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- We are literally days away from the official beginning of the school year here in the Carolinas, and as we close out on a very long, hot summer in the Carolinas, what are those things that continue to percolate?

I'm Chris William, and welcome again to the most widely watched and longest running source of Carolina business, policy and public affairs seen every week across North and South Carolina.

In a moment, we will welcome our guest, the CEO of UNC Health, Dr. Wesley Burks.

Before we do that, our panel of experts will unpack the issues of the day, and we start right now.

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On this edition of Carolina Business Review, Kevin J.

Price from the National Institute of Minority Economic Development, Joe Waters from Capita, and special guest Dr. Wesley Burks, CEO of UNC Health and Dean of the University of North Carolina School of Medicine.

(exciting music) - Well, welcome again to our program.

It has been a long, hot summer, for sure.

Maybe not for you, Joe Waters, up in Blowing Rock, but I know for Kevin and I down here in the lower country, it's been just steaming.

Kevin, let me start with you.

Here we have a long, hot summer.

We've had not runaway inflation, but record inflation.

We are now officially in a recession.

Have we reached tipping point?

Kevin, what are you hearing in your conversations with constituents and people that you know?

- Well Chris, thank you for inviting me.

This is great.

So glad to be here and spend some time with you and Joe.

I think what I'm hearing a lot these days is that we've been here before, and for minority populations in particular, minority business owners, we've experienced this many times before, and so it's how do we weather the storm.

We've gotten some relief from the federal government in terms of PPP and things like that that are out there that I think gave some early relief through the pandemic.

Now the state is responding and saying we have to do more to support minority and women-owned businesses in particular across the state, and we've been administering that to support them for the last two years, so I'm excited about that and where that's going, but I'm now thinking of how do we scale businesses and get them to start to think about growth again.

The VC world is somewhat contracting a little bit, so I'm a little concerned about that.

- Just venture cap?

You said venture capital specifically?

- Right, venture capital.

That's what I'm seeing right now, is we've got to continue to make capital available and resources available so we can weather the storm.

- Joe, as Kevin just said, here we are, we're in it, we've seen it before.

The sky isn't falling.

It's not quite the media hype that we we hear about, or is it?

I mean, what do you hear?

- Well, I think inflation is a very real issue for working families.

Despite the fact that we have great employment numbers, wage growth is not keeping up with inflation, so people are really feeling the pinch of what's happening right now in the economy, and certainly that takes a toll on lower income families who have to spend a disproportionate amount of their income on housing, which we know is not affordable in many places across the Carolinas, on childcare, and other essential goods that frankly over the last several decades have only gotten more expensive.

- Okay.

You both raise the red flag about communities of color, people of color, disproportionate impact, absolutely.

What do we do with it?

Kevin, you talked about support.

Specifically, what does support look like and how does it change the dynamic?

- Well, I think from the perspective that Joe raised of just working families, many are thinking about how do I go back to school and retool, rethink about skills that are available to me.

The community colleges have been doing just a fantastic job of making resources, making educational opportunities available so people can go back to school.

We're seeing an amazing surge of companies come into North Carolina, but they're coming in with a different set of skills that they're looking for, and so I think as we retool those who live in the community now somewhat away from manufacturing to look at technology and other types of jobs where you need a little bit of a different skill set, the community colleges are helping a lot in that space.

- Joe, South Carolina schools start, public schools start a week or two before North Carolina schools, and as we get back to school, is there a particular part of that that puts families and kids at risk now that we've got what we just laid out around the economy?

- Well, I think that's an interesting question.

I mean, certainly families are spending, particularly families with younger children, they're spending a disproportionate amount of their income on childcare, and when you look at the beginning of school, that's certainly a relief for many of those families.

But if you need to work for a full day or you need to work second or third shift, that doesn't help you, and so they're going to be looking at expenses around after school care and those sorts of things in addition to all of the stuff that kids want and need and you need to buy for them when they're going back to school.

So yeah, I think in many respects, going back to school is certainly an exciting time for many kids and many families, but obviously there are gonna be some stressors this year related to the economy in particular.

- Kevin, what do you think?

- I am seeing the community colleges respond to that as well for those adults, the parents, who are trying to also go back to school.

Part of the impediment of doing that has been childcare.

Where do I take my kids, where do they go and those sorts of things, so many schools are responding to that as well, saying we can support you in that space also.

So I'm excited about that and how for the first time, I think, well maybe not the first time, maybe in our lifetimes the first time, we're starting to see people think way outside the box.

This is the way it's always been, so that's the way we've always gotta do it.

We can do things differently.

- Yeah, and just to add onto that, I think you're absolutely right, particularly when you look at the number of students around the country.

I think it's something like one in five college students are also actively parenting a young child and they need support to help to make sure that they get to degree completion with some of those childcare costs, and I think a lot of schools around the country are really stepping up to support those student parents to make sure that they can finish their degree.

- The last time our guest was on this program, it was literally a week before this novel coronavirus, COVID-19 appeared.

It was also before Roe V. Wade reversal.

It was also before the accelerated M and A activity in hospitals across the Carolinas.

It was also before the acute increase in scrutiny around healthcare billing and costs, as well as the shortage of nursing and staff.

So not a few things have happened.

He is the CEO of the UNC Health.

He's the Dean of the UNC School of Medicine and the Vice Chancellor for Medical Affairs at the University of North Carolina Chapel Hill.

We welcome back Dr. Wesley Burks.

Dr. Burks, God bless you.

You've got a lot on your plate, sir.

- Chris, first, thanks for the opportunity to be with you.

I distinctly remember March of 2020 as we got together and talked about COVID and what we knew and what we thought we knew.

I'm not sure any of us could have predicted what would have happened.

The last two years have seemed like 20, honestly, for most of us, and it's been interesting, amazing, exhausting and exhilarating.

There's so many different ways to describe it, but I'm glad we're in a position we are right now.

- And not to be too cute and too much of a turn of phrase sir, but how do you triage all of those things that have happened since then?

How do you prioritize what's important, and where do you start and what do you manage first?

- First you have to be really clear about what your mission is and what your priorities are.

Our mission is to promote the health and the wellbeing of the people in North Carolina, and we literally talk about it every day.

What COVID did was to make us refine within that what our priorities were, and the two priorities were one, to take our best care of patients that have COVID and then everything else, and then take care of each other.

And so with those filters, that's how we made the decisions about what to do, when to do.

We did things that we never would've predicted, but with those filters, those priorities in mind and a process, then we got there.

We took care of a lot more patients than we ever thought we could.

We worked under conditions that were thought to be unbelievable previously, and people are tired right now, but they did it.

They did an amazing job.

- Okay, Joe, Kevin?

- Yeah, Dr. Burks, thanks so much.

It's good to meet you and good to talk with you today.

We've heard a lot over the last decade plus about the importance of the primary care workforce across North and South Carolina.

We've seen initiatives like the new medical school in Greenville, South Carolina, new residency programs like the one in Boone that MAHEC is sponsoring.

How are you thinking about encouraging med students very early in their training to think about primary care professions rather than specialties, particularly when frankly, the economics with student debt and everything else make those specialties very attractive?

- Joe, it's a really good question, and for our medical school and for the state, you understand better than most the importance of primary care and having good care throughout the state, not only in the urban areas but particularly in the rural areas.

As we recruit medical students to UNC, then one of the filters, the thoughts that we have is how do we recruit more students that are likely to go back to rural areas or likely to practice primary care, and the two things that really play a part in that are where they're from and their heart for doing primary care.

As we think about how we recruit into our medical school, that's a big part of what we're trying to do.

The other part of this is that what really best correlates with where people practice is their ultimate site of training, not where they went to medical school as much.

For us as a state to develop more residency programs, particularly in rural areas, people that train in rural areas that are from North Carolina, that's who will stay there.

And so us, with others like MAHEC, other parts of the AHEC system throughout the state to emphasize more training places for after medical school in rural areas, that's how we'll replenish that workforce.

- [Chris] Kevin?

- Dr. Burke, it's good to see you.

I mentioned to you earlier that I'd spent 14 years with Novant, and when I was there, part of what we used to talk about quite a bit was triple aim and how triple aim is designed to improve the patient experience, reduce per capital cost and then population health.

But what I've been hearing lately is that the triple aim has become the quadruple aim, and that is adding those triple aim elements and one more, that being more of an employee satisfaction or some have said joy, others have said health equity.

Has that helped with retention and recruitment and just the overall mental wellbeing of team members?

- It's a really good question.

We talked earlier about the two people that we really focused on.

One is our patient, the people that we want to participate in their healthcare, and the second one is my teammate, the people that I work with, and to really focus on them.

That's part of that now quadruple aim.

We've had programs in place for several years now around wellness for the physicians and the nurses and other people that I've worked with, putting a lot of resources there.

We can't take care of others, we can't meet our mission, unless we're taking care of ourselves and taking care of each other, and that's a big deal.

Embedded in that question is that we are a diverse group of people, that we work together.

That's how we'll best meet our mission of taking care of the people in North Carolina, rural, urban, all the different zip codes that we want to participate in their healthcare.

We have to pay attention to the people that we work with to help them feel good, help them work through again what's happened particularly in the last 28 months.

- You know, Dr. Berks, as I hear you talk about, and Kevin brought up the triple aim and quadruple aim.

And as you address that, I still think about being reactive and proactive to some degree, but being reactive to these things that present a present challenge right now, of course, but you said an interesting sentence in a letter to your colleagues, and I'll quote you.

You said we will wear these moral scars for years to come.

The time has changed, or the time has changed us all in ways that we don't yet understand.

You're clearly being reflectively philosophical.

How have these things changed the way you lead?

Can that bleed down into the organization?

Can you lead with this kind of wisdom as well?

- Of the many lessons we learned during COVID, and I could go on for days about what those are, the first one in a good way that we worked so much together, we learned that we liked each other.

We really worked hard nights and weekends, that like the people, we like each other, and that sounds trite, but it's really not for most places.

The second thing is that the empathy and grace that you had to walk through the last two and a half years, you had to do that and you had to extend it down into an organization for the immediate people I work with and for them to others, that you continued to thank people, but also try to understand where they were, how tired they were, the difficulties they were going through, and you continued to have to talk about it in a good way, not in a way that you just did it because it was fair and important.

And then the last part, the lesson we learned in a big way is that we can do things that we didn't think were possible.

If we trust each other and follow a process, we can escalate.

We can increase the things that we're doing in ways that we really had not anticipated before.

But the trust in each other, the process that you go through to examine all the issues around whatever it might be allow us to do things that we had not thought we could do before.

But for me, the biggest thing is the empathy and grace, and that's real, that you talk about that with the people that you work with.

- Joe?

- Yeah, Dr. Burks, we increasingly understand that loneliness and social isolation is a determinant of health.

We recently conducted a survey in North Carolina that found that one in three parents of young children describe themselves as lonely.

What do providers and health systems need to be doing across both Carolinas to support more social connection, which we know is really vital to improving the health of Carolina?

- From a big picture standpoint, our mental health as a society is different than it was two and a half years ago.

It's way different than it was a decade ago.

Our mental health as a group, but really personally plays a big part in our overall health.

People are increasingly talking about it, but like the example, North Carolina recently in some different surveys, business feedback, was rated number one in business climate, but number 28 in health, and a big part of that is how we take care of the mental health of the people in North Carolina.

Increasing focus on that not only personally for us as we take care of others, but also what do we do as a system?

What can we do as a state to make sure we're addressing the mental health needs of the people in North Carolina, particularly in children and adolescents.

For an adolescent today who has a mental health issue, if they can go to the emergency department or to jail and wait, if they come to the emergency department, their wait before we find them a place globally, all of us across the state, it's almost three days in the emergency department, and that's really not acceptable.

So we have to change how we're taking care of providing services for the mental health of the people in North Carolina.

That has an impact on our overall health in a big way.

- Kevin?

- Well Dr. Burks, Joe mentioned social determinants of health, and I often spend time with healthcare leaders talking about social determinants of health, but more from an economic development perspective in that we can't make healthcare affordable enough for people who don't have a job or don't have benefits that can pay for healthcare.

I'm curious of how UNC Health is addressing how you ensure inclusive supply chain so that we know that if there are diverse companies that were engaging in healthcare, they tend to hire people who are diverse, and then they come to you with the ability to pay for care.

So just curious how you are handling supplier diversity and supply inclusion within the system and if you've seen that with other hospital systems as well.

- Kevin, to go back to your original part of your question, the social determinants of health, the big picture, are about 80% of what determines one person's health, so it is a really big deal.

Food security, housing, work, benefits, all those are a big part for all of us as a group what makes us healthy or not healthy.

For us as a system, the recognition of that, to pay attention to it, pay attention in how we take care of that person I talked about earlier, how we take care of each other, and then how we do our normal work.

We have a UNC Health supplier diversity program that we started in 2021, and our goal by 2026 is to have about a little bit less than 10% of our non-labor spend with minority and women-owned businesses.

So we're not where we need to be, but we're trying to make progress to make sure that we can get there.

We have over 15,000 active healthcare vendors.

If you do the numbers there pretty quickly, then we can make differences in this program that we're doing.

It's the right thing to do, and we're pretty significant investments into getting there.

- Let me unpack this idea, certificate of need that's going on in the Carolinas, and we're gonna lead to a Medicaid question, Medicaid funding question, Dr. Burks.

In South Carolina, there's a real effort, at least I know in the senate, in the general assembly, of doing away, completely away, with a certificate of need process for hospitals.

In North Carolina, that seems to have become a bottleneck for Phil Berger and the senate, as it presented with the idea that North Carolina may or may not now accept Medicaid dollars, at least in this year.

Where do you come down?

How does the hospital come down?

We know how the hospital association comes down, but what are your thoughts?

How do you reflect on this idea of certificate of need modification and how it will end up characterizing what Medicaid acceptance in North Carolina would be?

- For us, the expansion of Medicaid is a really big deal to provide access in North Carolina for people beyond the hundreds of thousands that we could do with expanding Medicaid, that has primary importance for us.

Certificate of need, on how we best do that in the state, most people in North Carolina, almost three and a half million people live in rural areas.

That makes it a really different state than most.

We have second to Texas only the most people who live in rural areas, so the urban rural divide is very real here, and the certificate of need, how it plays out in both of those, is real.

I think we have to have discussions about certificate of need and how it looks different than it does right now, because that is an important part of us having Medicaid expansion.

So we're willing to sit down and talk about how it might look different going forward.

- Do you think that the inability of it possibly happening this year, which is looking less and less like it would, do you think it is just a matter of time?

Would you expect it to happen, Medicaid expansion, that is?

- I still have some hope that it will happen this year.

I don't think it is inevitable that it will happen at all, so that's why we're working hard with all the different constituencies to help them understand how important it is for us to meet our mission, which is to promote the health and the wellbeing of the people of the state, and the increase to access that Medicaid expansion provides is such a huge deal, so I have not lost hope.

I believe that we'll get there at some point, but it's not inevitable at all that we'll get there.

- [Chris] Okay, Joe?

- I just wanted to ask you if you could also prognosticate a little bit about future of mergers and acquisitions and health systems across the Carolinas.

We've seen a lot of activity, as Chris mentioned in the intro.

Where is that going?

Are hospitals just gonna continue to get bigger and bigger and bigger, and how will they continue to focus on the health of the people of the Carolinas as they do?

- The growth for healthcare systems has accelerated through the pandemic.

It had started previously.

My expectation, it will continue if not accelerate it more.

The finances of healthcare and being able to better meet that by that growth is such a big deal.

For us as an academic healthcare system, our filter in thinking about how we might grow is the effect that it has on our academic healthcare practice, our tertiary, quaternary care, the effect on our population health, which is a big deal for us, the effect on education and where we can provide sites for training more students and residents that we talked about earlier, as well as the research, that we can get research out to the people in North Carolina.

If we can do that better, particularly for the people in North Carolina and regionally, we'll continue to talk with people that we can partner with to do that, but big picture healthcare, I see that continuing, if not accelerating for the next several years.

For us, that filter or those filters that we talked about, we continue to keep in mind though our primary mission, which are the people in North Carolina.

- Kevin, we have literally about 90 seconds left.

Last question.

- So Dr. Burks, we see a lot more competitors now entering the healthcare space.

Just curious how traditional healthcare providers are responding or shifting their business models as new competitors enter the healthcare industry.

- We talked earlier, that two people that we talk about a lot.

One is the person we work with, and the second one is a person we want to participate in their healthcare.

Healthcare for decades has been built around a place, a hospital, and a provider.

In the future, healthcare has to be built around a person.

So their experience, their access, virtually, however it might be, then that's where healthcare systems are going and that's what we're trying to do.

How do we build a new healthcare system for the future around that person and them allow us to participate with them and their healthcare?

- Okay Dr. Burks, thank you for being on our program again.

I hope you'll come back, and I hope next time, when we look back on this appearance and this visit by you, that it's not quite as spectacular as it was from March '20 until now, but we hope you continue, and best, and thanks for your leadership at UNC Health.

- Thank you.

It's good to talk to you all today.

- Thank you.

Kevin, welcome to the program.

Please come back.

Hope we didn't scare you off, and we hope you'll come back.

- If you have me, I'll be back.

- Okay, please.

Thank you for watching our program.

If you have any questions or comments, CarolinaBusinessReview.org.

You can watch programs, share programs.

Until next week, happy weekend, happy summer, goodnight.

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