1 00:00:00,160 --> 00:00:02,259 Welcome to the Becker's Healthcare podcast. 2 00:00:02,720 --> 00:00:05,839 I'm Elizabeth Gregerson, a reporter here at Becker's, 3 00:00:05,839 --> 00:00:08,880 and I'm thrilled to interview today doctor Norma 4 00:00:08,880 --> 00:00:12,240 Keller, chief of cardiology at NYC Health and 5 00:00:12,240 --> 00:00:13,380 Hospitals Bellevue 6 00:00:13,684 --> 00:00:16,564 and also the system wide cardiovascular lead for 7 00:00:16,564 --> 00:00:18,024 NYC Health and Hospitals 8 00:00:18,404 --> 00:00:20,804 on the podcast today. Doctor Keller, thank you 9 00:00:20,804 --> 00:00:22,824 so much for joining me. I'm so grateful 10 00:00:23,125 --> 00:00:24,564 you took the time out of your day 11 00:00:24,564 --> 00:00:27,144 to share your insights with our podcast audience. 12 00:00:27,750 --> 00:00:28,410 Thank you, Elizabeth. It's 13 00:00:28,789 --> 00:00:29,449 a pleasure. 14 00:00:30,070 --> 00:00:32,070 Before I dive into my questions, if I 15 00:00:32,070 --> 00:00:34,070 could ask you to just kind of give 16 00:00:34,070 --> 00:00:36,890 a brief introduction of yourself and your organization, 17 00:00:37,429 --> 00:00:38,489 that would be great. 18 00:00:39,189 --> 00:00:40,994 Yeah. Fantastic. So, 19 00:00:41,475 --> 00:00:43,074 you already mentioned that I'm the chief of 20 00:00:43,074 --> 00:00:43,574 cardiology 21 00:00:43,954 --> 00:00:45,234 at Bellevue. And, 22 00:00:45,715 --> 00:00:48,994 Bellevue is, the flagship hospital within the larger 23 00:00:48,994 --> 00:00:51,875 New York City Health Plus hospital system, which 24 00:00:51,875 --> 00:00:54,354 is the largest municipal hospital in in the 25 00:00:54,354 --> 00:00:54,854 country. 26 00:00:55,420 --> 00:00:58,640 So that has its challenges as as well 27 00:00:58,780 --> 00:00:59,280 as, 28 00:00:59,820 --> 00:01:02,140 its amazing features as well in terms of 29 00:01:02,140 --> 00:01:03,359 what we can accomplish 30 00:01:03,979 --> 00:01:06,939 for, not just our Bellevue patients, but the 31 00:01:06,939 --> 00:01:08,000 entire system. 32 00:01:08,674 --> 00:01:10,995 I've been here for for many years since 33 00:01:10,995 --> 00:01:12,215 an intern. So, 34 00:01:12,834 --> 00:01:15,795 Bellevue is and and public health care is 35 00:01:15,795 --> 00:01:17,094 is really in my DNA, 36 00:01:18,435 --> 00:01:19,895 and and love, 37 00:01:20,435 --> 00:01:22,915 being part of this amazing mission that the 38 00:01:22,915 --> 00:01:23,814 system has. 39 00:01:24,489 --> 00:01:24,969 I'm also, 40 00:01:25,609 --> 00:01:28,329 associate professor of clinical medicine at NYU, and 41 00:01:28,329 --> 00:01:30,349 I do, teaching as well 42 00:01:30,650 --> 00:01:31,549 and and direct, 43 00:01:31,930 --> 00:01:34,409 one of the clerkships, the critical care clerkship 44 00:01:34,409 --> 00:01:36,829 at at NYU School of of Medicine. 45 00:01:38,034 --> 00:01:40,275 Perfect. Thank you so much. I'm grateful to 46 00:01:40,275 --> 00:01:42,135 be able to kind of elevate your insights, 47 00:01:42,754 --> 00:01:44,915 you know, not just in cardiology, but public 48 00:01:44,915 --> 00:01:46,375 health as as well. 49 00:01:46,674 --> 00:01:48,515 I think to kick us off, I'd love 50 00:01:48,515 --> 00:01:49,254 to start 51 00:01:50,049 --> 00:01:51,750 kind of with the topic with cardiovascular 52 00:01:52,209 --> 00:01:54,689 prevention and screening and and how that is 53 00:01:54,689 --> 00:01:56,609 a is a strategy in and of itself, 54 00:01:56,609 --> 00:01:57,909 right, as part of cardiovascular 55 00:01:58,450 --> 00:01:58,950 care. 56 00:01:59,569 --> 00:02:01,510 How do you, from your position, 57 00:02:02,129 --> 00:02:02,950 try to get 58 00:02:03,489 --> 00:02:04,629 those goals 59 00:02:05,944 --> 00:02:07,325 for screening prevention 60 00:02:07,704 --> 00:02:11,084 to align with broader system level goals? 61 00:02:11,864 --> 00:02:14,344 Yeah. In our system, it's it's pretty easy. 62 00:02:14,344 --> 00:02:15,305 Our our main, 63 00:02:15,625 --> 00:02:19,349 mission is to provide equitable care to, all 64 00:02:19,349 --> 00:02:20,949 folks who come to our system or in 65 00:02:20,949 --> 00:02:21,770 New York City, 66 00:02:22,469 --> 00:02:24,550 regardless of their ability to pay or any 67 00:02:24,550 --> 00:02:26,569 any social social or cultural, 68 00:02:27,669 --> 00:02:30,389 barriers or characteristics they might have, which is 69 00:02:30,389 --> 00:02:31,289 really liberating 70 00:02:31,590 --> 00:02:32,409 as a provider. 71 00:02:33,564 --> 00:02:35,504 And it includes emergent inpatient 72 00:02:35,965 --> 00:02:38,364 care, which is a huge focus. And sometimes 73 00:02:38,364 --> 00:02:39,104 we forget, 74 00:02:39,965 --> 00:02:42,044 about preventive, but that's actually one of our 75 00:02:42,205 --> 00:02:43,104 the core values 76 00:02:43,405 --> 00:02:45,884 of our system is is to also promote 77 00:02:45,884 --> 00:02:46,384 health. 78 00:02:46,969 --> 00:02:49,930 And it's so important in cardiology given it's 79 00:02:49,930 --> 00:02:51,449 the number one killer of, 80 00:02:52,090 --> 00:02:53,310 both men and women. 81 00:02:53,770 --> 00:02:55,849 And so it's not just a focus at 82 00:02:55,849 --> 00:02:57,710 Bellevue, but throughout the system. 83 00:02:58,090 --> 00:03:01,324 I think Bellevue plays a key role because 84 00:03:01,625 --> 00:03:04,905 some advanced preventive care can be can be 85 00:03:04,905 --> 00:03:07,784 delivered here, and all patients within the system 86 00:03:07,784 --> 00:03:09,405 have access to Bellevue. 87 00:03:09,705 --> 00:03:11,385 So when we think about Bellevue, we're we're 88 00:03:11,544 --> 00:03:13,560 our patients are are not just those that 89 00:03:13,560 --> 00:03:15,319 walk through our doors, but also that are 90 00:03:15,319 --> 00:03:15,819 referred 91 00:03:16,199 --> 00:03:18,360 here, and we we think about them in 92 00:03:18,360 --> 00:03:19,580 in the same way. 93 00:03:20,199 --> 00:03:21,979 So just for an example, 94 00:03:22,280 --> 00:03:23,900 our prevention program has 95 00:03:24,360 --> 00:03:25,580 advanced high blood pressure 96 00:03:25,879 --> 00:03:26,379 evaluations 97 00:03:26,759 --> 00:03:29,525 and support. So So for for folks that, 98 00:03:30,085 --> 00:03:32,004 might be having a a difficult time or 99 00:03:32,004 --> 00:03:34,564 have a complex diagnosis, they can be referred 100 00:03:34,564 --> 00:03:36,485 here. And we could see them here, care 101 00:03:36,485 --> 00:03:38,485 for them, and then we collaborate with their 102 00:03:38,485 --> 00:03:38,985 clinicians 103 00:03:39,284 --> 00:03:42,025 at their their home hospital pretty pretty seamlessly. 104 00:03:43,689 --> 00:03:45,289 Perfect. Yeah. I love how that's kind of 105 00:03:45,370 --> 00:03:48,009 it's already integrated into the system level goals. 106 00:03:48,650 --> 00:03:50,669 So it's it's not as hard to balance. 107 00:03:52,009 --> 00:03:54,110 How do you feel safety in the hospitals 108 00:03:54,169 --> 00:03:55,965 or health systems, you know, on the flip 109 00:03:55,965 --> 00:03:57,564 side of the coin so on the opposite 110 00:03:57,564 --> 00:03:59,185 side from prevention and screening, 111 00:03:59,805 --> 00:04:02,064 there can be, you know, these innovative cardiology 112 00:04:02,284 --> 00:04:03,745 procedures and new technology. 113 00:04:04,764 --> 00:04:05,264 How, 114 00:04:06,044 --> 00:04:08,604 from your perspective, can safety net hospitals, health 115 00:04:08,604 --> 00:04:09,104 systems 116 00:04:09,930 --> 00:04:11,629 adopt those types of innovative 117 00:04:12,330 --> 00:04:15,069 procedures or invest in that type of technology 118 00:04:15,610 --> 00:04:18,910 while still balancing, you know, financial risk, reimbursement, 119 00:04:19,529 --> 00:04:20,509 equity considerations? 120 00:04:21,610 --> 00:04:23,310 How do you juggle all that? 121 00:04:24,045 --> 00:04:26,524 Yeah. That's a huge challenge and a challenge 122 00:04:26,524 --> 00:04:27,904 that that we faced, 123 00:04:28,524 --> 00:04:29,665 in our system. 124 00:04:30,205 --> 00:04:32,444 And, it could be very difficult, but I 125 00:04:32,444 --> 00:04:32,925 think, 126 00:04:33,404 --> 00:04:35,665 the best answer to that is, 127 00:04:36,379 --> 00:04:38,060 I think you have to provide it with 128 00:04:38,060 --> 00:04:40,379 a within a system just so that there's 129 00:04:40,379 --> 00:04:42,879 equitable equitable care for for these patients. 130 00:04:43,259 --> 00:04:44,779 And the best way to do that is 131 00:04:44,779 --> 00:04:46,319 to just recognize that 132 00:04:46,779 --> 00:04:50,175 every hospital doesn't have to do everything. In 133 00:04:50,175 --> 00:04:52,894 fact, it's probably not in the best interest 134 00:04:52,894 --> 00:04:54,894 of quality of care. You don't really wanna 135 00:04:54,894 --> 00:04:55,394 have 136 00:04:55,694 --> 00:04:58,115 10 different experts in a in a niche, 137 00:04:58,495 --> 00:04:59,714 intervention or technology. 138 00:05:00,334 --> 00:05:02,210 You the system can invest in, 139 00:05:02,670 --> 00:05:03,410 that technology 140 00:05:03,710 --> 00:05:04,689 in one facility 141 00:05:05,069 --> 00:05:06,270 and have that, 142 00:05:06,670 --> 00:05:07,170 expertise 143 00:05:07,710 --> 00:05:09,730 at that one facility, but make sure 144 00:05:10,509 --> 00:05:14,110 that patients at our sister hospitals have access 145 00:05:14,110 --> 00:05:15,725 to that care pretty seamlessly. 146 00:05:16,584 --> 00:05:17,564 And that creates, 147 00:05:18,024 --> 00:05:19,404 and that really requires, 148 00:05:20,105 --> 00:05:21,004 strong collaboration 149 00:05:21,384 --> 00:05:21,884 between 150 00:05:22,504 --> 00:05:25,324 the the, main hospital that has a technology, 151 00:05:25,384 --> 00:05:27,084 which currently is is Bellevue, 152 00:05:28,080 --> 00:05:30,160 with each of our our sister facilities and 153 00:05:30,160 --> 00:05:31,459 having a bilateral 154 00:05:32,080 --> 00:05:32,580 communication 155 00:05:33,279 --> 00:05:33,759 and, 156 00:05:34,399 --> 00:05:36,500 process for access for their patients. 157 00:05:37,520 --> 00:05:38,819 I think that's probably 158 00:05:41,665 --> 00:05:43,125 mitigates the financial 159 00:05:43,585 --> 00:05:44,085 risk. 160 00:05:44,465 --> 00:05:46,405 And and I think it also ensures 161 00:05:47,025 --> 00:05:49,045 quality of care since 162 00:05:49,665 --> 00:05:51,605 a lot of this technology and 163 00:05:51,905 --> 00:05:56,290 innovative cardiology procedures really are, another skill set 164 00:05:56,290 --> 00:05:57,410 that needs to be, 165 00:05:57,970 --> 00:05:58,470 cultivated. 166 00:05:59,569 --> 00:06:01,889 Right. Okay. Perfect. So, yeah, it's kind of 167 00:06:01,889 --> 00:06:04,470 investing in, you know, those procedures and technologies, 168 00:06:04,529 --> 00:06:07,490 but doing it mindfully, intentionally, and, like you 169 00:06:07,490 --> 00:06:10,435 said, with NYC Health and Hospitals kind of 170 00:06:10,574 --> 00:06:13,774 centering that at Bellevue, but providing access to 171 00:06:13,774 --> 00:06:14,754 the whole system, 172 00:06:15,454 --> 00:06:18,914 through collaboration and integration. Does that sound right? 173 00:06:19,454 --> 00:06:22,354 Yeah. No. That's exactly right. Perfect. 174 00:06:23,294 --> 00:06:23,794 So 175 00:06:24,629 --> 00:06:27,050 in the same vein of, you know, cardiology 176 00:06:27,269 --> 00:06:29,910 service lines and and the tensions that they 177 00:06:29,910 --> 00:06:30,410 face, 178 00:06:30,870 --> 00:06:33,289 when it comes to high margin interventional 179 00:06:33,669 --> 00:06:36,709 growth and then upstream prevention strategy 180 00:06:37,189 --> 00:06:37,689 strategies 181 00:06:38,629 --> 00:06:41,004 that, you know, could have the potential to 182 00:06:41,004 --> 00:06:44,764 reduce that procedural volume long term. Are there 183 00:06:44,764 --> 00:06:47,564 competing incentives there? How do you reconcile or 184 00:06:47,564 --> 00:06:49,024 navigate those within, 185 00:06:49,404 --> 00:06:50,625 you know, one system? 186 00:06:51,564 --> 00:06:54,270 Elizabeth, that's a great question and certainly a 187 00:06:54,270 --> 00:06:55,410 challenge because, 188 00:06:55,949 --> 00:06:56,930 preventive procedures 189 00:06:57,389 --> 00:07:00,290 or you don't really see the financial, 190 00:07:01,629 --> 00:07:03,889 reward for preventive cardiac 191 00:07:04,350 --> 00:07:06,524 maintenance. So I think that that's a real 192 00:07:06,524 --> 00:07:07,024 concern. 193 00:07:07,485 --> 00:07:09,138 So I think in order to address that, 194 00:07:09,138 --> 00:07:11,564 it there really needs to be a shift 195 00:07:11,564 --> 00:07:12,704 in in philosophy, 196 00:07:14,125 --> 00:07:14,524 with, 197 00:07:15,004 --> 00:07:15,504 finance, 198 00:07:16,444 --> 00:07:18,144 administrators, and and clinicians 199 00:07:18,604 --> 00:07:20,144 as well as legislatively 200 00:07:20,685 --> 00:07:23,480 as well. And I think it's important for, 201 00:07:24,660 --> 00:07:27,639 us to advocate for legislate to ensure that, 202 00:07:28,980 --> 00:07:32,339 preventive health care is is valued and and 203 00:07:32,339 --> 00:07:32,839 reimbursed. 204 00:07:33,699 --> 00:07:36,040 One example of of that is 205 00:07:36,495 --> 00:07:40,175 cardiac rehab, which is really important, and it, 206 00:07:40,814 --> 00:07:41,714 has really, 207 00:07:43,134 --> 00:07:44,435 demonstrated positive 208 00:07:44,814 --> 00:07:47,634 outcomes for for patients who have heart failure 209 00:07:47,694 --> 00:07:49,714 and MIS and cardiac procedures. 210 00:07:50,519 --> 00:07:50,839 But, 211 00:07:51,319 --> 00:07:53,319 you don't really see the financial gain of 212 00:07:53,319 --> 00:07:54,060 that. It's 213 00:07:54,439 --> 00:07:57,100 it's resource intense and it's not highly reimbursed, 214 00:07:57,240 --> 00:07:57,720 but, 215 00:07:58,680 --> 00:07:59,980 it prevents readmissions, 216 00:08:00,680 --> 00:08:01,180 improves, 217 00:08:01,560 --> 00:08:03,180 quality of life tremendously, 218 00:08:03,639 --> 00:08:05,579 and and and has even harder 219 00:08:05,935 --> 00:08:06,435 endpoints. 220 00:08:07,134 --> 00:08:07,615 And, 221 00:08:07,935 --> 00:08:10,514 the American College of Cardiology and other organizations 222 00:08:11,055 --> 00:08:13,055 pushed for legislation to just to make sure 223 00:08:13,055 --> 00:08:15,794 that that could be reimbursed and it's now. 224 00:08:16,254 --> 00:08:17,134 So I think it's, 225 00:08:17,774 --> 00:08:19,709 it needs to be attacked at multiple levels 226 00:08:19,870 --> 00:08:23,729 from, a finance perspective, a legislative perspective, insurance 227 00:08:23,870 --> 00:08:24,370 perspective, 228 00:08:24,829 --> 00:08:27,169 and then a a different philosophy 229 00:08:27,709 --> 00:08:29,009 for for providers. 230 00:08:30,509 --> 00:08:32,190 Got it. Yeah. And thank you for using, 231 00:08:32,190 --> 00:08:34,529 you know, cardiac rehab as as an example 232 00:08:34,589 --> 00:08:36,995 of of that. I can't tell you how 233 00:08:36,995 --> 00:08:38,214 many times it comes up 234 00:08:38,595 --> 00:08:39,495 in my coverage 235 00:08:39,875 --> 00:08:42,134 of just seeing the benefits and the long, 236 00:08:42,355 --> 00:08:44,835 you know, the long term downstream benefits of 237 00:08:44,835 --> 00:08:45,075 it. 238 00:08:45,955 --> 00:08:47,794 So I think it's a perfect example to 239 00:08:47,794 --> 00:08:49,475 kind of model, you know, like we said, 240 00:08:49,475 --> 00:08:49,975 those 241 00:08:50,720 --> 00:08:54,340 competing incentives and and balancing it all. Mhmm. 242 00:08:54,639 --> 00:08:57,279 For my final question and to kind of 243 00:08:57,279 --> 00:08:59,120 wrap things up for us, you know, our 244 00:08:59,120 --> 00:09:01,620 audience is hospital and health system leaders, 245 00:09:01,920 --> 00:09:03,460 some from public health systems, 246 00:09:04,274 --> 00:09:06,754 academic medical centers. You know, we've got the 247 00:09:06,754 --> 00:09:08,054 whole audience there. 248 00:09:08,754 --> 00:09:11,254 From your position at NYC Health and Hospitals, 249 00:09:11,554 --> 00:09:13,254 what do you feel are some 250 00:09:13,714 --> 00:09:15,315 of the most or maybe one of the 251 00:09:15,315 --> 00:09:16,615 most commonly misunderstood 252 00:09:17,235 --> 00:09:17,735 operational 253 00:09:18,115 --> 00:09:19,654 or financial realities 254 00:09:20,269 --> 00:09:22,929 of running a cardiology service line specifically 255 00:09:23,230 --> 00:09:25,090 within a public health system? 256 00:09:26,830 --> 00:09:27,330 Another 257 00:09:27,790 --> 00:09:29,250 great question. Mhmm. 258 00:09:29,710 --> 00:09:30,850 I think the biggest, 259 00:09:32,425 --> 00:09:34,045 misconception is probably 260 00:09:34,825 --> 00:09:38,045 there's a futility or feeling like it's impossible 261 00:09:38,504 --> 00:09:39,004 to, 262 00:09:40,425 --> 00:09:43,565 stand up programs that are very resource intense 263 00:09:43,705 --> 00:09:44,100 yet 264 00:09:44,980 --> 00:09:47,480 really beneficial for for cardiovascular 265 00:09:47,860 --> 00:09:48,360 patients. 266 00:09:48,819 --> 00:09:51,539 And I think a good example of that 267 00:09:51,539 --> 00:09:52,440 is ECMO, 268 00:09:54,419 --> 00:09:54,919 both, 269 00:09:55,620 --> 00:09:58,154 BV as well as as VA ECMO. We 270 00:09:58,154 --> 00:09:59,855 we have a a comprehensive 271 00:10:00,475 --> 00:10:02,254 program here that's a little bit 272 00:10:02,715 --> 00:10:03,215 unique, 273 00:10:04,075 --> 00:10:06,154 and developed because we are in a a 274 00:10:06,154 --> 00:10:08,315 public health system. But it took us a 275 00:10:08,315 --> 00:10:10,894 long time working with finance and administration 276 00:10:11,355 --> 00:10:12,949 and and our our cardiovascular, 277 00:10:14,049 --> 00:10:14,549 team 278 00:10:15,169 --> 00:10:15,649 to, 279 00:10:16,049 --> 00:10:18,529 develop a program that was gonna be viable 280 00:10:18,529 --> 00:10:19,350 and sustainable 281 00:10:19,970 --> 00:10:22,069 just because the equipment is expensive. 282 00:10:22,610 --> 00:10:23,990 The tech, the expertise, 283 00:10:24,769 --> 00:10:26,629 needs to be, provided, 284 00:10:27,355 --> 00:10:30,654 and multiple different disciplines need this expertise. So, 285 00:10:31,115 --> 00:10:33,514 it it's quite intense in terms of of 286 00:10:33,514 --> 00:10:34,014 resources. 287 00:10:34,875 --> 00:10:35,355 But, 288 00:10:35,835 --> 00:10:37,274 I think if you have the right people 289 00:10:37,274 --> 00:10:39,054 at the table and you can articulate 290 00:10:39,595 --> 00:10:41,100 the the benefit, 291 00:10:41,639 --> 00:10:43,639 it can be done in a public health 292 00:10:43,639 --> 00:10:46,120 system with and I think, again, you it 293 00:10:46,120 --> 00:10:48,120 can't be done at every single hospital, so 294 00:10:48,120 --> 00:10:49,340 you really have to have 295 00:10:49,720 --> 00:10:50,779 a central hub 296 00:10:51,320 --> 00:10:53,320 that other systems really, 297 00:10:53,720 --> 00:10:55,100 can engage and access 298 00:10:55,399 --> 00:10:55,899 quickly. 299 00:10:56,764 --> 00:10:59,725 We stood up our ECMO program actually during 300 00:10:59,725 --> 00:11:00,225 COVID 301 00:11:00,845 --> 00:11:03,245 Wow. Or it was critically needed just the 302 00:11:03,245 --> 00:11:06,144 the, veno venous portion of ECMO. 303 00:11:06,684 --> 00:11:08,205 And thank god we we did that and 304 00:11:08,205 --> 00:11:10,764 we're able to do that, because we were 305 00:11:10,764 --> 00:11:13,519 almost at the point of of initiating it. 306 00:11:13,740 --> 00:11:15,419 And that turned out to be just so 307 00:11:15,419 --> 00:11:17,500 so valuable for our patients who are other 308 00:11:17,580 --> 00:11:19,740 otherwise would have would have died during the 309 00:11:19,740 --> 00:11:20,559 the pandemic. 310 00:11:21,179 --> 00:11:23,100 So I think that's the probably the the 311 00:11:23,100 --> 00:11:23,580 the, 312 00:11:24,065 --> 00:11:26,544 clearest example that I can give as something 313 00:11:26,544 --> 00:11:29,184 that is takes a tremendous effort to stand 314 00:11:29,184 --> 00:11:31,845 up within a public hospital or a system, 315 00:11:32,304 --> 00:11:34,725 but can be done with the right people 316 00:11:34,784 --> 00:11:35,684 at the table, 317 00:11:36,625 --> 00:11:38,164 and and a unified 318 00:11:38,544 --> 00:11:39,044 vision. 319 00:11:39,730 --> 00:11:41,570 Even something as simple as cardiac rehab is 320 00:11:41,570 --> 00:11:43,330 is hard to stand up within a public 321 00:11:43,330 --> 00:11:45,649 hospital system as well because it's not highly 322 00:11:45,649 --> 00:11:48,210 reimbursed and because you need different disciplines for 323 00:11:48,210 --> 00:11:49,669 it to be really comprehensive 324 00:11:50,210 --> 00:11:50,870 and effective, 325 00:11:51,250 --> 00:11:52,230 but that too, 326 00:11:53,014 --> 00:11:54,875 can be done and be successful. 327 00:11:55,894 --> 00:11:58,294 We have a a comprehensive program here that 328 00:11:58,294 --> 00:12:00,534 we started a couple years ago that is 329 00:12:00,534 --> 00:12:03,095 highly successful, and there are hundreds of patients 330 00:12:03,095 --> 00:12:04,235 down the waiting list. 331 00:12:04,615 --> 00:12:06,899 So we are working with our other sister 332 00:12:06,899 --> 00:12:09,399 facilities to see how we can have satellites 333 00:12:09,459 --> 00:12:11,639 or provide this access, broader 334 00:12:12,100 --> 00:12:14,179 than, just at the at the our main 335 00:12:14,179 --> 00:12:14,679 site. 336 00:12:15,220 --> 00:12:18,360 I think it's also important for, cardiovascular 337 00:12:18,740 --> 00:12:22,164 leaders to think about new technology that's coming 338 00:12:22,164 --> 00:12:24,725 out and and knowing the landscape and devising 339 00:12:24,725 --> 00:12:26,804 a plan to make sure that all our 340 00:12:26,804 --> 00:12:29,924 patients have access to that. Another example of 341 00:12:29,924 --> 00:12:32,565 that was our structural heart program led by 342 00:12:32,565 --> 00:12:35,000 doctor Harari here, which we started, 343 00:12:35,300 --> 00:12:37,620 several years ago. And now we can have, 344 00:12:38,420 --> 00:12:40,040 our patients within our system 345 00:12:40,500 --> 00:12:41,879 have a nonsurgical 346 00:12:42,420 --> 00:12:45,879 replacement of the aortic valve TAVR, which is 347 00:12:45,940 --> 00:12:46,679 a great 348 00:12:47,059 --> 00:12:49,160 modality and growing indications. 349 00:12:49,985 --> 00:12:51,825 And now that our patients have access to 350 00:12:51,825 --> 00:12:53,745 that, I think that's really important as well 351 00:12:53,745 --> 00:12:55,665 as other structural heart, 352 00:12:56,384 --> 00:12:56,884 procedures. 353 00:12:57,585 --> 00:13:00,565 So it'd be wonderful if more public hospitals 354 00:13:00,625 --> 00:13:02,805 were able to provide that, 355 00:13:03,700 --> 00:13:04,200 comprehensive, 356 00:13:04,980 --> 00:13:07,000 vascular care to patients as well. 357 00:13:08,259 --> 00:13:10,179 Absolutely. Thank you for giving those two, you 358 00:13:10,179 --> 00:13:12,360 know, concrete examples. I think they perfectly 359 00:13:12,980 --> 00:13:15,320 encapsulate, you know, what you were saying of 360 00:13:15,460 --> 00:13:18,259 of kind of that misunderstood mindset of, oh, 361 00:13:18,259 --> 00:13:19,034 it must be impossible 362 00:13:20,794 --> 00:13:22,014 when it's not. So, 363 00:13:22,315 --> 00:13:24,554 as always, I appreciate you, you know, taking 364 00:13:24,554 --> 00:13:26,475 the time to share your perspective and your 365 00:13:26,475 --> 00:13:28,235 insights, and and thank you so much for 366 00:13:28,235 --> 00:13:30,334 joining me today. It's been a great discussion. 367 00:13:31,034 --> 00:13:32,794 Thank you. It was a pleasure. Thank you, 368 00:13:32,794 --> 00:13:33,294 Elizabeth. 369 00:13:33,769 --> 00:13:35,610 Perfect. And I invite our listeners to tune 370 00:13:35,610 --> 00:13:37,850 in to more podcasts from Becker's Health Care 371 00:13:37,850 --> 00:13:42,490 by visiting our podcast page @beckershospitalreview.com. 372 00:13:42,490 --> 00:13:44,730 Thank you again, doctor Keller. Hope everyone has 373 00:13:44,730 --> 00:13:46,269 a wonderful rest of their day.