Anya and Logan chat with Francisco Olalde from the University of Iowa’s Office of Statewide Clinical Education Programs (OSCEP). He talks about his work with visiting consultant clinics in the state of Iowa, especially in rural communities. He also covers his experience working on both MBA and Executive MHA degrees–at the same time.

Learn more about OSCEP at medicine.uiowa.edu/oscep/

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Anya Morozov:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Anya Morozov, and I am joined today by Logan Schmidt. If this is your first time with us, welcome. We’re a student run podcast that talks about major issues in public health and how they are relevant to anyone, both in and outside the field of public health. Today, we are talking with Francisco Olalde, who is an assistant manager at the Health Professions Tracking Center within the Office of Statewide Clinical Education Programs, otherwise known as OSCEP. He is working towards two master’s degrees right now. He is a candidate for an MBA within the University of Iowa’s Tippie College of Business, and a Master of Health Administration from our very own College of Public Health’s executive MHA program. And he plans to graduate from both programs this August. Today he is here to talk with us about his career and specifically about his work tracking the distribution of visiting consultant clinics (VVCs) across the state of Iowa. Welcome to the show, Frank.

Francisco Olalde:

Thank you. It’s good to be here.

Anya Morozov:

To start, can you walk us through your background and what led you to your current role as assistant manager at the Health Professions Tracking Center?

Francisco Olalde:

Thank you for the question. My association with the University of Iowa began when I attended as an undergraduate student in political science and psychology. I started my association with the University of Iowa Hospitals and Clinics while working as a student clerk in chart control in [inaudible 00:01:40]. Now this was when chart control still had physical charts, as well as filmers had physical films. So a small army of students would run throughout the hospital collecting and distributing these charts and films throughout the hospital. A lot of that is gone by the wayside with the digital HER–electronic health records–that we have today.

Francisco Olalde:

After graduation, I held various positions working on political campaigns and telecommunications, which allowed me to develop my communications skills. These skills would come in handy when I rejoined the University of Iowa Carver College of Medicine’s Office of Statewide Clinical Education programs, as a clerk three, working on what was then the Iowa Nurse Tracking project, a pilot program that was started to track registered nurses throughout the state of Iowa in a specific geographic section of the state. I was able to further develop my skills to become a Iowa Health Professions Tracking Center Assistant Manager through my various experience and knowledge that I’ve gained through the department.

Anya Morozov:

And before we move on, can you talk about just what it’s like to be working towards two master’s degrees and working and having a family?

Francisco Olalde:

Well, it’s an interesting experience I will tell you. It’s a bit different. You really have to excel in time management skills. And there are times where there’s pretty much late nights that you may recall from our undergraduate programs when we weren’t as skilled at time management. But let’s just say it’s been a unique experience, one that I would not trade for the world because I have learned so much from both my executive MHA cohort, as well as my MBA cohort and the various professors in each programs. I really cannot say enough good things about both of these programs. They have provided rich experience. And the fact that these two programs that I’ve entered into were offering a part-time track, which allowed me to keep my full-time position was something that I really looked for in both of these programs. And I’ve had a tremendous support from both faculty as well as my classmates. So I had a really good time and I’m looking to wrap it up.

Logan Schmidt:

Frank, you’re quite the overachiever. And we’ve talked before, I didn’t realize you had such a diverse background in politics and communication. So it’s interesting to hear that first hand here. You explained Health Professions Tracking Center and that’s within OSCEP, but can you explain the purpose of OSCEP and how your department helps accomplish its mission?

Francisco Olalde:

Well, as we all know, it goes back to our mission at the University of Iowa healthcare organization, the mission is changing medicine, changing lives. OSCEP’s role in that mission statement, let me take you back a trip through time, which OSCEP was established in 1974 as a division of the Carver College of Medicine’s administration. OSCEP was a principal responsibility for developing and coordinating collegiate outreach programs for medical education and community service. From that, we also offer community based medical education for students and residents. So OSCEP would oversee the university of Iowa affiliated family practice training network and the college’s visiting professor program. The community based medical programs constitute the statewide medical education system. In addition to that, there’s another prong to OSCEP’s department, which is community service program. They support private practice medical practitioners throughout the state. That includes items like contract views and assisting and determining where a practitioner would like to practice in consideration for their own personal goals, as well as family considerations and cultural considerations that each of these practitioners would consider before choosing an optimal location to practice.

Francisco Olalde:

In addition, community service program would serve community hospitals by providing practice, support, and technical assistance. In this, I speak specifically to Iowa opportunities directories, which is an annual survey that we conduct to collect opportunities for physicians, advanced registered nurse practitioners, and physician assistants. In addition to that, we would also review contracts that employers offer to potential candidates to ensure that they remain competitive in today’s marketplace. The last division within OSCEP, which is the division that I am currently attached to is information systems and research, otherwise known as the Iowa Health Professions Tracking Center. And in that center, we track physicians, physician assistants, advanced registered nurse practitioners, pharmacists, and dentists throughout the state of Iowa. And we’ve done this for a number of decades now, and we’re quite good at it. We maintain continuous inventory of all practitioners. We describe the provider population using those metrics. We monitor trends in practice and where specialties are located throughout the state.

Francisco Olalde:

We support and evaluate collegiate programs. We conduct research, inform policy makers, and produce data products and services. Now I can go on through specific fields, but we can discuss that further as conversations allow. But the sources that we elect information is from providers themselves, the communities we contact through our various staff in our office, hospitals. We actually purchase news clipping services, so variety of newspapers throughout the state of Iowa, we have access to those digitally and we review those press clippings for accuracy, and then confirm anything. We come to make changes to our database. We also collect information from social media, which is a newer data source, but proves to be highly effective. We also collect information from professional associations, UI affiliated entities, reference documents, newsletters, respective boards of licensure. And if you can find them, good old fashioned telephone directories. So we have a variety of sources, but we employ them daily to make sure that we keep the most accurate data possible.

Francisco Olalde:

And how we differ from information that, say the boards of licensure are able to provide, is we touch upon employers a minimum of twice per year. Whereas respective boards of licensure updates their information as individuals renew their licenses to practice in the state. And the other difference is even though an individual is licensed practice in the state of Iowa, that does not require them to serve Iowa. So anyone who’s licensed practice in say, Illinois and practices in Illinois, may find it beneficial to have an active Iowa license, but they are under no obligation to practice within the state of Iowa. Our database ensures that they are practicing within the state in addition to being fully licensed.

Anya Morozov:

Wow. So it sounds like there are a lot of different components to OSCEP and even within the health professions tracking center, a lot goes into actually tracking the health professions in the state of Iowa. Now let’s kind of get into the main topic of today’s episode. To start out with the basics, what exactly is a visiting consultant clinic?

Francisco Olalde:

A visiting consulting clinic is an arrangement for regular visits to a rural site by specialist, usually one from a nearby urban area. These clinics are a collaborative effort between a specialty practice and the rural hospital or clinic located in the communities that are too small to support their own specialists. So typically we see specialists in communities that are over a population size of 50,000. In population sizes between 25,000 people and 50,000 people, the case to open a practice is very shaky and the local population or the service area may not be able to support a specialist being there full time. A visiting consultant clinic allows a specialist to provide service there at least part of the time. And there are various arrangements that could occur.

Francisco Olalde:

An arrangement can be as simple as PRN or as needed, or they could range from two times per week or one time per week. And any variability in between. Specialty outreach improves the access to specialty care for our rural residents in the state of Iowa, it increases the quality of care available in rural areas, and results in better health outcomes. Outside the United States, visiting consulting clinics are organized by national or regional government entities. However, in the United States, visiting consulting clinics are market driven solutions, which originate with agreements between these independent entities.

Logan Schmidt:

So you explain visiting consultant clinics and the need of providing access to areas that specialists may not otherwise go to. So those relationships and those agreements between a larger organization and a more rural organization are really important. When it comes to your health professions tracking center, what are the benefits of identifying these relationships?

Francisco Olalde:

The knowledge gained from understanding visiting consultant clinics in Iowa allows the Carver College of Medicine to understand which Iowans have access to care by the specialties observed and the frequency of bad access to that care that is located in your home. This helps the college to better understand whether Iowans must commute longer distances to access certain specialties. And if marketing conditions would support a provider in a given area where a VCC is currently present, can a specialist make a go of being an independent practice within a certain market area? That remains to be seen, however, VCC helps provide a clear picture to assess the market conditions that would allow both a full-time provider to flourish or a VCC to flourish if a full-time provider would not be supported by the market area.

Anya Morozov:

Yeah, it does sound like they’re really important, especially in a state like Iowa that is very rural. And I didn’t even really know they existed until I’m meeting you actually. But somebody who needs to see a neurologist or something in the middle of a small town in Iowa, a neurologist probably isn’t going to be able to like set up a practice. So it’s cool that they’re able to do these visiting consulting clinics and set.

Francisco Olalde:

Yes. And the benefit of visiting consulting clinics is depending on the success of the visiting consulting clinic, health systems can either scale up or scale down the number of providers and the frequency that a provider goes to these rural locations. So say two neurologists visiting a south central Iowa location two times a week. If after a few months that is unsustainable, the health system could then throttle back and choose to send one neurologist once per month at that same location to kind of right size the availability of care for the number of patients that can support that practice.

Francisco Olalde:

And therefore the health system maintains a footprint in that area providing that specialized care so a competitor would not seek to expand in that area. So it’s a protective measure plus it’s a convenience measure for the patients. Patients would much rather see a provider much closer to home than say travel two to three hours, including taking potentially that time away from work and making childcare arrangements say if the visit and commute time takes longer than the average school day, if school is in session. So that alleviates stressors and barriers in seeking care for certain specialties around the state.

Anya Morozov:

When you talk about how they can kind of change up the amount of times that people are visiting these rural areas, it does sound like it would lead to some challenges in terms of tracking the visiting consultant clinics. So can you talk to us kind of more about the process to track visiting consultant clinics across the state of Iowa?

Francisco Olalde:

I’d be happy to. The process begins with collecting press releases throughout the year. And the visiting consultant clinic study occurs once per year. So each time we collect that information, the information collected is a snapshot in time. It is not a dynamic number that moves throughout the year as the rest of our tracking may occur for providers. Since this is a static report, we acknowledge that changes can and do occur throughout the year. However, a benchmark is better than no information at all in terms of expansion of care. So once a year, we begin the study by printing out call sheets from our database that have identified existing visiting call centers within our database. And we confirm whether or not the information is the same as it was last year, if there are new providers that have joined in providing visiting consulting clinics, including new specialists, providers that are providing services at the visiting consulting clinic location, or if visits and specialists have stopped providing those services at the destination side or the community hosting the clinics.

Francisco Olalde:

Each sheet contains community served, the facility that houses the VCC site, the provider name, the frequency of their visit, the procedures they provide, if that’s known, the origin side of the physician as well as the specialty of the physician. That is what is captured within each call sheet that we generate. So for an example, last year, we captured a total of 46 specialties in 104 communities. And these communities can host more than one clinic at a time. So with 104 communities, there were 720 unique clinics throughout the state. These unique clinics are identified by origin, practice name, and location. I took a snapshot of the top 10 specialties that we track. Included in that is cardiovascular disease clinics, orthopedic surgery, clinics, otolaryngology clinics or ear nose, throat, urology clinics, nephrology, medical oncology, general surgical clinics, obstetrics and gynecology, as well as allergy, immunology. Those are the top 10 specialties that we track across the state and so they vary greatly.

Francisco Olalde:

Cardiovascular disease has the highest number of host communities, which is 80, and a total number of unique clinics is 113. By contrast, the bottom of the top 10, which is allergy and immunology clinics. They are in 25 specific host communities and offer only 26 unique clinics throughout the state. So that is quite a bit variability of the top 10. And if you go below the top 10, there is even more variability that we capture.

Logan Schmidt:

OSCEP has been around since the seventies. And so how has this data collection evolved over time? And you did talk a little bit about the different sources that you collect this information from, but has the data collection varied or evolved in terms of what you collect over those years as well?

Francisco Olalde:

Well, as I mentioned before, we used to be able to collect the procedure that many of the medical specialists were able to provide at these rural locations. Procedures have really fallen by the wayside in terms of information that is shared with our office. With the increasing amount of information available on the internet, we find that our person to person communication decreases in kind of equal measure. So while there’s more generalized information available online, the more specific information is fallen by the wayside. And that may be a function of just the nature of medicine as a whole, because whereas some procedures may have been warranted in the past, medications may account for specific treatment options, whereas before procedures may have been the route to go. But that is something we can’t really speak to. It, it kind of gets out of our wheelhouse in OSCEP. However, specific data collection, which includes contacting both the clinic sites and origin sites on occasion, that remains the gold standard.

Francisco Olalde:

So whenever we come across a press release of social media advertisement, we always attempt to verify that information with typically the host clinic site would be the ideal. If that is not available, we contact the origin site to confirm that information is still accurate. Because as I mentioned before, the nature of visiting consultant clinics is dynamic, even though the report itself is not dynamic. Things may change from when an advertisement went to print or was posted on social media versus the day we contact to verify that information. And there is a quite a bit of variability available when we collect that information. So we always try to lock in as accurate as information as possible. We don’t want to print something that is not true.

Anya Morozov:

Yeah. That makes a lot of sense. How do you think the visiting consultant clinic landscape is changing as telehealth becomes more common?

Francisco Olalde:

That is an excellent question. And just for some background, visiting consultant clinics is in a state of decline that predate telehealth. The volume of visiting consultant clinics peaked at 1,233 clinics in the year 2000 and have been slowly declining ever since. The number of communities that host clinics peaked at the year 2001 at 124 communities. For perspective, in 2021, our report yielded at 104 host communities. The prior five year average was 110 host communities. So between the prior five year average and 2021, there was a five and a half percent decrease in the number of communities hosting visiting consultant clinics. In addition, when reviewing unique clinics, 2021 yielded 720 unique clinics. By contrast the five year average was 975 unique clinics before 2021, so that’s a 26% decrease. So while telehealth may explain some of the prior five year decline and what we were capturing in 2021, we kind of feel that it’s the pandemic we’re seeing such drastic decline for the year 2021. Because in the prior five years, there was an increased activity in advanced practice providers providing visiting consulting clinics that predate the pandemic.

Francisco Olalde:

So we are seeing more nurse practitioners and physician assistants participate in visiting consulting clinics than in the past. And we are attempting to capture that information, but we are not yet ready to report out on that information because of challenges regarding visiting advanced practice providers. They’re a bit harder to pin down than say physicians which have more solid schedules. We can’t really address that component, however, we are aware of it. Specifically during the pandemic, there were proclamations issued by governor Reynolds that were intended to limit foot traffic in hospitals. So because of that, outpatient surgeries were greatly reduced as well as outpatient clinics were greatly reduced in an effort to focus all hands on deck on addressing the pandemic and hospital cases within local community hospitals. So many specialty clinics such as VCC were temporarily halted. And as I mentioned, the dynamic nature of visiting consulting clinics, the business case was most hospitals, including the origin hospitals saw drastically reduced revenues because of the ongoing pandemic.

Francisco Olalde:

So what the origin hospitals wanted to do was keep their specialists on hand to drum up as much business as possible locally to keep that revenue as high as they can make it. In combination with reducing the fiscal foot track thick in the hospital, trying to retain as much revenue as possible because of the complexities of the pandemic. Telehealth also exploded because outpatient visits switched from physical visits to remote visits, where patients could see a specialist or any provider, really, from the comfort of their home, reducing the spread and tried and flatten down that curve while maintaining access to care in some capacity using telehealth services. And we feel that visiting consultant clinics may have been affected by the advanced usage of telehealth in many specialties where in the prior five years, we did not see that [inaudible 00:21:35] at all, specifically due to the pandemic. Whether that remains to be seen as I believe telehealth parity rules, rules specifically addressing the pandemic, I believe are ending if they have not ended already. We will see if that parity will reduce future specialty visits going forward. That’s something that remains be seen.

Anya Morozov:

And what are telehealth parity rules?

Francisco Olalde:

Telehealth parity rules basically indicate whether or not specifically insurance will cover at the same rate of an in person visit as a telehealth visit. So they want to make sure that providers are receiving fair compensation for remote visits as they would if they saw a patient in the clinic physically. Now, without those parity rules, there can be a business case from insurance companies that says if they are seen via telehealth or remotely, they are paid at a certain scale, different from an in person clinic visit.

Anya Morozov:

So in terms of parity laws, if you get in a situation where it’s more expensive for an in person visit than a telehealth visit, then practitioners might be incentivized to do the in person visits more?

Francisco Olalde:

Yes, that’s correct.

Anya Morozov:

Okay.

Logan Schmidt:

As a follow up question as well, could you speak a little bit upon how you’re seeing visiting consultant clinics transitioning from being physician driven to advanced practice driven clinics? What does that mean for access of services in rural areas? You spoke about how VCCs are decreasing, but that’s mainly from the inability to accurately track advanced practice clinics. But understanding scope of practice laws, advanced practice nurses and physician assistants still can’t do everything a physician can do. So what does that mean in terms of access to rural areas?

Francisco Olalde:

Logan, that’s an excellent question. And honestly, that is not something that is easily answerable from our perspective because we are not quite sure what the differences are for advanced registered nurse practitioners versus a physician assistant. Advanced registered nurse practitioners are often credentialed in a very different way than say a physician licensure. A physician licensure and their specialties are just far different than what advanced registered nurse practitioner licensing and credentialing developed. They are independent of each other and they do not really cross easily. And depending on your audience, people tend to bristle when they are equated because they want to maintain that professional level of competency. And each provider interest group is very protective of what their providers can do regarding scope of practice. So unfortunately, I cannot really speak to that as thoroughly as I would like to. But I just don’t know.

Logan Schmidt:

Totally understandable. And I’m assuming that this kind of conversation or debate of what does that mean is happening at a national level and nobody exactly knows. But going off of our conversation, what have these clinics taught you about collaboration between organizations and relieving this ultimate rural health disparity that we are seeing grow substantially over the years?

Francisco Olalde:

Historically going back, visiting consulting clinics would often, you would often see arrangements occur from completely independent practices that have no further level collaboration than establishing a visiting consultant clinic. However, since integrated health systems have grown and rural hospitals have themselves become affiliated with much larger health systems both in and outside of Iowa, we have seen a strategy develop for integrated health system affiliated rural hospitals to have improved access to specialists that they would not otherwise have access to because they are a part of a large health system. So the larger health system is able to attract specialists that a rural community hospital would never have been competitive enough or provided incentive enough for specialists to relocate, to provide service there. However, once they join a larger health system, the health system recruits.

Francisco Olalde:

And because of that, they’re able to have competitive advantage because they have a specialist on salary who is re responsible for their own patient loan, but they could be strategically deployed within the system via physically or now with remote telehealth options, to rural locations to increase their footprint in more rural locations, providing a competitive advantage that was not previously observed without these integrated health systems. So they were able to expand their services in a limited service area because of the smaller market, but they’re able to provide much more specialized providers in those locations. And they want to maintain a competitive advantage throughout their health system and allow access to specialists that would not otherwise make sufficient profit to travel to rural locations if not for being employed by the larger health system. In addition, you see the benefit of consolidated health systems by sharing like electronic health records, efficiencies in appointment scheduling and processes, they remain the same if they’re in part of a single health system, just at a different location. There’s less inefficiency associated with these types of arrangements. So that’s a net gain for these health systems.

Francisco Olalde:

And let’s be honest, it’s a net positive for our rural Iowans because they could access that level of care closer to home at their local hospitals or with the advent of telehealth, from the comfort of their homes and just go to the hospitals. If they need labs or tests, all those referrals are processed in house, and can be executed at the local level, even if somebody is visiting via telehealth, as opposed to the local hospital physician’s office. Without that coordination, a specialty physician’s office is farther away. And as I mentioned before, patients would be forced to miss work, come up with child arrangements. Gasoline is not getting any cheaper anytime soon so the cost to travel to these clinics is much more expensive. And those are all increasing barriers to care when taken as a whole. Without visiting consulting clinics and by extension telehealth clinics, these patients could possibly be at a loss for specialized care that they need, if not for visiting consultant clinics.

Anya Morozov:

When you think of travel time, maybe having to get a hotel if you need to see someone who’s very far away, these visiting consultant clinics, it sounds like they can have really great benefit both to the providers, like you were talking about the economic benefit, and to the patients themselves. Last question, what is one thing you thought you knew, but were later wrong about?

Francisco Olalde:

When health systems originally were going to align, there was real concern that visiting consultant clinics negatively impacted. But as I mentioned before, the shift from independent practices to practices affiliated with larger health systems, they’ve been able to deploy physicians more efficiently to rural locations. Let me give you an example. An independent physician may visit a rural location, say once a week. And because of the independent nature of the physician, their clinic may be two or only three providers in their entire clinic. However, with a larger health system, they are able to pull all of their specialists from a variety of urban origin sites. So whereas the one in three clinic, let’s say a larger health system has a six person clinic or a six total specialist they’re able to draw from in their pool, that single provider providing clinic once per week, each month say that practice now becomes still able to visit once a week each month, but instead that single physician goes every six weeks, as opposed to every week themselves, or every third week themselves.

Francisco Olalde:

They’re rotating their providers through to these rural locations but each provider only goes once every six weeks. But overall, the practice is able to maintain that one visit per week each month. That decreases the level of stress on commute times for our physicians, as well as advanced practice providers if they participate. Again, we don’t track that. So it’s harder for us to gauge, but when they’re able to rotate through those providers, that creates less disruption in their own home practices for each provider. And they are able to maintain their level of enthusiasm when providing care to these rural occasions. The electronic health records would allow these rotating staff to be fully engaged with the patients and apprised of any changes, both in and out of the specialty clinics. So they would have access to say a family medicine clinic in that community because they’re part of the same health system.

Francisco Olalde:

So say if they’re patients that they follow for neurological reasons, to keep up with that example, the neurologists that are visiting that facility can see if the individual recently had COVID-19 or any other type of malady that may impact their status quo for their specialty care. So it’s that consolidated information that’s available at the specialist’s fingertips that allow that continuity of care and efficiencies in delivery of care. That coordinated care would be established and maintained by the health system and not solid in these independent practices as they were before integrated health systems made their big move into the visiting consultant clinic arena.

Anya Morozov:

I don’t want to put you on the spot too much.

Francisco Olalde:

Sure.

Anya Morozov:

Sometimes the question is a little more like a personal thing that you thought you knew, but were later wrong about. Personally, what is the thing you thought you knew, but were later wrong about?

Francisco Olalde:

Oh my gosh, so many things. What I’ve learned the most of my career in OSCEP is make time for your personal development. A lot of times we get caught up in our day to day operations, we forget to stretch ourselves. And I’ve really learned to make the effort and take the time to stretch myself and my abilities and to reach out and make those connections with other people. It’s something that I really recommend that we all do in our professional careers to make sure that not only we keep our skillset sharp, but our ability to reach out and make new allies in our careers. I really recommend that we all take the time to reach out and make new allies in our careers, whether they be mentors or just professional acquaintances. It never hurts to speak to someone new, take that risk, put yourself out there. And you never know what good opportunity can come from that. So I would encourage everyone to do that.

Anya Morozov:

Thank you for that advice and for teaching us so much about visiting consultant clinics and the trends and the state of them across Iowa throughout this episode. It was really great having you on the show.

Francisco Olalde:

I appreciate it. Thank you very much for the opportunity.

Logan Schmidt:

There we have it, that’s it for our episode this week. Thanks to Francisco Olalde day for coming on with us today. This episode was hosted and written by Anya Morozov and Logan Schmidt, and edited and produced by myself, Logan Schmidt. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple podcasts, and Soundcloud. If you enjoyed this episode and would like to help support the podcast, please share with your colleagues, friends, or anyone interested in public health. Have an idea for the show? You can reach us at CPH-gradambassador@UIowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.