James H. Johnson, Jr. William Rand Kenan, Jr. Distinguished Professor of Entrepreneurship & Strategy Kenan-Flagler Business School Director, Urban Investment Strategies Center Frank Hawkins Kenan Institute of Private Enterprise University of North Carolina at Chapel Hill DISRUPTIVE DEMOGRAPHICS The Changing Face of the Patient of the Future

Overview l Disruptive Demographics l Opportunities & Challenges l Implications for Healthcare Planning & Delivery

Disruptive Demographics l The “Browning” of America l The “Greying” of America l The Nexus of Diversity Issues

Veterans ( ) Baby Boomers ( ) Generation X ( ) Generation Y ( ) Core ValuesRespect for authority Conformers Discipline Optimism Involvement Skepticism Fun Informality Realism Confidence Extreme fun Social FamilyTraditional Nuclear DisintegratingLatch-key kidsMerged families EducationA dreamA birthrightA way to get thereAn incredible expense Communication media Rotary phones One-on-one Write a memo Touch-tone phones Call me anytime Cell phones Call me only at work Internet Picture phones Dealing with Money Put it away Pay cash Buy now, pay laterCautious Conservative Save, save, save Earn to spend Personal and Lifestyle Characteristics by Generation

Veterans ( ) Baby Boomers ( ) Generation X ( ) Generation Y ( ) Work Ethic and Values Hard work Respect Authority Sacrifice Duty before fun Adhere to rules Workaholics Work efficiently Crusading causes Personal fulfillment Desire quality Question authority Eliminate the task Self-reliance Want structure and direction Skeptical What’s next Multitasking Tenacity Entrepreneurial Tolerant Goal Oriented Work is ….. An obligationAn exciting adventureA difficult challenge A contract A means to an end Fulfillment Leadership Style Directive Command-and-control Consensual Collegial Everyone is the same Challenging others Ask why *TBD Interactive Style IndividualTeam Player Loves to have meetings EntrepreneurParticipative WORKPLACE CHARACTERISTICS

(CONT’D) Veterans ( ) Baby Boomers ( ) Generation X ( ) Generation Y ( ) Communications Formal Memo In personDirect Immediate Voice mail Feedback and Rewards No news is good news Satisfaction in a job well done Don’t appreciate it Money Title recognition Sorry to interrupt but how am I doing? Freedom is the best reward Whenever I want it, at the push of a button Meaningful work Messages That Motivate Your experience is respected You are valued You are needed Do it your way Forget the rules You will work with other bright, creative people Work and Family Life Ne’er the twain shall meet No balance Work to live Balance

People On The Move

Legal Immigrants: l : 206,000 annually l : 561,000 annually l : 800,654 annually l : 879,400 annually l : 1,137,000 annually Refugees, Parolees, Asylees l : 2.1 million (65,000 annually) l : 428,361 (85,672 annually) l : 487,386 (81,231 annually) l : 203,642 (75,661 annually) Illegal Immigrants: l 300,000 to 400,000 annually over the past two decades l Three million granted amnesty in 1986 l 2.7 million illegal immigrants remained in U.S. after 1986 reforms l October 1996: INS estimated that there were 5 million illegal immigrants in the U.S. l August 2005: Illegal population range from 7 to 15 million. The Numbers

YearAll ClassesExchange Visitors Academic & Vocational Students ,756,903108,023 (1%)271,861 (2%) 19859,539,880141,213 (1%)285,496 (3%) ,574,055214,644 (1%)355,207 (2%) ,640,540241,364 (1%)395,480 (2%) ,690,082351,743 (1%)699,953 (2%) ,824,088389,435 (1%)741,921 (2%) ,907,139370,176 (1%)687,506 (2%) ,781,330360,777(1%)656,373(2%) ,381,928506,138 (1%)917,373(2%) Non-Immigrants Admitted to the United States

World Region of Birth for U.S. Population,

GROUP% CHANGE All Races50% Whites29% Blacks94% Native Americans109% Hispanics238% Asians/Pacific Islanders412% Population Estimates by Race/Ethnicity

RACE / ETHNICITY TOTAL FERTILITY RATE Hispanic2.99 Non-Hispanic White1.87 Blacks2.13 Asian2.04 Native American1.86 Total Fertility Rates of U.S. Women by Race/Ethnicity

America’s Color Adjustment Race/Ethnicity White Blacks Hispanics Asian American Indian0.70.9

Relative Distribution of U.S. Population by Race/Ethnicity, 2005 & 2050 RACE / ETHNICITY White67%47% Blacks12.8%13% Hispanics14%29% Asian5%9%

Women who had a birth in the last 12 months, Ages 15 – 50, by Select Characteristics 2006 CHARACTERISTIC Births per 1,000 Women All U.S. Women55 Nativity Native Born52 Foreign Born71

Women who had a birth in the last 12 months, Ages 15 – 50, by Select Characteristics 2006 (Cont’d) CHARACTERISTIC Births per 1,000 Women All U.S. Women55 Race White, non-Hispanic50 Black58 American Indian/Alaska Native68 Asian54 Native Hawaiian and Pacific Islander61 Some other Race78 Two or More Races58

Women who had a birth in the last 12 months, Ages 15 – 50, by Select Characteristics 2006 (Cont’d) CHARACTERISTIC Births per 1,000 Women All U.S. Women55 Hispanic Origin Hispanic (any race)74 Non-Hispanic51

Women who had a birth in the last 12 months, Ages 15 – 50, by Select Characteristics 2006 (Cont’d) CHARACTERISTIC Births per 1,000 Women All U.S. Women55 Citizenship Naturalized Citizen49 Not a Citizen83

Percent Distribution of U.S. Births by Race/Ethnicity 1990 & 2008 RACE / ETHNICITY White66%50% Blacks17%16% Hispanics15%26% Other2%8%

RaceTotalMaleFemale United States White Alone White, Non-Hispanic Black Alone AIAN Alone Asian Alone NHPI Alone Two or More Races Hispanic Median Age of U.S. Population by Race, Hispanic Origin & Gender, 2009

Completed Fertility for Women Years Old Year Percent Childless Avg. Number of Children Percent Higher Order Births* *Three or more Children

U.S. Total and Foreign Born Population Change, Population Absolute Change % Change Total 281,243,49933,323, % Foreign Born 32,989,42911,472, % Hispanic (Foreign Born) 14,410,7036,331, % Hispanic (Native Born) 20,760,7347,057, %

Change in Regional Distribution of Foreign Born Population,

Percent Change in Total and Foreign Born Population, by Region,

Net Population Change Attributable to Non-White Population Growth, Region 2000 Population Net Change % of Net Change Due to Nonwhite Population Growth United States281,421,90632,712,03365% Northeast53,594,3782,785,149100% Midwest64,392,7764,724,14462% South 100,236,82014,790,89052% West63,197,93210,411,85069%

Net Population Change Attributable to Non-White Population Growth, Region2004 Population Net Change % of Net Change Due to Nonwhite Population Growth United States293,655,40412,233, % Northeast54,571,147976, % Midwest65,729,8521,337, % South 105,944,9655,708, % West67,409,4404,211, %

In-Migration, Out-Migration, Net Migration, and Movers from Abroad for Regions, RegionInOut Net Internal Migration Movers From Abroad Net Migration (including from abroad) Northeast3,6666,178-2,5122, Midwest6,9786,909691,6411,711 South11,7619,3572,4044,1856,588 West6,7516,731384,1854,222

New EnglandMidwestSouthWest -1,032-2,008+2, TOTAL Black Hispanic Elderly Foreign Born Foreign Born = Net Import = Net Export Net Migration Trends,

U.S. Population Change by Region, Region 2009 Population Absolute Population Change, Percent Population Change, U.S.307,006,550248,345,9328.8% Northeast55,283,6791,616,1733.0% Midwest66,836,9112,342,9553.6% South113,317,87912,757, % West71,568,8798,117, % North Carolina9,380,8841,301, %

Population by Race and Hispanic Origin for the United States: 2000 RACE & HISPANIC OR LATINONUMBER% OF TOTAL Total Population281,421, % One Race274,595, % White211,460, % Black or African American 34,658, % American Indian & Alaskan Native 2,475,9860.9% Asian 10,242,9983.6% Native Hawaiian & Other Pacific Islander 398,8350.1% Some other Race 15,359,0735.5% Two or More Races 6,826,2282.4% Hispanic or Latino (of any race) 35,305, %

Net Population Change in the United States by Race and Hispanic or Latino Origin, Race and Hispanic or Latino 2000 Population Net Gain Percent Change Total281,421,90632,712, % White211,460,62611,774,5565.9% Black or African American34,658,1904,672, % American Indian or Alaska Native2,475, % Asian10,242,9983,334, % Native Hawaiian and other Pacific Islander398,83533,8119.3% Some Other Race15,359,0735,554, % Hispanic or Latino (of any race)35,305,81812,951, %

Race2009 Population Absolute Change 2000 – 2009 Percentage Change Total 307,806,55024,834, Non-Hispanic 258,587,22612,057, White 199,851,2404,088, Black 37,681,5443,276, AIAN 2,360,807256, Asian 13,686,0833,233, NHPI 448,51079, Two or More Races 4,559,0421,123, Hispanic 48,419,32412,776, U.S. Population Change by Race & Ethnicity, U.S. Population Change by Race & Ethnicity,

U.S. Population Turning 50, 55, 62, and 65 Years of Age, Age 50Age 55Age 62Age 65 Average Number / Day12,34411,5419,2218,032 Average Number / Minute

Absolute and Relative Change in the Gender/Age Composition of the U.S. Population, Gender/Age 2000 Population Net Change % Change Total281,421,90632,712, % Male138,053,56316,814, % Female143,368,34315,897, % Age ,035,178-2,878, % Age ,826,47920,024, % Age ,274,6843,126, % Age 65+34,991,7533,749, %

Age2009 Absolute Change Percentage Change <25104,960,2505,258, ,096,278-1,898, ,379,43916,977, ,570,5904,496, TOTAL307,006,55024,834, U.S. Population Change By Age,

Age Profile of UNC - CH Faculty, 2002 Employee TypeNumber< Average Age Tenured/Tenure Track 1, , (%) (100)(17)(67)(16) Fixed Term (%) (100)(29)(66)(5) Total 2, , (%) (100)(21)(66)(13)

Absolute and Percent Change in U.S. Population by Age, * Age % Change Total % Age % Age % Age %

Implications and Challenges l Managing transition from the “graying” to the “browning” of America. l Competition for talent will be fierce – and global. l Successful recruitment and retention will hinge on your ability to effectively manage the full nexus of “diversity” issues. l Patient- & Staff-Centric Cultural Elasticity will be in great demand.

Age * Total186 million255 million Hispanic Share14%31% Foreign-born Share15%23% Change in Foreign Born and Hispanic Shares of Working Age Population (18-64),

In-, Out-, and Net- Migration, North Carolina, YearArriving MigrantsDeparting MigrantsNet Migration ,29395,917+28, ,10797,352+41, ,540101,273+41, ,936103,941+40,995

Major Redistributors of Population to North Carolina, State of OriginNumber of Arriving Migrants Florida62,528 Virginia53,536 New York49,284 South Carolina39,096 Georgia28,264 California27,813 Pennsylvania23,185 New Jersey22,620 Foreign22,533

Per Capita Income of Arriving & Departing Migrants, North Carolina, YearArriving IncomeDeparting IncomeDifference $22,464$21,124$1, $23,327$22,333$ $24,576$22,422$2, $25,000$23,530$1,470

NC Population Change by Race & Ethnicity, Population Absolute Population Change, Percent Population Change, Total9,380,8841,301, % White Alone8,663,222967, % White, Non-Hispanic6,267,309591, % Black Alone1,990,501253, % AIAN Alone105,5828,8929.2% Asian Alone187,86670, % NHPI Alone5,0771, % Two or More Races106,88741, % Hispanic717,662334, %

Median Age of U.S. and N.C. Population by Race & Hispanic Origin, 2009 USNC Total36.8%36.9% White Alone38.3%38.6% White, Non-Hispanic41.2%40.5% Black Alone31.3%32.7% AIAN Alone29.5%32.2% Asian Alone33.6%32.5% NHPI Alone29.9%27.2% Two or More Races19.7%16.8% Hispanic27.4%23.6%

North Carolina’s Hispanic and Not-Hispanic Population by Age, 2009

Population Change by Age, North Carolina, Age 2009 Population Absolute Population Change, Percent Population Change, <251,560,551214, % ,283,42037,6323.0% ,253,434309, % ,294111, %

Demand for Cultural Elasticity l Linguistic l Religious l Family Structure l Lifestyle l Sexual Orientation l Generational

Older Workers in U.S. Workforce 65 or Older75 or Older %7.3% %4.7%

Strategies to Attract and Retain Older Workers l Flexible work arrangements (consultant, temporary and part-time assignments) l Phased-retirement program l Retirement health benefits l Prescription drug coverage l Superior vision and dental plans l Defined benefit pension l Long-term care insurance

Outsourcing Trends in Health Care Industry Administrative Services l Information Technology l Revenue Cycle Functions l Insurance Claims Processing l Medical Transcription l Virtual Practice Management l Telemarketing Activities l Fulfillment Services

Outsourcing Trends in Health Care Industry Patient Care Services l Tele-radiology Services l Intensive Care Unit Monitoring l Medical Tourism

Medical Tourism Cost Comparison TypeU.S.India Hip Replacement (partial) $18,000$4,500 Hip Replacement (full)$39,000$3,000 Orthopedic surgery$4,500$18,000 Cardiac surgery$40,000$6,500 Gall bladder surgery$60,000$7,500

Implications for NC’s Health and Competitiveness l Create healthy and viable communities l Active living by design l Health eating by design l Infuse health and wellness education throughout K-16 curriculum l Strategically re-position health disparities as a competitiveness issue.