once again to Doctor Alexander and to our members and friends of the City Club.

I'm Emily Campbell and the forum is now adjourned.

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