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Welcome everyone to the Becker's
Healthcare podcast series.

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I'm Ryan Muhammad with
Becker's Healthcare.

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I'm thrilled to have with me today Dr.
Joseph Kraft from St. Luke's Hospital.

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Dr. Kraft is so nice to talk
with you today. How are you?

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I'm, I'm well. Thank you
for having me on. I've, uh,

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enjoyed listening to some of the other
podcasts that you guys have published,

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and I think it's great what you're doing.

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I appreciate you trying to share
the word about heart health.

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Oh, yeah, absolutely. Thank you
so much for those kind words,

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and we are so excited to have
you on today. Uh, to begin,

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would you mind please introducing
yourself and telling us a bit about your

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background?

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Sure. My name is Joe Kraft. I'm a
cardiologist in St. Louis, Missouri. Uh,

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I trained,

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I did college at University of North
Carolina and I did medical school at Wake

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Forest University.

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I did a residency in internal medicine
and a chief resident year at Vanderbilt

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University, and I did a cardiology
fellowship at Washington University in St.

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Louis on board certified in
internal medicine, cardiology,

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echocardiography, and
nuclear cardiology. And, uh,

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I'm a general cardiologist. I
love taking care of patients. Um,

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that's what gets me out
of bed in the morning.

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But I also have an interest
in the business of healthcare,

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including everything
including policy, finance, uh,

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technology and population health.

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And so I've had the pleasure of
holding some leadership positions. Uh,

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currently I'm the president of the medical
staff at St. Luke's Hospital at St.

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Louis. St. Luke's is, um, an
independent health system,

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uh, of medium size. We have a
30 locations throughout the St.

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Louis metropolitan area. Um,
high, very high quality place.

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We pride ourselves on that, uh,

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Medicare five star rating
for the flagship hospital.

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We have a alliance in partnership with
Cleveland Clinic, and, um, we have a,

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a mix of, uh, employed physicians
and private physicians. And, um,

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culture is very important to us.

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Yes, absolutely.

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Thank you so much for sharing that
background knowledge and with all of your

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experience in healthcare. The one
thing I wanted to ask you first is,

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what are the top three biggest
issues in cardiology today?

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Well, I'm sure, uh,

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you'd get a lot of different responses
from different people in the field,

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but some of the things that I think
are interesting and I think are dynamic

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features in our world, uh, day-to-day,

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both for the folks of those of us who
work in the trenches and see patients

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every day, but also for the folks
who step back and look at, uh,

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cardiovascular care
from a bird's eye view,

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maybe around the country
or around the world.

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One of the things that we struggle
with is what I like to call therapeutic

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optimization. Uh,

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when we develop therapies to try to help
people for various heart conditions,

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and there's, there's so much
heart disease out there, uh,

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we have a hard time translating
that from established, qualified,

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good quality evidence to
widespread adoption and access to

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patients who need those things.
So numbers have been diff have,

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have been quoted differently,

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but there's a lot of reports to
suggest that it takes 10 to 15 years

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until high quality
publications are available to

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physicians,

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even published in large white paper
guidelines accepted by professional

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societies before those same
therapies are widely adopted.

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Um, so we have a gap.

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We have a gap between
evidence-based and widespread use,

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uh, and availability to patients.

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There were a lot of
people who felt that the,

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on the introduction of electronic health
records in the mid two thousands were

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gonna solve a lot of those
problems. Unfortunately,

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electronic health records really have
been mostly disappointing with respect to

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their ability to impact population
based healthcare in a, in a large way,

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whether that is the population
of a PHY single physician's

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panel or a small practice
or, uh, you know,

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thinking about the country as a whole.

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So I think one of the things that's
interesting is there are, uh,

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with the introduction of a lot of AI
tools, artificial intelligence tools,

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there,

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there may be an opportunity
finally for us to accelerate

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the rate at which we as a medical
community adopt highly qualified

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therapies to make a difference.
Here, I'll give you an example in,

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in taking care of patients
with congestive heart failure,

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those people with heart failure, we
call with a reduced ejection fraction.

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We now have a pretty commonly
accepted four drug regimen,

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um, that has well-established use,

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is endorsed by all the cardiology
professional societies. Um,

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however, if you look at nearly
every group of physicians, uh,

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almost any way you slice the pie, you
can see that, um, use of one of those,

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or maybe two of those medications,
uh, is relatively commonly done.

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But getting all three
or all four medications,

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and even this is include excluding
people who are allergic or having

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intolerances. We just
haven't gotten there yet.

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Some of this information is newer,

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but we want to accelerate
the timeline to adoption.

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We know that there is a big difference
sometimes adding years of life

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going from two of these heart failure
medications to four of these heart failure

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medications. So, um, one of the tools
that we're using, and I don't have,

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I have no disclosure, no financial
disclosures, but I think it's interesting,

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one of the tools that we're using in
our health system is called cardio care.

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Cardio care is a software tool.

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It's part of the Edwards Life
Sciences family of companies and

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cardio care, as an example, uh,
has the ability to pull out,

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to extract a lot of data from,
as an external software piece,

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from the electronic health record,

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and analyze it in a sophisticated
way and give us reports of how

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many patients from our population are on
the four drug regimen who would qualify

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based on their ejection fraction
and their symptoms. It's a,

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it's a really robust reporting
tool. It's very insightful,

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and it can be updated in real time. Um,

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and it can be given this information
be provided to physicians,

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to nurse case managers, um,

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to population health teams to try
to help impact care and deliver

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care to a larger group of folks.
So I use that as an example, and I,

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I hope that's one, uh,

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one insight into what the next
year or two or five could look

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like as we try to make high quality
cardiovascular care, more dynamic,

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more responsive to, um,

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data that gets published and help our
patients live longer and live better.

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Yeah, absolutely. Thank you so
much for all of that insight. I,

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like you said at the very
beginning, I can definitely, uh,

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I hear a lot of different answers
to this question, but you know,

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I'm excited that you spoke about something
that I don't hear about too often.

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And keeping in mind those big issues,

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how do you see heart care
evolving over the next 18 months?

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Do you think that some of those
issues will be solved by then?

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I, I, i see. I guess I would say,
um, I would, I I'd say there's, uh,

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challenges, concerns, and
there are opportunities.

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Let me kind of highlight
one of the challenges.

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So we have workforce
challenges in, in cardiology,

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as many of your listeners
may know. As of 2010,

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the baby boomer group started hitting
Medicare age and we have an aging

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population,

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and roughly 10 to 12,000 people
reached 65 years old in the

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United States every single
day. And as we get older,

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cardiology tends to be care
of mostly older folks. Um,

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and so we anticipate a lot
of increased care needs. So,

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um,

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the challenge though is that we have a
cardiology workforce that is not growing.

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So among cardiologists
in the United States,

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we lose about anywhere from 500 to
a thousand cardiologists that's been

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estimated per year out of the workforce.
And that's for a lot of reasons.

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One of those is because at present,

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about 60% of cardiologists are over the
age of 55, 20 5% are over the age of

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65. Those numbers are going to increase.

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We have long training timelines.

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People start into medical school
in this era a little later in life,

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a couple years later in life than
they did 15, 20 years ago. Um,

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we have physicians who are field
burnout for lots of reasons,

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have been worked very hard, COVID didn't,
nothing did nothing to help that. Um,

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so we have some people who
are scaling back their work.

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Some people are retiring early, and
that's resulted in the shorters.

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At the same time, we have an arguably
bigger problem in the United States, uh,

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that we have a tidal wave
of nursing shortages coming.

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It's estimated that around
2026 we'll have anywhere from

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300,000 to 500,000 nursing
positions open and unfilled in the

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United States. It is very
challenging to hire nurses right now.

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So on the supply side, uh, for the,

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for the expected increase
need of our population,

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we're gonna have less people to do that.

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So there are gonna be lots
of clever ways. I hope,

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I hope there'll be lots of clever ways
to try to increase that. There's some,

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uh,

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activity on the legislative side in
trying to increase the number of approved

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and paid for, uh, residency positions.

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There are some medical schools that have
been ex have been growing and expanding

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and trying to graduate more doctors.
There will be a lot of extension,

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including the use of nurse practitioners
and physician assistants and

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physicians leading those care teams to
try to take care of all of our folks.

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But that will for sure be it.
So that's for sure a challenge.

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I think one of the things that's
interesting that will happen in that same

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context is

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roughly 85% of the,

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of the cardiologists in the United States
are employed or tightly aligned with

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health systems.

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That's a flip from the way things worked
25 years ago when it was around 25% of

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cardiologists had such alignments.

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So health system and cardiology care
teams are working tightly together,

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and they are working in,

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in the context of a changing
kind of care venues.

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So for example, we anticipate
the inpatient cardiology needs,

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hospital-based cardiology
care to increase around 5%,

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maybe 6% over the next decade.
That's a national estimate,

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but the outpatient care
needs, we expect to grow 25%.

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Health systems historically
have been very focused on

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bricks and mortar patient heads and beds.

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What do we do on the inpatient side?

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And many have not been really
focused on seeing the outpatient

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realm of care as their future.

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And I think all of us are gonna have
to sort of adopt a mindset that the

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outpatient realm where we care for
patients is really gonna be our future.

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So how are we gonna get to that and our
health system's gonna be able to make

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that transition effectively. You know,

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their health systems are under financial
strain. It's a, it's a tough industry.

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Those are kind of small margin.
Um, it's a small margin business.

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Um,

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and we see an influx and an
increased interest in other,

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uh, other groups coming
into the outpatient realm.

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And among several is
includes Amazon, Walmart, uh,

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United Healthcares, Optum have been, uh,

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moving more into the
outpatient care realm.

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So it's gonna be very interesting to
see if over the next five years there's

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some disruption in where we take care
of patients and who is taking care

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of those patients in that outpatient
realm. I think it's gonna be very,

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very interesting. My hope is, I guess I,

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I'm kind of a glass half full kind
of guy, so you, you asked about, um,

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you know, you asked about
opportunities and threats.

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I I hope that this landscape,
um, shakes things up. Uh,

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healthcare by its nature has not
always been very fast moving. And,

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and I think it would be really exciting
if it were a time of accelerated change

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and increasing innovation,

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maybe even out from outside of some
traditional healthcare players to try to

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shake things up and help us take
care of people better. For me,

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that would be fun. And uh, that would
be fun change. That would be exciting.

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Yes, absolutely. I completely agree
with many things you said. Um,

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and we definitely do need some creativity
in dealing with some of those issues

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arising. Uh, however,
before I let you go, doctor,

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the last thing I wanted to ask you is
what are you excited about and also what

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is making you nervous? I know
something you mentioned about, uh,

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nerve shortages and that can
definitely make one nervous <laugh>.

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So,

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so the things that I'm nervous about
are having an increasingly strained

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healthcare system, both on the hospital
side where we don't have enough nurses,

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where we still struggle
with high expenses,

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that we don't have enough
cardiologists and, um,

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support team to take care of the patient
care need. That, that's my concern.

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What, what I'm hopeful about,

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what I'm optimistic about is that
there'll be an increasing push to

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address these things in new
ways. So, um, for example,

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if, if we were to take care
of patients in a better way,

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I mentioned this therapeutic
optimization concept.

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If we were able to figure out
among the thousands of patients,

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say in our health system that we care
for and that we know have chronic

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conditions that we have
to manage over time,

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if we can figure out who those people
are, if we can learn about them,

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if we can get data,
feedback them in real time,

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and now it seems like we're at the
advent of having tools to effectively do

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that. Um, I think that we can make a
major impact in those patients care,

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help keep them out of the hospital, help
keep them happier and living longer.

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We're also starting to see some software
applications that are gonna have

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increasing opportunity to impact
the electronic health records. Um,

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despite the best efforts,

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many of those electronic health records
haven't evolved very fast over the last

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15 years or so since
they've been available. Um,

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there are also artificial intelligence
and voice recognition tools that

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hopefully are gonna get doctors
and nurses less and less

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obligated to do data entry, uh, typing
all day long and clicking all day long.

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Uh,

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it is the bane of the existence of those
of us who take care of patients every

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day and it's a time suck. And we really,

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really need to get away from that
in order to allow people time,

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face-to-face with patients, which is what
patients want. If we do those things,

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I think we'll have both a happier
healthcare workforce and patients who are

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better cared for.

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Yes. Thank you so much for
those final thoughts, doctor.

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This has been an amazing discussion.

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So I do wanna thank you so much for
coming on Becker's Healthcare to, uh,

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speak with me today and I look forward
to connecting with you again soon.

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Right. It's been a pleasure.

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Thanks for what you're doing and
I'll look forward to the next time.

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Thank you.