Building a Better Primary Care System In A Rural Region - Dr. Timothy Collins, CEO of University of California Riverside Health


About one-third of Californians live in areas where there's a shortage of primary care providers, and this gap is especially apparent in what's known as the Inland Empire -- a rural region in the southern part of the state. As we’ll learn on today’s episode, the barriers to access this creates might only get worse because population is expected to grow sharply in that area. Our guest, Dr. Timothy Collins, has the challenge and opportunity of developing solutions to these thorny problems as CEO of UCR Health, a clinical enterprise affiliated with the University of California Riverside School of Medicine. “I think tremendous opportunities exist to create a more integrated network that's focused on quality and access to be able to address all of these challenges,” he tells host Michael Carrese. Strategies including connecting with K-12 students to get them to see themselves as future physicians and helping to clear the pathways to med school. “You can change the game if you can move backwards to create opportunities for individuals that may not see a pathway towards success.” Tune in to learn about other tactics being used -- including debt forgiveness and optimizing healthcare teams -- and find out how UCR Riverside is working to increase the level of engagement by patients in their own care. Mentioned in this episode: https://www.ucrhealth.org/




Michael Carrese: Hi, everybody. I'm Michael Carrese, welcoming you to another edition of Raise the Linewith Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare.


According to the California Healthcare Foundation, about a third of Californians live in areas where there's a shortage of primary care providers, and this gap is especially apparent in what's known as the Inland Empire -- that's a rural region in the southern part of the state. In addition to creating barriers to access, an overmatched workforce of physicians is at higher risk of burnout, of course, which only worsens the problem. 


Well, our guest today has the challenge and opportunity of developing solutions to these thorny problems, which are common to rural areas throughout the United States. Dr. Timothy Collins is CEO of UCR Health, a clinical enterprise affiliated with the University of California Riverside School of Medicine. He came to the role in 2023 with more than thirty years of leadership experience at academic medical centers, acute care hospitals, and health systems, including spending many years in the Scripps Health System in San Diego. 


Dr. Collins, thanks very much for being with us today. 


Dr. Timothy Collins: Thanks, Michael. I'm excited to be here. 


Michael: So, we always like to start with learning more about our guests, and I understand that your interest in medicine first started when you were a lifeguard and got drawn into an interest in emergency medicine. Tell us about that. 


Dr. Collins: Yes, yes. Well, I've spent my entire career in healthcare, and I don't know that there's a lot of people who can say that. But it did start on the beaches in Laguna Beach, and people say, well, what happened? I was an EMT at that point in time trained to guard the beaches and to rescue people in the water and surrounding areas and we treated them on the beach. I always wondered, well, gosh, what happened after they left? 


Michael: Right.


Dr. Collins: And that really spurred my interest. I was going to school at that point in time and I started to do some research in healthcare, what is this healthcare thing? And then, thanks goes to Hoag Memorial in Newport Beach which had a project called Project Wipeout. They allowed the first responders to come in and see what happened after they left the beaches. I actually found one of the victims -- we called them victims at that point -- I pulled out of the water. It was a neck back injury, and the person had survived, and they were in the unit. I was like, wow, I really made an impact. 


Michael: Wow. 


Dr. Collins: So, that's how it started for me, and I've continued my career. I have my undergraduate degree in business finance, my graduate degree in healthcare administration, and my doctorate degree in interdisciplinary leadership, where I focused on change management and what's called value creation. That's creating quality, improved outcomes, lowering cost, and things like that...the meaningful part of change and what you can get out of it. 


Michael: So when did the interest in that clinical role that you were playing merge into the business side of healthcare?


Dr. Collins: Probably when I realized that I could do both. I had taken the opportunity in some of these projects in college to write about healthcare organizations and do research on healthcare organizations and I really saw the blend between the business aspect of healthcare and the clinical aspect. So the best part of my day was always being able to round with our staff, understanding what they do, finding out what barriers existed, and then working with them to eliminate those barriers and that's as close as I could get to clinical care. 


But to be honest with you, I've still maintained my emergency medical technician license. 


Michael: Oh, wow. 


Dr. Collins: During COVID, while it was appropriate, I was able to provide vaccines. In 2015, I led a team to Nepal where we did a humanitarian exercise after the earthquake. We saw thousands of patients back in the hills and in those inaccessible regions. So, I've fortunately been given the opportunity to blend that clinical experience with the business experience to create some unique opportunities. 


Michael: Yeah, that's wonderful that you've been able to do that. So, as I noted, you've been In the healthcare system a long time, worked in leadership positions at various places. What path led you to UCR Health particularly? 


Dr. Collins: Well, I think that there are three key things that really made the opportunity as CEO of UC Riverside Health appealing. One is the growing market, and it's astounding when you look at the market growth. By 2048, they're projecting a 20% increase in the population in the inland southern California market -- that's Riverside and San Bernardino -- and that's outpacing the growth rate in California. Growth creates opportunities, but it also needs kind of creative solutions. That's one thing.


The second one is the challenge, and we have probably got one of the lowest ratio of primary care physicians per one hundred thousand population in the State of California. The average is about sixty. We're at about forty-one. 


Michael: Wow.


Dr. Collins: So, that's a significant issue that needs to be addressed and we have to do something about recruiting, retaining, and building a larger physician workforce. And the last part would be just the compelling need. When you look at the inland Southern California marketplace, there are gaps in health equity. There are gaps in timely access. There are gaps overall that when you put yourself in the role of a patient, it's a very fragmented network. So, I think tremendous opportunities exist to create a more integrated network that's focused on quality and access to be able to address all of these challenges.


Michael: Why is the primary care shortage worse in your area, do you think? 


Dr. Collins: I think there are a couple of different reasons. One is that it's very expensive to become a physician and the debt load associated with what it takes to get through school is significant.


Two, I don't know that we do the best job in identifying talent early on and eliminating barriers for those individuals. I think what we've been able to do through the School of Medicine is to reach back, meaning going to K through twelve and creating different forums and opportunities for those budding and blossoming students who might not even think that they're capable of being a physician to say, ‘I can and I will and there's pathways for me to do it.'


I think to be also honest with you, some of the mechanisms where we always tend to identify with people that have similar lifestyles, histories, experiences, et cetera and a lot of these individuals are looking for people to have mentors who were there in your position once, too. They were a son or daughter of a first generation immigrant to the United States that became a physician, and so creating these possibilities for people when they didn't think that it was possible. 


Michael: I'm reminded of that phrase. If you see it, you can be it. 


Dr. Collins: Yes. Yes. That kind of role modeling aspect. Yeah. That has a lot to do with it.

If I see somebody who's been there, I'm going to latch on to him and say, ‘how did you do it? I want to do it as well.’ And you can identify him early on. Maybe they don't set out to be a physician, but maybe they'll be a great nurse or be maybe they'll be a radiation technologist. But you can change the game if you can move backwards to create opportunities for individuals that may not see a pathway towards success. 


Michael: Makes total sense. So, you mentioned the School of Medicine there. It would be great for our audience to get kind of an overview of it, what you think the strengths are, and also understand this relationship between the organization you run and the School of Medicine.


Dr. Collins: Yeah, to answer the second question first, UCR Health is the clinical enterprise of the School of Medicine. To make it simple, it's those facilities or locations where the physicians come into practice, and so there might be faculty and there might be medical students that are doing the rotation. So, the clinical enterprise is where the clinical experience is had and where they learn, have direct patient care.


I would consider the School of Medicine a multiplier. First and foremost, when you look at what the School of Medicine can and will and is doing, it's identifying ways in which we can create the future of medicine for those people that might not think that there's a pathway. We’re a community based medical school, which means that we don't have a hospital. We're also very focused, and so our placements for medical school rotations are through our community hospitals. What we do really, really, really well is identify, as I mentioned before, the pathways for individuals to work their way through the system.


We have scholarships available for individuals. As I mentioned, it's expensive to become an MD. So there are scholarships that exist and we try to steer individuals towards those scholarships so that when you graduate, if you come back to the inland southern California marketplace, your debt is wiped out over the course of five years. When we mentioned the challenges we have with retaining, physicians seek out the income they need to pay back their debt. If you wipe the debt away, they're going to make different decisions.


Michael: So, in other words, primary care, which doesn't pay as much, suddenly becomes more realistic instead of having to go into a specialty. 


Dr. Collins: Yes, exactly. So, that's one thing. We're creating the futures for people who didn't know they had a future there, and then I think we also differentiate ourselves by being a holistic medical school. We’re looking at recruiting people from underserved areas, first generation physicians or clinicians that we can put in place. We're really thinking about what will make that physician successful in the future both for themselves as well as for patients.


We're very focused on listening, engaging the patient in the dialogue rather than feeling like the physician is just talking at them.


Michael: Right. 


Dr. Collins: We've got programs and educational content that allows the physicians to understand how to get that message out, how to engage that patient in their care rather than just being done to them. Studies have proven that when patients are engaged in their care, it's not done to them as much...wow you have changes around population health benefit and changes in outcomes and everything else. So, we're really taking a holistic view to address all of those challenges and barriers that exist.


Michael: You mentioned shortages, barriers to access, a fragmented system and the need to expand to meet an expanding population, so can you talk from a business standpoint and a leadership standpoint about how you're going to execute on handling all of that and what your plans are for trying to expand services?


Dr. Collins: One of the things that we have to do better is retain the physicians that we have in the marketplace and produce more physicians. I think it goes without being said, but being a physician is really hard work. When you look at the access issue -- about having forty primary care physicians per one hundred thousand people -- that puts tremendous burden on the physicians to carry more weight, to do more. The guilt that they have in a lot of cases of ‘I’ve got to work harder. There's so many people who depend on me. There are so many patients that need care that I could work twenty-four hours a day.’ So, physician burnout is a really big thing that we're focused on, and there's really no simple answer to that.


But what we're trying to do is to lighten the load of those physicians by reducing the burden that they individually carry. We're expanding the scope of work around the medical assistants that we have. We're improving the communication mechanisms around feedback between physician and patient. If there’s something as simple as a request that they have for a referral, or an email message, rather than it going to the physician and overburdening them, it goes to the medical assistant. We’re creating these care teams.  


We're also optimizing what we use for our electronic medical records. If you were to take a survey, you'd probably find out that one of the biggest burdens for physicians is that gosh darn electronic medical record, which has been game changing for the industry because it allows better documentation, but who does the documentation? The physician. So what we're trying to do is to build scripts -- preset order structures -- so that if a patient comes in and meets this condition, there's a pre-scripted order set that could be customized for that physician, by that physician and for the physician so that they can copy and paste. It doesn't affect patient care, but what it does is if you have swelling after surgery, you don't need to type it out every single time, right? So, we're trying to optimize those type of things.


I had also mentioned that retention is also tied to the financial piece and we're trying to work on ways that we can make education more affordable, especially if you come back in this marketplace, and that's one of our goals is just to recruit and retain physicians that are sensitive to the local market and will obviously come back to the market and stay.


Michael: While you're talking about administrative burden, just a quick side question about AI. Are there any tools that you folks are seeing out there that could be plugged in to your clinician's workflow to help with some of this?


Dr. Collins: Yes, we're exploring those right now. I think in healthcare in general, we're a little bit hesitant to go all the way. AI poses great opportunity, but it has to be managed. One of the things we're looking at is like when a physician begins an office visit, that direct communication that when you enter as a physician, you enter into the exam room, you want to have a direct, “Hello, Mrs. Jones, Mr. Jones, et cetera.”


The worst thing that a physician brings forward is, “Hi, Mrs. Jones,” and they start typing on the computer, right? It's like they disconnect and they start looking at the computer and they go, “Yeah…Mrs. Jones. Yeah…” and they're so focused on typing. So, one of the things that we're looking at is when a physician comes in the room, there's technology available right now to improve the documentation process. So, a physician comes in, they might do a badge swipe, our electronic medical record identifies who the physician is, that they're saying that Mrs. Jones has come in for these tests and then it starts to help capture information for the physician during the office visit that allows them to -- rather than typing all that out again -- allows them to go back to the record and check it for accuracy. So it becomes more iterative with the use around AI. 


Michael: Is this like an audio transcription tool? 


Dr. Collins: Yes, it is. There's also a matching element so that when a patient comes in, with certain conditions, the AI system will go, you know, these are the four things that you might want to think about, right? Like how you would talk about the education around Osmosis with the education of some of the medical school students in the training. It's also bringing those top of mind issues. “Oh, okay. This patient is complaining of these four things that the MA captured, ask them about their history around this.” It becomes more interactive so they're not starting over every single time and it becomes a team sport rather than one individual physician trying to do everything themselves. So, there's a lot of leveraging that's going on right now. We're moving cautiously to make sure that we're documenting the right information and capturing it and using it appropriately and that patients are aware that we're using AI as well and how we're using it. 


Michael: Yeah, and as you know, clinical practices are getting hit up all the time with new products and services and systems and all that stuff. So, you know, you also don't want to overwhelm them and it takes time for it to get ironed out and worked into their workflow. 


Dr. Collins: Yes, it does. 


Michael: You mentioned teamwork a couple of times, and I'm wondering how that impacts the education side of this because as folks are stepping into these roles, say medical assistant, things are changing with the scope of practice for that and other roles. How does that impact how you guys are preparing them? 


Dr. Collins: Well, it's actually very exciting because we're seeing a push for some of the medical assistants to do more for the physicians. For example, we're trying to support the MA functioning at their top ability, at the maximum capability that they have based on licensure and certification. In a lot of cases, they come in with lower expectations around how they've done it in the past. We need them to be a part of the care team. That has not always been the case. So this model around the physician being the hero, and the single point of reference...physicians are starting to realize it is a team sport. 


So, we are using our medical assistants at the top of their license and certification to be involved with patients directly, to handle inbox management, to filter and screen those things. We're also looking at nurse practitioners and how that fits within our model. And it might sound blasé to say, well, we're looking at it, but we want to make sure that there's a value add because the patient wants to have a physician, but we also need that supplemental model around a nurse practitioner or a physician's assistant, if it's appropriate. How do they fit with the practice, especially around education? 


So we're evolving and then developing the tools as well. What's also cool is we've now got these work groups that we've set up with our medical assistants. I mentioned before about change, and I view change in two different ways: there's change you're a part of, and there's change that’s done to you. A lot of times in healthcare, we do change to people. What we're opting to do instead is we've engaged the medical assistants to completely redesign what we call our patient rooming process. We will have the MAs take the patient in, we'll get all the history of the individual, we'll do all the health screening -- which we want to do for our quality of care measures -- and that's all part of what we call standard work for the medical assistants. 


I wouldn't call it templated, but it's as close to being standard work and templated as you can get with some variation. What does that allow? That allows the MA to come in and own that rooming process. Then we’re coupling the physician with that to say, does that rooming process get me what I need to be able to start doing the diagnosis? Then the physicians are going, well, how about if you ask this question? Well, now we're teaming. Now I understand what you're doing. Now you understand what I'm doing and we want the best outcome. 


So, we get this cross-pollination between the two when each side is involved in the overarching care. That's where you get the pickup. That's where you get the teaming model. And then you load into that everything that's a wrap around, around communication and we're building all of this around the patient, which again, rather than the care being done to the patient, have the patient be a part of that whole experience. 


Michael: Well, there certainly is no end to the change in healthcare and everybody's sort of in that mindset, I think, where you come in every day and you’ve got to adjust to something else. But also, as you're suggesting, it creates new opportunities for folks and for certain position, so that's good too. 


So, as you know, we're a teaching company and one of the questions we love asking our guests is, is there a knowledge gap, a myth, something along those lines that you care about particularly, that you would say to Osmosis, “You guys, it would be great if you could make a video about that or a course to fill that gap.” What would that be? 


Dr. Collins: I think the biggest part that we're seeing in our industry gets back to what I mentioned before, which is care being directed and I don't think that we as an industry do a good enough job of listening. When I hear about concerns from patients and their families, it's usually around, ‘you didn't listen to me.’ It's usually around, ‘I've been going through this and you didn't respect me enough to ask the questions and to engage me. You told me what you thought, and you did this to me, and I know my body.’ So, I think it comes down to that active, engaged, listening and humble inquiry, which comes from lean management. 


It is really understanding what's going on in that patient's world, because most of the time, what we face is much broader than just the patient themselves. It could be the environment they live in. It could be the food that they're eating. It could be transportation. So, unless you truly understand the patient and what they're living by asking humble questions and allowing them to be a partner in the care, I think you'll never get to the solution. 


So, to answer to your question, I think it would be worth having modules around asking really good questions, listening to the results, and then formulating questions from what you hear to create a plan. It's almost like a different level of negotiation with the patient to say, “This is what I'm hearing from you. This is the clinical nature of what's going on. How can we work to change some of these things little by little to get you to improved cardiovascular care or reduce your issues around diabetes.” That's where you're going to get the game changing events. It's not going to come by people telling you what to do. It's by creating this participation between patient and clinician. 


Michael: Very well put. We're almost out of time, but we do want to give you an opportunity to answer one of our other favorite questions, which is, with our younger audience in mind, what is your advice to folks entering healthcare careers about coming in at a time when there's just so much challenge and adversity? 


Dr. Collins: I think one of the things that that I always tell people who come and seek advice is to do a couple things and do them well. One is to take on responsibility where others won't. Be willing to take a risk and know that if you bring in others, you won't fall. Find organizations that create a culture or have a culture that want you to fail. Obviously in healthcare, we're very risk averse, right? 


Michael: You’ve got to be careful where the failure happens. 


Dr. Collins: I need to caveat that with, you can't kill anybody by doing what you do, right? But when you want to do something around a new product or open a new line of business, step forward and then build your network of mentors. I think that's the other thing: seek out mentors throughout your career who can help you, advise you and give you guidance along the way.  


The third thing that I'd recommend is to always think in terms of the Wayne Gretzky saying about anticipating where the puck is going. Think about where healthcare is going? Where is the puck going to be? How can I position myself with the right skills so that as you see things evolving, you're there. Maybe in my career horizon, I won't see the tremendous multiplier effect of AI, but I do see it coming and I'm doing everything I can to learn about it and also I'm seeking out others who are more knowledgeable about it. Like, you know, going outside our industry, going outside of healthcare to understand how others are using it and maybe you can learn from it and take a little bit of that back. 


So, always think broader than what you're currently experiencing because then you'll see where the thought leadership is and how to use it more effectively. 


Michael: That's great. You know, I think Wayne Gretzky is probably quoted as much by business leaders as by hockey players because that is such a great encapsulation of how to approach whatever business you're in. 


Dr. Collins: Yeah. My other favorite quote is Colin Powell's quote...something to the effect of, “It’ll be more clear in the morning.” I guess the other thing that I’d offer people as an add or a supplement is don’t beat yourself up because you don’t have an answer right now. Let it stew. It’ll come to you. It’ll be more clear in the morning when you’ve thought about it. So, don’t put unnecessary pressure on yourself to be 100% a perfectionist. Know that good enough is good enough, and allow yourself to think through these complex problems. There's a reason why they're problems, right? Nobody can solve them. 


Michael: Yeah, nobody else has figured it out yet. 


Dr. Collins: Exactly. Exactly. That's why they still exist. So, don't beat yourself up. Bring a team in and think through those things to solve these complex problems. 


Michael: That's a great perspective, and I'm sure appreciated by our audience. We really appreciate you taking the time to be with us today, Dr. Collins. It's been a pleasure. 


Dr. Collins: It's been my pleasure. Thanks so much. 


Michael: I’m Michael Carrese. Thanks for checking out today's show and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.