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News Room: Press Releases

Virtua CEO discusses changing healthcare environment with hospital industry leaders

Virtua CEO Richard P. Miller

Virtua CEO Richard P. Miller

Becker's Hospital Review hosted its Hospital Strategy Roundtable this summer at the Four Seasons Hotel in Chicago, bringing together seven hospital industry leaders from across the country to discuss current challenges and opportunities facing the industry, how hospital strategy will need to change to survive and which strategies will provide a foundation for long-term success. Virtua CEO Richard P. Miller was one of the seven panelists.

Participants

Jim Abrams, COO, Medline Industries (Mundelein, Ill.)
Scott Becker, JD, Publisher, Becker's Hospital Review, Partner, McGuireWoods
Alan Channing, President and CEO, Sinai Health System (Chicago)
Andrew Hayek, President and CEO of Surgical Care Affiliates and chairman of the ASC Advocacy Committee
Chuck Lauer (Moderator), Former Publisher, Modern Healthcare, Career Coach and Public Speaker
Stephen L. Mansfield, PhD, President and CEO, Methodist Health System (Dallas)
Mark Newton, President and CEO, Swedish Covenant Hospital (Chicago)
Richard P. Miller, President/CEO, Virtua (Marlton, N.J.)
Kristian Werling, JD, Partner, McGuireWoods

Chuck Lauer: The one thing you can say about healthcare is it's continually changing every day. It's the most dynamic industry in the world. What an exciting time to be in healthcare. I've never seen quite the confusion and the turmoil that's going on in the minds of so many people in the industry. The first question I'll pose for you all is a pretty simple one: What are you priorities right now? In terms of the things you go about in your day-to-day activities, what are the things that are really important to you as you hit the office?

Stephen Mansfield: I'll mention three. I think it's a long list, and what's my priority today could be different tomorrow. For our organization it's passionately communicating the why, what and how of healthcare reform to all of our organizational stakeholders. I'm still struck by the challenge to get everybody comfortable or at the same place [in understanding] the why, what and how of healthcare reform. That's a priority for me. I think it's a role I can't delegate to anyone else. It's a CEO question. I think there's a lot of discussion about what healthcare reform is and how we plan to accomplish it, but not nearly as much — and especially in our sector — about the why.

Secondly, I would say I find myself spending a lot of my time with strategy….trying to have a relevant strategic plan with all the uncertainty is probably as challenging as it's ever been in my four-decade career. Within all of that, I find myself struggling with organizational pacing. We know what we want to do, we know what our priorities are, but we physically can't get it all done so we have to revisit periodically about the pace.

Third, I'd say all stakeholder groups are important but I find myself with a lot more meetings and a lot more complexities around medical staff issues. It's always been a major part about what we do, but the complexity and the number of times now I'm being asked, "What should I do?" by physicians is a new phenomenon for me.

Mark Newton: Well, there are multiple priorities, but the things I'm most concerned about are what I call, in healthcare reform, the 'unintended consequences.' My own perspective of this is that the consumer is not engaged in healthcare reform, and there's a huge void that is looming out there where the average patient has no concept of what's going to hit them and their responsibilities. I'm immensely worried about the lack of attention being paid to the public consumer. I also believe that the legislators have no concept how to implement this and we're certainly scrambling as well. I'm just trying to figure out our role and my role in addressing or trying to get some clarity around all these things that are uncontrollable, and articulate the consequences so at least members of the public and legislators know. It's unfortunate hospitals have really been put in the role of explaining that.

Richard Miller: I think everything that Steve and Mark stated is spot on. I think the thing I try to work on regularly is talent development for people in my organization. I think if you develop talent, it gives you the ability to maneuver and to grow quickly and in a proper way. So if you find people that are very talented, to me it's the most important thing you can to do, and that's probably true in any industry, but in healthcare today I think it's especially important.

Secondly, I think [hospitals] are the ones that will eventually be required to deal with the health of our communities. So how are healthcare systems in the future going to be able to care for the public and help them with chronic disease issues? I see that as something for which we are preparing. I think one of the major challenges of any healthcare organization today is, the transition from one economic system (fee for service) to the assumption of risk in a population based economic model. In my opinion, the economics aren't there yet for healthcare to totally move to population-based management, so to speak. So, you're trying to prepare for that future, but you can't turn that light switch on yet, because economically you can't afford to completely move in that direction.

Finally, the physician component is a big issue as well. Physicians are looking for partnerships and employment, as we've seen in our part of the country, the wave of physicians coming to us for employment is overwhelming. We can't keep up with it at this point in time, so it creates a dilemma for us economically.

Alan Channing: When I meet with our new employees, I talk about what an exciting time it is to be in healthcare. It sort of reminds me of the old Chinese curse, "May you live in interesting times." When you look at [Sinai's] payor mix, we're about 60 percent Medicaid, 20 percent Medicare, 15 percent uninsured and 5 percent everything else. So, we're excited about healthcare reform because at least two-thirds of that 15 percent are going to be covered, and we think we're uniquely positioned to care for that population. What you can control and what you can't control, though, are the things I struggle with.

Chuck Lauer: One of the paramount things that has come out of just distilling these comments a little bit is that nearly all of you have mentioned physicians. I'm intrigued by what kind of models you're setting up for the physicians in terms of working with them. What kind of models are you exploring? I think this is going to be a whole new movement that's going to be fascinating to observe, and it's tough one for each of you who are in the business of running hospitals.

Richard Miller: I think the approach is to use a myriad of strategies on the physician front. We have an acquisition/employment strategy for doctors, primarily primary care. We're very invested in primary care in our community but specialty now, too. It's amazing how many cardiologists now are looking for employment. A second strategy, with our surgeons, is joint venture. We have five surgical centers that have been very successful for us. That part of our business has actually grown. We're looking at some co-management models as well, particularly for the cardiologists. Then, we have our independent physicians [who] want to stay independent. We support their independence. From my perspective, you have to have a multiple tiered perspective to deal with everybody's needs. Five years ago I didn't see hardly any of this type of activity, now it's an onslaught and you have to be prepared for it. The problem is the economics are tough.

Mark Newton: For Swedish Covenant, it's a combination of independence and employment combined with training programs for primary care physicians in order to form a "farm team" so that people who understand the culture and understand the community stay with the organization. It's so much easier to train someone for four years and bring them into a delivery system in more formal way [than it is to recruit already practicing physicians]. Over the last couple of years, this has been a huge piece of our overall strategy. We do have that creative tension between employed and independent [physicians], and it's like a teeter totter managing that balance. You really do need to be engaged in [multiple strategies] concurrently, you can't just take one strategy or tactic and make it work.

Chuck Lauer: Steve, you're in a hotbed of physicians in Dallas. You've got a lot of action going on.

Stephen Mansfield: It's the wild, wild West. As you all said earlier, I do think you have to be pluralist in you approach. We have everything on a continuum from shared ownership in two of our hospitals to medical directorship, which I guess are probably the most benign. I was reading that almost 50 percent of physicians are employed or in relationships with hospitals, and almost 76 get money from a hospital in some form or fashion. So, the vast majority of physicians are in some kind of financial relationship along the continuum with hospitals.

I would reflect maybe on two things. I try every three years to do about 60-80 interviews with different members of our medical staff. This past time, last fall, I met with a group of our employed physicians and I initially dreaded the meeting because I thought it could be a gripe session. But, I was so impressed by how engaged they were in the things I was interested in. As I reflected upon why, I think one is that Texas is a corporate practice of medicine state, so we're forced into governance structures that allow physicians to self govern, as you would want to do anyway. And, the structure that's been in place at Methodist since long before I arrived there really does allow the doctors to feel like they're captain of the ship, because they really are.

Scott Becker: I've heard a couple of you say it's about a pluralistic strategy, not a one-size-fits-all [approach]. But, if you look at three or four different strategies — employment, co-management, joint ventures or other types of some financial relationship — do you have to have a core strategy for physician alignment?

Stephen Mansfield: Well, for us, we're spending much of our energy and a fair amount of our money right now on trying to put together an acceptable clinical integration strategy, because most of our medical staff members are still independent. We want enough scale on the primary care side that they pay attention to us. Our strategy for independent physicians is to bring them together in clinical integration model that allows us to load the bank based on performance metrics and distribute out of the bank based on quality metrics, and that's oversimplified, but that is something I want. We're trying to figure out how to get all of our independent physicians aligned with us in a meaningful way.

Mark Newton: When reflecting on what our core strategy is for physicians, I go back to communication. We've established a board committee specifically on physician relationships, so governance is deeply engaged. I have a very disciplined structure in terms of business rounding through roundtable-like conversations with physicians. I have calendars that are totally blocked out for private lunches with physicians, and I have four physician liaisons who are out in marketplace. I've got a meeting at 8:30 am on Monday for an hour to talk about physician strategy for the week. And it's all related to communication, translated to a very fast, real-time response. So the structural concept of employment, joint ventures and training are all superseded by very aggressive very tight communucation.

Scott Becker: In terms of the constant communication and engagement, is this done by the CEO directly versus lieutenants of yours?

Mark Newton: It's, right now, consuming probably 40 percent of my time.

Richard Miller: Most of the physicians want to talk to the CEO.

Chuck Lauer: They want to talk to the boss. They want to talk to the top guy. Andrew, do you have some reflections?

Andrew Hayek: This all resonates. The thing that we spend a lot of a lot of time on in each market with each or our health system partners is the appropriate strategy for that market and the strategies for each sub-segment of the market. There might be a core area that our health system partners is trying to penetrate into, and there are different strategies for that area for different physician specialties — primary care versus cardiologists versus surgeons, etc. Of course, when you get to surgeons we craft strategies in the market that are different by specialty and by area, and sometimes that strategy includes co-management with hospital departments. We've seen some great success when we align financial incentives for surgeons in the hospital setting, mimicking some of the same alignment from the ASC setting and bringing that to a hospital surgery department.

We use a variety of models with our health system partners, which underscores the importance of recruiting and developing highly talented leaders. You have to have very sophisticated thinkers that can draft different strategies by specialty and by geography. Our partners and [SCA] try to be very strategic.


Chuck Lauer:
Alan, any thoughts around the issue of physicians?

Alan Channing: I was actually just thinking this is the one area where I don't envy the rest of you. I've been in that seat and understand the pressures dealing with the medical staff and trying to do the things all of you have described. We're in a very unique circumstance; nobody wants to be in practice where the market is primarily Medicaid. So, I employ my physicians, and for first time in my rich career when I go to medical staff meeting everybody is well-behaved. It's just amazing. Now, having said that, there is obviously some tension. I employ specialists, primarily because of teaching and trauma programs. We really function as a referral center for safety-hospitals on the West Side of Chicago. So where does my primary care support come from? It comes from a federally qualified healthcare clinic, which layers a whole different dynamic in terms of relationships.

Scott Becker: Mark, you mentioned spending 40 percent of your time on physician relationships. How much time do the rest of you find on hospital-physician relationships?

Stephen Mansfield: I don't spend 40 percent of my time, but I have seven hospital presidents that do a wonderful job, and I really expect them to be well-known and to be very active listeners and attuned to their respective medical staffs. You have to be careful not to usurp [the individual hospital presidents], otherwise you become the only one who can give them an answer.

Richard Miller: I don't know if it's 30 percent, but most of the time I spend might not be directly with physicians, but I spend a lot of time on the physician strategy front. My early and late day — dinners and breakfasts — is usually spent with physicians. The COOs for each hospital deal with the medical staff issues, and I deal more with the strategic issues.

Chuck Lauer: Jim, how was the changing dynamic between physicians and hospitals affected your company's role as a supplier?

Jim Abrams: From our perspective, we're seeing way more of our discussions taking place with clinicians, such as the chief medical or chief nursing officer. Frankly, if the culture of improving quality doesn't start with the C-suite, including the CMO and CNO, it's not going to happen. A very significant amount of leadership at Medline now is spent on high-level clinical discussions, because improving outcomes is what we've been task with under healthcare reform, or doing our part of the process anyway.

Chuck Lauer: Is it silly to ask if the salaries paid to physicians in an employed model are sustainable?

Mark Newton: Right now [this is a] scarcity premium. At some point, that premium will go away. The more looming issues are the cuts in graduate medical education; that's very concerning for hospitals that use training as a way to attract physicians.

Richard Miller: I think it depends on the market. Employment is becoming a defensive strategy in a lot of systems. If the strategy is completely defensive and not part of an overall growth strategy, the cost will become overwhelming.

Stephen Mansfield: It strikes me that if healthcare reform successful in keeping more chronically ill care out of the hospital, that also largely means keeping it away from the specialists, those that cut and do procedures. I have to think there is a point in time coming given that there is such a disparity between some of the high-end specialist salaries and primary care salaries will move closer. I don't see primary care salaries going down in our market, I see them going up.

Scott Becker: Andrew, from what you've observed, what's your sense on where physician employment is going?

Andrew Hayek: From what I'm seeing, primary care and cardiology are moving the fastest. I think the surgeons are quite different. There are some groups that are seeking employment, but I'd say that's the exception. At the same time, a large segment of surgeons are interested some form of alignment: medical directorships, co-management agreements or joint ventures. I do see a lot of reticence from surgeons on the full employment model.

Chuck Lauer: This talk of outpatient joint ventures brought to my mind the growing shift of inpatient care to an outpatient setting. How will the role of hospitals change given this?

Richard Miller: Surgery will go significantly more outpatient. We know that; we see that. To me, if you're going to partner, the time to partner with doctors and surgeons around outpatient is now. Frankly, it's a pretty lucrative business — in orthopedics extremely so. It's something you want to really be thinking about if you're not doing.

Scott Becker: Are you all seeing a decrease in total surgeries? I know we've all seen reports suggesting this recently, in part because of the lagging economy.

Stephen Mansfield: I know across our market and as I talk to people across the country, I think elective surgery is down related to the economy.

Andrew Hayek: What I would add to the economy is the growth in the pervasiveness of high-deductible plans, and we don't see that trend reversing when the economy recovers. A deductible of two thousand dollars or more dissuades a segment of people from getting certain types of care. Our guess is that it will be a flat-ish market for quite some time.

Richard Miller: I think hospitals really should include an outpatient strategy as a major part of their overall strategy because that's where it's going.

Chuck Lauer: So what are the unintended consequences of that?

Stephen Mansfield: I think one of consequences is there is going to be a lot of new competition in the outpatient space, because unlike the large brick and mortar costs needed for entry to inpatient care, that's comparatively less expensive. So, you have Walgreens and others I wouldn't really consider a competitor today that may competitors in the years to come.

Mark Newton: I would say we're seeing a very steady increase of 2-3 percent growth on the outpatient side and probably a light decrease on the inpatient side. It takes about six outpatient visits to replicate one inpatient in terms of revenues and contribution margins.

Scott Becker: Six outpatient episodes of some sort to make up for one inpatient. And you've got just this intense competition on the outpatient side. That's just got to be a challenging spot.

Mark Newton: That's one of the reasons you want to have employment strategy with physicians.

Jim Abrams: I think eventually the hospital is going to be the lynchpin in the community. Everyone's going to come to the hospital because they're going to get incentivized to reduce that readmission rate. Once that really hits and the money becomes significant, I think we'll begin to see hospitals choose outpatient partners even more strategically than they probably already do now.


Chuck Lauer:
I want to turn the conversation to another big challenge for health systems right now — health IT. How much are you spending on IT now and how do you feel about IT?

Stephen Mansfield: I'll tell you every day IT is a frustration to me because of the disparate systems. Technologically, we do not have what I know we're going to need to have. It's not what I'm spending today, it's that I know I have to come back and spend it again. I think having an effective EHR that gives you actionable data that impacts quality at the bedside is like unicorn…Everybody can describe it but no one has really seen one. Health information exchanges and cloud technology may help some, but until someone can take all of these disparate systems and get data in one place that has a common vernacular and can give data back to clinicians and others at the bedside in a way that can give them real-time information to improve performance — then I'm frustrated with it. I don't see an end to that imminently.

Kristian Werling: To add to Steve's point on the data not being used, I recently attended the TechWeek Expo here in Chicago and the keynote address was by Aneesh Chopra, chief technology officer of the United States. In his address, he told the attendees that if they wanted to make a billion dollars, they should look beyond creating the next Groupon and instead try to find a way to take the pile of data from health information technology and use it. His message was no one is doing that well now, and he really encouraged this huge room full of entrepreneurs and techies that this is the next threshold of opportunity.

Chuck Lauer: Very interesting. How about the rest of you? What are you all doing in terms of IT spend?

Richard Miller: Our spend in six years has been around $175 million and that includes the system, infrastructure, acute, outpatient and administration. It's a big spend and I'm still trying to figure out the overall return on investment for us. For me, the ROI is improved clinical quality and safety. At the end of the day, that's what we're measuring and I want to see that happen. I think the disparate systems are the critical issue. I told my CIO this year before I do another spend we're going to fix that. We have to fix that because we are wasting a lot of clinician time and energy on flow of information.

Mark Newton: We're at Stage 6 [of EHR implementation] and have been for a good number of years. I pretty much target about 10 percent of capital expenditure on IT total. We try to stay with just one system and are an alpha site for our HIE. We move very predictably, but I'm not picking up the pace. One of the observations I would add is I actually caution our independent physicians to go very slowly on an EMR. We're constantly telling physicians, 'Why are you putting a $25,000 server room into your office? Who's maintaining that?'

Richard Miller: To add to that, it's not only the IT piece, it's the integration of clinical technology into information technology. There's a lot of moving parts. But in saying all this, I must say, it's a must-spend. From the information perspective, I think it's something all hospitals are going to invest in.

Scott Becker: How do your systems deal with integrating the various systems used by your physicians?

Stephen Mansfield: What we've done, which has been a differentiating issue for us, is that we've said if you want to be employed by us, then you have to get on our system. We help with the cost of it. The advantage is once everybody gets on it and uses it you have standardized processes that are awesome, but everyone is coming from a different place and the productivity impact of having them go from how they've always done it to how they have to do it is challenging. We're having to patch around that with our reimbursement formula, frankly. The physicians do say though that because they're charting is so much better, their billing per case goes up. But, when you put that together with the lost productivity, that's still a negative that we're having to offset. Not bad, but a bit.

Scott Becker: Is that a temporary thing that they're going through?

Stephen Mansfield: We hope so.

Richard Miller: The other issue is the fact that many physicians today are splitter physicians. They go to a number of hospitals, and there are different systems in every hospital. We demanded that our physician base learn our system, but if you multiply that by 3 or 4 of 5 area hospitals, I feel sorry for the physician in that case. It's very difficult.

Stephen Mansfield: It's a tough issue. I agree that an opportunity for an EHR system that truly impacts quality will be available, but I think it's just going to take some time. But, I don't think anyone would advocate not investing in IT. You have to do it, but you have to know more investment is probably going to be necessary in future iterations.

Alan Channing: When you go back to physician relationships, this [HIT] is the one area I've had them knocking on my door. They want to know, 'How will I have to change my practice to make this work for me?' Speaking of scarce resources, there's not enough talent out there. There's not enough IT educators that can speak the language the physicians understand.

Chuck Lauer: I'd like to get into another topic. I'm always taken with the quality and caliber of people running our nation's hospitals. It's a very tough job. One of the things I have seen I guess in last 2-4 years is how mentoring has virtually disappeared from the stage. The time element seems to be the constraint. You just don't have the time any longer.

Stephen Mansfield: Going back in my own career, I never was in an official mentoring program but had wonderful mentors, but the pace was so different then than it is now. Young women and men considering a healthcare career and already in healthcare do come to try and talk, and I try to honor as many as I can, but I can't honor them all. It disappoints me in myself, because I think giving back is a part of our jobs. You just get to the point you're physically and mentally exhausted and can't squeeze everything in. I've never worked like this in my life. I think mentoring now is more on the fly — people watching what you do.

To reflect on another comment, I was talking with a recruiter for a senior level position recently and I said to him, 'I know every generation probably says this, but is there a generation behind us that is willing to do this job? Intellectually I know they're smart or smarter, but are they going to want to put in this kind of effort?' He said to me, 'Steve, this is a crisis. And I run into it every week more than the week before as I'm trying to recruit executives.' So, it's a dilemma. It's tough. I cannot put the time into mentoring I wish I could.

Richard Miller: I have to agree. The time commitment required compared to when I got into this business years ago is much different than it is today. It's every night of every week and weekends. And, it's not only the time commitment; it's the pressure and complexity of the work. It's a much different business than when I started. It's fully deregulated now, and I think a lot of people struggle with the fact that you're competing. It's a business. That takes a very different mindset than when hospitals were cost reimbursed.

Scott Becker: To this point of talent management and mentoring, Krist holds an MBA from Kellogg School of Management at Northwestern University. I'd be interested to hear his thoughts on this issue.

Kristian Werling: I don't think a mentor necessarily has to spend a ton of time sitting down and talking about certain things, but it's more about getting promising talent in front of key people and involved in key events. When I work with hospital CEOs now, it seems the great ones have a potential future leader by their side for physician negotiations, for supplier negotiations. That's the kind of mentoring I'm seeing today.

Mark Newton: There's no question there's intense pressure and it's very easy to get inundated with all of the different things that are [thrown] at you. But, I've really had great success from hiring people from other industries. I wasn't trained to be a hospital CEO. Having worked in airlines and hospital supply and international business, I find great success from bringing people in from different industries. They are marvelous, and they learn incredibly quickly. I don't go back to the typical intern route. I wouldn't say it's antiquated, but I'd say it's good to spice the organization up with talent that comes in with a different perspective. When I need a physician liaison, for example, I go to a sales person. We teach them a little bit about healthcare, and boy do they get it.

Scott Becker: And, that's the key. You find great, really bright people and spend a lot of time on recruiting. Employees can find their way very quickly.

Richard Miller: I actually spend a lot of time looking for talent in the middle of our organization. We found a young HR person that today runs our physician business. He's talented and he knows what to do and he does it well.

Mark Newton: We had an Olympic-ranked swimmer running the aquatics program at our fitness center who now oversees implant purchasing. Within six months, I can't begin to tell you how much cost he's driven out of the organization. The other thing I'd say is I spend a lot of time trying to model more business-driven behaviors and that corporate mindset that can sometimes be foreign in healthcare.

Scott Becker: What do you all have in terms of talent processes?

Richard Miller: We have three what we call 'best people review meetings' a year, where we evaluate the performance of our management team, and I sit in every one of those meetings. We group our managers into three categories: top talent, valued contributor and needs improvement. That's really how we mine top talent in the organization. About 65-70 percent fit into that middle category. I'm looking at people now edging toward top talent or in top talent and thinking about what their future roles will be in our organization.

We've learned every goal needs to have a measure, and we've learned that from the private industry. It's got to be measurable. If it's not measurable, we go back. The other thing we try to do: we don't talk about variance. That doesn't work in our organization. We want to know what will fix it and what's the timeline around the fix.

Chuck Lauer: To bring our discussion to a close, I would like to ask each of you, are you happy you chose healthcare as a career?

Stephen Mansfield: I'm happy. It's always been a blend of ministry and a job for me, personally. It was from the very beginning and it is still today. The ministry aspect has changed, and now I find myself as migrating to feeling like the most important thing I can do to make a difference is to communicate a message of hope and optimism and encouragement to all our employees and stakeholders. The times are so difficult and so uncertain and the complexity is so high, but yet we're in the miracle business. I mean, how many people get to work in the miracle business everyday? I think the message a CEO can give to their organization in this time of uncertainty is to make sure you pay attention to why, what and how as you deliver an optimistic story about your organization and the future. [That] is very gratifying to me. So, yes, I'm delighted to have chosen it, and I wouldn't make the decision differently if I could go back.

Richard Miller: I agree. I still love what I do. It's more of a vocation than it is work to me, and I think the key is to stay focused on why you're here. You're here for the patient. I'm a patient advocate through and through. To me, it's about the patient consistently. You have to go back to make sure the patient care is optimized. To, me though, there's the balance with the family too. I have to consider how long I can do this. I know I like to do this, but I have to consider my family too.

Alan Channing: Well, I'm a 60s kid. I grew up when we all believed we could make a difference in world and I still believe that. As to what Steve and Richard said — I can use different words and say exact same thing — to establish environment where the people I have the pleasure to work with see a difference in people's lives and see a future and to help them move in that direction is incredibly rewarding. There were times in my career where I thought I'd do something different, so I'd look around, but nothing came close to allowing me to influence people's lives in such a deep and personal way.

Mark Newton: The thing I most enjoy are the stories of how people in my organization have impacted and changed someone's life. It's so much fun just to hear that, and it puts everything else to rest. The other thing that's really fun is that when you tell people working in your organization that it's ok if you take your personal passion and combine it with a professional passion. I get to give them that freedom and tell them that that's exactly what we want them to do and see how they do that.

Jim Abrams: I will add I think we're all in a collective position to do good for other people. Every day you look at the number of people who are needing care, and as Baby Boomers age, we're all going to be in a place where we or some loved one needs care. I feel like if we play our part right, we can truly impact care.

Mark Newton: One other dimension for me that is very motivating personally is the concept of justice. I've often questioned why some people, based on where they grow up, gets access to care differently than others. Anything I can do to address that idea of inequity or injustice is very motivating.

Chuck Lauer: Thank you all for your valuable insights. Scott, any closing comments?

Scott Becker: I would just say this has been fascinating, and healthcare is just an absolutely fascinating industry. It just continues to evolve. Being a hospital CEO is a 24/7 job like no other. To be a CEO, you've got to love it. It's just an amazing thing. Thank you all again for talking with us.