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- Well, against a backdrop of everything that's going on, financial uncertainty, peak political drama, and in general, these widespread, anxious social issues that go on.

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Welcome again to the most widely-watched and the longest running program on Carolina business policy and public affairs.

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Thank you.

I'm Chris William, and we unpack some of these issues at hand and later on we welcome back to the dialogue, the chief doc, if you will, from MUSC in Charleston, Dr. Patrick Cawley.

Stay with us.

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On this edition of Carolina Business Review, Anna Beavon Gravely from NCFREE, Chris Finn of the South Carolina I-77 Alliance, and special guest, Dr. Patrick J. Cawley, CEO of MUSC Health System.

(invigorating music) - Welcome to our program.

Thank you again for supporting this program.

Note here at the top of this dialogue is Chris Finn from the I-77 Alliance, is not here, not on the set.

He was not able to make the dialogue.

So Anna Beavon, once again, and you've done, you've pinched hit for us last time.

This doesn't happen a lot when we have people that can't show or don't show.

But you were nice enough to say, "Sure.

Yeah.

Put me in, coach."

So you're in.

- Put me in, coach.

I think it's gotta be me.

It has to be at this point.

One more time and we're gonna know for sure it's me.

- Let's start with education.

- [Anna] Yeah.

- And I wanna start with South Carolina because this is, this is pretty amazing and it's also pretty amazing in North Carolina.

On May 4th, so, recent headlines, have South Carolina Governor Henry McMaster signing legislation.

Highly debated, much talked about for a long time in South Carolina that will provide annually about $6,000 for private education, school choice in South Carolina.

I'm probably not doing that complete justice by the way I describe it, but the governor signed this into law in North Carolina, and I wanna read a headline on that NC site, North Carolina.

It says, "Bills expanding private and charter school funding get approval from the House Education Committee."

Where did this come from in North Carolina?

And is this going to happen in North Carolina too?

This is pretty amazing, isn't it?

- It is absolutely amazing.

So, North Carolina has a long history of really expanding school choice.

In 2010, they released the cap on charter schools, which is originally capped at a hundred charter schools.

And then we've seen a voucher program, or opportunity scholarship grant, and then an ESA- educational savings account.

And as we've seen, as years have progressed, and when Republicans have taken over the General Assembly, they wanted to provide more choice.

They wanted the dollars to follow the student instead of the dollars to follow the school.

And so having parents have more choices for their kid to figure out what kind of education model fits for them is really on the hearts and minds of many of the legislators.

And obviously, it's on public opinions, on the favor of public opinion as well.

- You know, the opposition to this, it didn't melt away completely, but- - [Anna] No.

- It went away enough to know that it's gonna happen.

It's happened in South Carolina.

It's gonna happen in North Carolina.

A good chance it's gonna happen in North Carolina.

Why did that happen?

Was it the pandemic?

Did that have people look at education differently that much?

- Oh, I absolutely think the pandemic impacted everything.

We've talked about it before, how the pandemic has impacted many areas of public policy.

But when you have parents who are sitting there watching their kids for a year and more than a year in some places, try to learn online and see they're more involved in their children's lives and their schooling than they really have been before.

It's not that they didn't care before, but they're seeing it in a different way now.

And so they wanna get more involved.

And so that's where public opinion comes into play.

And truthfully, North Carolina has expanded the Opportunity Scholarship Grant in virtually every budget we've had, and then the many budgets when we had a tough budget season.

And so, instead of just going a little bit at a time, I think the thought here was that lawmakers would take the hit all at one time of expanding to universal voucher program instead of just incrementally taking the public hits.

- Yeah.

Since we're on education, Anna Beavon, let's talk a little bit about the community college system in South Carolina.

It's a technical college system, but they're both pretty much the same and they're both very important to community develop, economic development, family development, personal development, all of those things.

North Carolina has named a new president of the college system, Dr. Jeff Cox from Allegheny County, originally in North Carolina.

So how does that, how does the naming of a new community college system president in North Carolina, how does that unfold against the backdrop of what seems to be the general assembly in North Carolina's consolidating power and wants more sway over the community college system?

Is that the right way to look at it?

- Well, I would sort of, I would look at it a little bit differently.

So we, in North Carolina, the community college president, we've had six in the last seven years I think.

- That's a pretty high turnover.

- That's a lot.

That's a really high turnover rate, which is ultimately a market signal that something's just not sticking.

And so I think with this, the goal with the legislation being discussed, about really dividing powers, is to create clear, distinct lines of operations so that the board knows what their job is and the community college president knows what their job is and can carry on tasks.

And so, it's more of dividing vision versus task.

That's how I really view that.

And so it's not necessarily like pulling power or consolidating power, but really creating clear lines of, of roles and responsibilities.

- We've got about a minute before we bring the guest on.

Do you think Jeff Cox is the guy for the job?

- I think we'll find out.

I certainly hope so.

- Yeah.

Okay.

That'll be enough.

Thank you.

- [Anna] Yeah.

- Let's bring our guest out.

And again, thanks for stepping in on your own here.

(Anna laughing) Wonderful job.

Coming up on this program.

We like to do this every year around the beginning of the season- and that's the summer season.

Unpack what tourism looks like.

It is the single largest industry in both North and South Carolina by the numbers, by total revenue.

So what is tourism saying about the year 2023?

Along the coast, along the beaches, in the mountains, et cetera, et cetera.

We will do that with Wit Tuttell from North Carolina's Tourism.

And also Duane Parrish from what's called PRT in South Carolina's Parks, Recreation, and Tourism.

They are the dynamic duo for sure.

They work together closely and we're gonna unpack some things with them in just a bit.

So, our guest has been at the medical university in South Carolina for more than 20 years now.

It's hard to believe that.

A couple of questions.

Was that his plan from the beginning?

Well, we're gonna find that out.

Joining us now, and we're glad to have back on the program, the Chief Executive Officer of the Medical University of South Carolina, Dr. Pat Cawley.

Dr. Cawley, welcome to the program.

Did you think you were gonna be there for 20 years?

How'd that happen?

- Of course not.

You always think you're going to a place just for a few years and you know, we moved to Charleston when one of my kids was young and we had two more kids while we were there.

And then, you know, you end up raising a family, it's harder to move.

But MUSC has been a fantastic run.

There's growth in South Carolina, there's growth in across MUSC and you know, I spent almost 10 years as the chief medical officer and then last 10 as the CEO.

And it just continues to be a great place to work and practice medicine, and exert leadership.

I'm not leaving until I'm- When I'm no longer having fun, I'll leave.

But I'm still having fun.

- So you're an MD - Yes.

- You're an MBA.

- Yes.

- You've brought that to bear, as you said, CEO for the last 10 years, Dr. Cawley.

So let's look at the industry.

You've got an industry that has been, I'm gonna call it "under fire" to some degree.

But seemingly, in the last few years, has been in a triage mode.

And of course that's my description.

But you've got rising healthcare costs, you've got inflation, you've got a shortage in workers, you've got folks that tend to be fearful and pessimistic about the healthcare industry.

How do all of these things, when you look forward, what do you need to get right?

What does MUSC need to get right as you grow the system and as you try to do what you are supposed to be doing?

- I think your characterization of "under fire" is accurate.

And that's not new.

And people have heard a lot about the healthcare system and engaged with it over the pandemic.

But this was going on a long time prior to that.

I mean, my entire time as CEO, over 10 years, has been dealing with this, you know, almost siege mentality.

The pandemic just sped a whole bunch of things up, right?

Healthcare is expensive.

Probably the number one thing we have to figure out is how can we deliver care that's less expensive?

We are firmly committed to that at MUSC.

That's not an easy thing to do, but we gotta make healthcare less expensive.

The second thing about healthcare is, we have to be patient and family centric and you know, we always don't get that right.

We're firmly committed to that at MUSC as well.

You know, the last thing I would point out is the workforce.

And the workforce, once again, if you asked me prior to the pandemic, one of the things I worried about was burnout in healthcare.

Pandemic comes along and it's just lit that rocket.

And so we're dealing with burnout across the entire industry.

And we gotta get that right.

Cause then if we don't get that right, we can't do the other things.

So we spend a lot of time right now on how do you address burnout?

How you address.

How do you get new workers?

How you invest in them early.

And that's kind of what we're finding.

We're finding that what we have to do is we have to partner with educational institutions to all levels, right?

We have to bring people in early, make them part of the family early and let them grow with us.

But that's, you know, that's not something you can turn on a dime.

It's something you work on for a number of years.

- And, you know, Dr. Cawley, I don't wanna look for- I'm not seeking drama here.

But as you describe it, I think it sounds like, as you called it, "under siege", it sounds like an industry that is beyond a turning point.

That is, I mean, so when you're in that state all the time, how do you manage through that?

Truly?

How do you manage through that?

- Well, you know, first of all, I have a very positive outlook on life.

I'll use those words "under siege", that's what it feels like sometimes.

But I'm a very optimistic person.

We focus on things that are, that make patients better, that make families better.

At MUSC we have the fortitude to be working on some of the very cutting edge stuff.

And I always find that, as a physician, to be very, very helpful and just, you know, just continue to look at the positive side.

But there are things we gotta fix in this country.

Primary care, mental health care, you know, palliative care.

I mean, these are things we have to fix, you know, we'll work on them in our individual health systems, but these are things we gotta get right across society, and culturally.

And those are some of the things that if we don't get them fixed, we're never really gonna get our arms around a lower cost of healthcare.

- [Chris] Yeah.

Maybe.

- So, Gallup had a poll that recently came out that said that 88% of employees were unhappy at their jobs, which is overwhelming.

And so as you talk about burnout and the research that you guys have done, and working with the individual, or your employees, from the beginning and growing with them.

What other ways are you seeing opportunities to come alongside them and really, I guess, fly in the face of that statistic?

- People ask me all the time about what I worry about.

What do I focus on?

The number one thing I worry about is burnout.

And the number one thing I focus on at MUSC is our employee engagement.

Cause if I can improve employee engagement and satisfaction, everything else is easy.

You know, the finances are easy, the quality's easy, all that.

So I focus on that and I lead that as CEO.

And people know at MUSC I'm gonna be asking about it.

- [Anna] Yeah.

- A lot of that's at the local leader level.

I mean, you have to empower leaders to lead teams, invest in leadership.

And I'm proud to say that, you know, we all took a hit with the pandemic as things got tough and our employee engagement did go down with the pandemic.

It didn't go down as far as others cause we had been working on it 5, 6, 7 years prior to that.

And then I just got our results a few weeks ago on our survey this year, and we've popped out of it relatively quickly, right?

But I'm not gonna take that for granted.

I mean, we have to keep worrying about it.

We have to find what people and our employees want.

You know, right now we're spending a lot of time trying to partner up with different kind of healthcare institutions, as well as education institutions, at all levels, at the grade school level, the high school level, the tech schools, and on up.

To try to get people into healthcare early.

People don't realize the number of and types of jobs that we have in healthcare system.

- You mean beyond being just what a healthcare professional has traditionally done?

- I mean, they know about doctors, they know about nurses, but they don't know about respiratory therapist or a surgical technician or a nursing technician.

They don't know about these positions.

And these are good-paying, solid jobs that you could have for your entire life.

And you can take time off from those jobs and always come back to them.

- One of the things you said at the beginning of the top of the program, or the top of the dialogue with you was the this idea of cost and how it's important to you.

And I believe you're very sincere about that.

So how do you approach what has been an opaque, what many people call an opaque pricing model, that they don't understand.

Price transparency is an issue and people will complain about, "Well, I don't know, why did I pay that for an x-ray?

How much is that really?"

How do you unpack that?

How do you level that playing field?

Is there an easy way to do it?

- You know, this is an incredibly difficult topic.

It gets to me personally, because at the end of the day, one of the things that causes this is this decades-old charge system and everything works off the charge.

And a charge is not a cost.

Now I'm blowing your mind right now, but that's essentially what we deal with.

We deal with these charges that were set in the late '60s and early '70s, and that system has to be thrown out somehow.

I almost wonder, if I could, if you asked me if I was king for a day, what I'd do, I would throw that system out and I'd restart the way we price in healthcare because, you know, people see these million-dollar bills.

It's a charge, it really means nothing.

There's already been a negotiation with an insurance company that there's a fraction on a dollar being paid there.

Right?

But it's confusing.

I get it, I get it.

You see a million-dollar bill and I tell you it doesn't mean anything but the, you know, the 5% charge we're really getting paid, that's what really counts.

It's too confusing.

So I don't think we're gonna get our arms around it until we actually make the system of how we price and how people pay in healthcare a lot more simple.

It's just that, I've been part of task forces over 20 years to try to simplify it, to be more transparent, and I know there's a lot of good people working on it, but it's almost like the current system just has to be thrown out.

- Do the payers wanna do that too?

- Well, it's tricky, and I get it because, you know, they...

I get it.

A hospital submits a bill with a million-dollar charge on it.

Right?

And it sometimes pits the payers against the providers.

You know, the payers can say, "If not for us, you'd of had to pay a million dollars."

- [Chris] Yeah.

- Well, there is, it's just not the facts.

- It might be true, but not accurate.

- So, I think we really all gotta come together.

We gotta say, "This system is antiquated, it's built on a system that came out of the '60s and '70s.

It's just not the right way to think about it anymore."

And throw it out.

- [Chris] Okay.

Anna Beavon.

- So in North Carolina, we've had a lot of conversation about Medicaid expansion, and associated with that has been some certificate of need regulations and some repealing of those regulations.

In South Carolina, you guys are also working down the road of repealing certificate of need.

How do you think that's gonna impact your landscape?

- There's been a ton of debate about certificate of need.

- [Anna] Sure.

- In the middle of it is, you know, and just yesterday, the legislature, the Senate voted and confirmed a house bill to repeal parts of CON immediately for certain ambulatory, outpatient type of buildings.

And then in three years, repeal the hospital portion of that.

So we got repeal coming.

It's just gonna be staggered over the next, next several years.

So it is gonna happen.

- [Chris] Will McMaster sign that bill you think?

- I think it's probably gonna be signed today.

Maybe Monday at the latest.

But I think it's gonna happen very, very shortly.

I don't see any reason why, it was unanimous in both houses.

So, it's probably gonna be signed.

From our perspective from CON, to be successful in healthcare, you need three things.

You need money, you need doctors, you need patients, right?

I think there's sometimes a belief that if you had money, you're gonna be successful.

And I've been in this long enough that that is not at all the case.

So, we have dollars, you know, we have borrowing ability at MUSC, we certainly have the doctors, and we certainly have the patients who follow the doctors.

So, as long as we stay with that, we're gonna be perfectly fine.

There will be a lot of competition coming into the state over the next, you know, three to five years.

You know, if you look at other high-growing states such as Florida, which repealed CON, and I would say Florida is probably the most like South Carolina, potentially North Carolina, if they end up repealing.

There's gonna be a lot of money come into the state and there'll be a lot of, you know, different things happening for three to five years and things will settle out.

That's what happens.

So, I think we'll be fine.

Most health systems will be fine.

They'll be new entrance into the market.

There'll be new partnerships.

I think it'll be fine.

I'd like to see though, North Carolina, match what South Carolina's doing.

Right?

I'd like to see Georgia do the same thing.

Makes it a little bit tricky for us as a healthcare provider when you're on one side of the border and the other side of the border can do what they want.

- You know, do you think South Carolina will match North Carolina when it comes to Medicaid expansion?

- I think South Carolina's taken a little bit different tact.

South Carolina Department of HHS under director Robbie Kerr has looked at how to pay better.

So I think that's, you know, at the end of the day, that's really what it is.

- [Chris] It's effectively the same.

- And I think he's trying to incentivize providers to actually see more Medicaid patients.

That's the tact he's taking right now.

And that's what we'll be working on over the next few years.

- Yeah.

Okay.

Anna Beavon?

- So, you said that you're gonna stay in this job until you stop having fun.

What are some of the really fun things that you've done that maybe aren't getting the coverage that you would like them to?

Or you're sort of like noodling on them?

Are there any previews to fun things?

- You know, we've done a lot of great things in my time at MUSC.

I've had a phenomenal team.

You know, I'll show you one of them.

I mean, we, just across the border here in Lancaster County, we developed a kidney-transplant program in a small community hospital.

That is not done across the United States.

But we felt, for a lot of different reasons, if we're gonna make that hospital sustainable in the long term, we gotta bring new things to that hospital.

So we brought a kidney-transplant program to that hospital.

I mean, that's unique.

We're getting people transplanted.

We're getting them closer to things that they need.

Telehealth is another one.

When I first started this job, MUSC started to trickle into telehealth.

And that has been something that has really been a game changer.

Pandemic came along and everybody got into telehealth.

- [Chris] Yeah.

- And I do think telehealth is gonna continue to change the way healthcare is delivered.

And as people get more and more comfortable with it, and there are a lot of different kinds of telehealth, people just tend to think about the one where, "I'm on a video here and you're on a video there", but there's many, many different kinds.

We have over 80-some programs at MUSC that we're trying to develop.

And at the end of the day, it's all about trying to bring easier healthcare access to people.

- Yeah.

And as you talked about the fun things, the not so fun thing, but maybe one of the most acute, is mental health.

In fact, in 2021, if memory serves me right, a release study from MUSC, from the pediatric side of the hospital, talked about the dramatic increase in child and teen suicides.

What's your role in leadership around- and not just that, Dr. Cawley, but this mental health bugaboo that is really like an octopus?

- Well, you actually said it right.

I do think MUSC needs to step into a new leadership position in mental health.

Right?

And I would even classify kind of our new leadership position as one of those fun things.

I really do think we have to get our arms around mental health in this nation, and it's gonna require different thinking.

MUSC, for a long time, has been a big mental healthcare provider in the state of South Carolina.

We have one of the biggest inpatient facilities in the state.

We take care of a lot of very, very, very, very sick, on the end of one spectrum, people with mental health disorders.

But that's insufficient.

And so we have determined we're doing a complete strategic repositioning here.

We have to get more in the outpatient space.

We have to use our telehealth in a way to, you know, when people are starting to spiral down, let's try to connect them quicker.

We also have to build new facilities.

South Carolina is a growing state.

We're partnering up with the state.

We're gonna build a brand new mental health facility in Florence, South Carolina.

The state has given us the dollars to do that.

So, we're gonna build a brand new facility.

We're gonna combine inpatient and outpatient and clinics and telehealth.

And that's our partnership with the state, with McLeod Health, with the Department of Mental Health.

And so we're gonna try something new there.

So, we are gonna step hard into delivering and trying to find ways to deliver mental healthcare.

And that's not even the right term.

It's behavioral healthcare.

Cause behavioral healthcare is both mental healthcare and substance abuse.

- Is the mental- and we only have a minute- is the mental health thing just a funding issue?

If you had more, if you had more oxygen in it, then you could do it.

- Part of it's funding, but part of it's finding the right way to connect with people.

You know, how do people get therapies?

How do people get diagnosed?

This is just, you know, there's just not as much maturity and that part of the healthcare system as there is in other parts.

- Do you think that telehealth is a step in that direction to sort of normalize?

- And we have 30 seconds.

- Absolutely.

One of the most, believe it or not, one of the things we found in the last 10 years that people are most satisfied with is telemental health or telebehavioral health services.

- [Anna] Oh wow.

Interesting.

- It's very- it's private.

It's in your own home.

- Yeah.

- And there still is a stigma in behavioral healthcare.

- Thank you.

MUSC was a leader on that.

I remember early days with telehealth and MUSC's name was wrapped around that.

So, thank you for your leadership.

- Absolutely.

- Thanks for making the trip from the low country to Charlotte to see us.

- I'm always happy to come and talk.

- Thank you.

It's nice to see you, Pat.

And Anna Beavon, thank you again.

- Happy to be here.

- For carrying water for both panelists.

(Anna laughing) Until next week, I'm Chris William.

Certainly hope your weekend's good.

And good night.

Thank you.

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