(Photo by Greenville Headshots. From left, Tony Kouskolekas, Dr. Marjorie Jenkins, Wayne Fraleigh, Kiersten Colovin)

The American health care system has been covered extensively in the news in recent years, as debates have taken place about everything from the Affordable Care Act to the role of artificial intelligence in health care.

Integrated Media Publishing hosted a roundtable discussion with four leaders in the world of health care on March 25, 2024.

Here are excerpts from that conversation, edited for brevity and clarity. A full version of the conversation can be found on our websites.

The panelists were:

Kiersten Colovin, Vice President of Experience, Insights, and Innovation for Interim HealthCare of the Upstate

Wayne Fraleigh, chief operating officer for Bon Secours Medical Group in Greenville

Dr. Marjorie Jenkins, dean of the University of South Carolina School of Medicine in Greenville and chief academic officer for Prisma Health in the Upstate

Tony Kouskolekas, president of Pelham Medical Center

Integrated Media Publishing Editor David Dykes moderated the discussion.

Question: I'd like to get your take on the future of health care. Where do you see it now, and where do you see it needing to go?

Colovin: The current state of health care is highly fragmented with substantial challenges to access and a mix of a payer landscape that makes things very challenging. Because on one hand, you're focused on value, and on (the other) hand, you've got a fee for service and volume-based healthcare. So, it's the big transition, and where it's going, I think, is more on preventative and wellness, and how are we engaging patients sooner. And also creating a creative workspace for physicians and nurses because the generations are different now, and what they demand is different from a work standpoint.

Kouskolekas: I would just add that I think no matter what, health care is always going to be local. Even if that means you're getting some kind of virtual care. Health care is local. People's support networks are generally local, and people want care where they live. I think we should be committed to offering that no matter what the vehicle for service delivery is.

Jenkins: I think we're going to have to diversify our teams because physicians are leaving medicine at a rapid rate. We lost 70,000 physicians leaving the medical field a couple of years ago. The new generations do demand different things. I agree with that. We need to think about different models, shared positions, etc. In our state, we have 67 underserved regions. We're a very rural state. We need to lean on technology, remote monitoring, community health workers. Also, really, I think health care must leverage artificial intelligence, AI, in the future.

Fraleigh: I think what's unique, especially here in Greenville, health care is personal. I still believe those in Greenville still want that personalized relationship between the physician and the patient. But because of things being fragmented, because of changes within technology and how utilize it, it's definitely put a lot of burden, not just on the provider, but also on the patient. And we're in this consumerism world, right? People want things how they want, when they want it, where they want it. And so, health care is trying to figure out how do we meet that need and still provide great care for the community. And I think that's what's causing a lot of the bottlenecks and the frustrations that we're all feeling in health care from a personal perspective as well as from a patient perspective.

Q. Wayne, let me address this question to you. It's been more than a year and a half and three years, respectively, since federal price transparency rules went into effect for payers and hospitals. Together, the two rules require public disclosure of all commercial payer provider-negotiated rates. They include other provisions aimed at improving price transparency. After a slow start, payers and hospitals have made progress toward publishing negotiated rights, but regulators are continuing to take actions to further advance price transparency. How do you see that now?

Fraleigh: Because of the cost of where health care is right now, I think you have to have that price transparency. That's something we're also following (as a ministry and from the federal regulation perspective). But I think the market is going to fix itself. I think here within South Carolina, with the certificate of need being repealed, it's going to create that competition. I think it's going to help drive a little bit more of that price transparency as patients have to pay more out of pocket. They're going to be more educated as far as how or where they get their health care.

Q. A follow-up question: When I started out in this business years ago, I had several health insurance plans for which I could choose with deductibles and so on. When I left the Greenville News a few years ago, we had one health care option that the price was more expensive than I'd ever paid, for fewer benefits. Is that part of the trend that you're seeing? And what does the future hold as far as corporate health care policies are concerned, do you think?

Fraleigh: I’m not sure about corporate health policy, but I see that trend. Even within our own employer plans, you have one that if you stay within your network, it's going to be a lower cost, lower deductible, lower copay, to (another) where if you want more of a PPO, for a plan where you can go anywhere, to our high-deductible plan. Each of those have the pros and cons, and it all depends on, really, where that family's health condition is and what's probably going to be the best plan. Even being a health care provider leading the medical group, I have a hard time sometimes trying to figure out, OK, which one do I do? Because is someone going to get more sick? … I’ve got a kid in Ohio. Is she going to be covered? When I'm living in Greenville? These are real questions. And truly, these are things that our system is trying to figure out. How do we help be an advocate for this provider resource to be able to help answer some of those questions. From a Bon Secours ministry perspective, we have resources … to be able to help our employees and associates to be able to make the best informed decision for themselves.

Colovin: I think if done well, the intent is continuity of care, right? One of the greatest barriers we face in health care is integration. We're behind in technology tenfold. When you compare to other industries where I can deposit a check from my phone to my bank, we can barely navigate health care for our patients easily through communication and continuity of care. We have the same issue with documentation and records and integration. Some of the intent of the narrow network, certainly cost is a factor, but also how are we sharing data so that patient's not going through repetitive testing in each care setting? I think it's a double-edged sword.

Kouskolekas: To me, pricing, on the one hand, it's great. I'm a free-market capitalist. In theory, it presents the consumer with an opportunity to evaluate on cost. I think as everybody knows, there's not a lot of free-market principles in health care, with the exception of plastic surgery. … If you don't like what he or she has to offer you as a quality or as a cost, you can go to another one. When people go to the hospital for an emergency or have some other urgent need, they're not thinking about that. So, on the one hand, I think it's interesting and maybe good for the consumer. On the other hand, what people pay is very plan-dependent. If they are on one BlueCross plan versus another, versus a different insurer, ultimately what you pay is going to be dictated by your plan. I'm not really sure how, at least right now, it effectively helps the consumer. It guides them a little bit. Most health care systems are better now about being able to really probe down into someone's insurance plan and give them a real clear, you're going to have to spend X with this procedure.

The other side of that is with health care insurance companies, we have negotiated rates. And so, no health care system is going to want to have another health care system know its negotiated rates, nor are the insurers going to want to see negotiated rates published because those are proprietary. And every other health care system and every other insurer is going to be bickering with each other now of, You're paying them more than you're paying me. At least right now, I don't see it as a solution.

Jenkins: I think that occasionally we make the we make the villain the health care system because that's where patients are getting their billing from. And as you talk about rates, I have three children in their 20s here in Greenville, and they work, and they're paying hundreds of dollars a month. And they are three healthy young adults in their 20s. And I think as we look at that, health care systems are challenged to find better ways to care for populations. Our state is number 43 out of 50 for unhealthy health indices. And so when you look at some of the third parties who like to tout the big bad health system, I think we need to look at their $30 billion in profit that they made last year.

Q. Marjorie, let me follow up with you on that because you hit on a good point. South Carolina ranks fifth in terms of emergency room visits, the costliest form of health care. And we average, I think the figure is 8,503 visits per 10,000 population. What does that tell you about where we are? But more importantly, what does it tell you we have to do?

Jenkins: Access. It's about access. When people aren't able to see physicians regularly or nurse practitioners or other health care providers, they're going to seek that care where they can get it, and they know that they can come to the emergency department. Sometimes it's just for refills on medications. We really do have a fragmented system. Another thing that dovetails into this is prevention. In the U.S., we spend five cents on every dollar on prevention and 95 on treatment, and a third of that in the last decade of life. There needs to be some real emphasis on prevention. There needs to be some emphasis on getting people access to health care providers. As I did mention before, diversifying the teams. So that nurse practitioners, family medicine physicians, they're the ones going out into the rural communities. And so, we need to focus on that. And I think it's not just one health system responsibility. It's all of our responsibility to think about ways to create a multifactorial approach to this issue.

Fraleigh: Yeah, I think (we need to) continue to recognize that there are health disparities. I'm sure if we looked at that number and did a deeper dive, we'd probably see that it's those that are underserved, dying, and poor. How do we manage that? I know within our health system, if anybody does come through the EDs (emergency departments) but then gets put on an inpatient floor, we are doing a full assessment for the mental as well as physical and social well-being and looking at their social determinants of health and make sure that they have resources as well as a follow-up back into the medical group clinic. Because otherwise it's going to be just another repeat where they're going to be back into the ED in a month. The difficult part is a lot of these people don't have the transportation. Sometimes they don't have the motivation. That's where it becomes more difficult. We all have to work together in order to be able to take care of the community, especially those that probably don't know how to take care of themselves.

Jenkins: Our health systems in South Carolina are doing that. They do have specific areas where they're working with the marginalized people, the underserved people, and looking at social determinants of health. It is a heavy lift right now to do that.

Fraleigh: We have a medical mobile clinic that we send out daily throughout all the different districts here within the county. And I wish there were still better utilization within them. So, then it comes down to, how do you get the word out and ensure that people utilize it? Because there's definitely a need. I think it's just what's going to be the best approach to meet the community.

Q. A couple of you have mentioned prevention. With South Carolina's obesity and rates of diabetes, you're getting the end results of that. Like you said, the mobile clinics are a good step in that direction. But so much more needs to be done. What are the priorities? 

Kouskolekas: I would agree with what Dr. Jenkins said, and I think everybody has said it, access is really the key, whether that's with a primary care physician, a nurse practitioner, or even virtual connections. There are many things that people come to our emergency departments for that they don't really need to be there. These are things that are treatable or manageable if they are connected. The challenge is when people either don't have an ability to pay or choose not to take care of the issue and it gets exacerbated. They get some treatment, they get better for a little while, but then the problem comes back again. I do think access is the biggest barrier today. I think some of it is driven by human behavior, but I think as all health care systems, and there are disruptors in our field as well. You can go to traditional pharmacies now and get care. That's not a bad thing that people can choose to go where they can get care for the things that are treatable.

 Jenkins: Did you know the six counties in the Upstate are Appalachia? That is so interesting to me, and I learned that when I first came into the area and growing up as an Appalachian. There's a lot of fear of knowing something about your health. There's some fear of the health system as well as accessing. So, as you mentioned, when the mobile units aren't being booked fully. Because we have to go into these communities and build trust and really explain why. Usually, people are taking care of their families and others before they're taking care of themselves. And so, we really need to go on to that aspect as well.

 Q. But that also now raises a question about the physician and nursing shortage. What can be done? 

Colovin: I think it's tied back into diversification of teams. When we think in the box of traditional health care, we don't start thinking about preventive care, and we miss that mark. Working in home health, hospice, and private duty, we see the gaps all the time. A lot of times there are things that the patient has been seen in several different care settings, and several different locations that potentially, had they had interventions sooner from a wellness perspective and intervened with counseling or therapy or dietary guidance and counseling, they may not have been in the state that they're in. So, I think it's just that we've got to get outside of what a traditional care team looks like in order for our providers to really treat what they went to school to treat. And then those that need other aspects of care in the community, we can leverage those resources. 

Jenkins: I just reviewed Senator Lindsey Graham's federal appropriations for this year, and five or six of the line items were for nursing expansion, and Claflin, and Clemson, and USC. I think that we need to continue to expand our nursing programs, and we need investment to do that. 

Kouskolekas: I think it's an expansion of many things. I think nursing, physicians, mid-level providers, trying to produce more is great. We've got to get more educators to be able to produce more. I also think a couple of people have said this already, but I think we've got to look at the way jobs are designed in health care today and how people can collaborate. Some of that might involve technology. Some of it could just be redesigning jobs so that people are capable of doing more, hopefully being more economically prosperous with additional skills, but redesigning who does what. There are really relatively few things, for example, that a nurse has to do, but he or she today is asked to do many things. So, having a team of people to support those resources that are regulated is something that we've got to look at. 

Q. Does that include that nurses commonly work 12-hour shifts? 

Kouskolekas: I think that's more of a market thing. It's funny. You can make the argument that that's a long day. It is. They get tired. But when you talk about changing things to an eight- or a 10-hour day, people say, No, I like having my four days off a week. I think that has generally been a market thing, I think, that has less to do with any scarcity. 

Fraleigh: There's definitely been … workforce challenges. Burnout is a big part. … I agree from a nursing and from a support team. I think that's where I've seen the last two years here within Greenville. Looking at more from a medical group clinic side, it's hard to find a certified medical assistant. And then with some other federal regulations that changed, they made it a little bit more difficult this past year, year and a half. So, we've worked with our different groups to be able to help change some of those laws. But if you don't have the support staff to help support your physicians and your ABCs, that there's more burden on them. Just trying to have those CMAs even work at the top of their license because you can't find nurses and LPNs as well. So, it's just a vicious cycle to where being limited in one workforce because what we hear, it’s easier to go work at Chick-Fil-A or Kentucky Fried Chicken for the same pay that you're going to have working within a medical group. 

Q. What specifically would each of you be doing to address the burnout among health care professionals? 

Fraleigh: We've taken a very active approach. We had a physician who personally was dealing with some of the burnout herself. She sought some professional support groups to be able to assist. And we tragically had one of our surgeons commit suicide. And it really had the whole physician and provider community come around that. And through the foundation and through different proactiveness from the family, we've created a well-being fund to be able to help support our providers and physicians. So, we're moving into year two of this. In March, we started what we call a buddy program (for new physicians to help with) the day-to-day stuff. What physician should I see for my family? Where daycare should I go to? So, it's really simple questions that we don't think much of, but there's a lot of stress on families and practitioners, but also ensuring that we're staying in touch to that wellness side as well. We also felt that the workforce demands have been put more on to our providers, managing their in-baskets. And because we're such a consumerism world, that MyChart, Epic, is great. But we've also allowed it to where physicians now have to be working 24/7 because now they're seeing their 25, 30 patients during the day, but now they have to answer 25, 30 more MyChart messages that patients are asking questions. So, providing resources to be able to help support the physician and managing at least that part that maybe their MA or nurse can be able to help support. And the last one is we created what we call a Caring for Colleagues crisis line. This is something that was developed more at the ministry level, which means that if you're having any issues at all, you can call this line – everything's anonymous – and be able to get the help and support that you need. But we're also creating one now here locally to be able to help provide that. 

Q. Let me ask each of you, what are you most proud of in your current role?

Jenkins: I try not to be prideful, to be honest with you, but I'm most proud of our school reaching out into first-gen students, students from low socioeconomic (backgrounds) who've had very long distances traveled to get to medical school. And I’m really proud of, I think, our medical school living into the destiny that when then-Greenville Health System decided that they would build a medical school with the university, that we are living into that destiny. … Our second decade, is going to be around health disparities and narrowing that gap. And so that's a broad answer. I'm really proud of our school, but I think that just being able to bring South Carolinians into medical school that never thought they'd have an opportunity to do that. I love being able to assist with that in any way I can.

Kouskolekas: I try to be humble, but our team has really developed a wonderful culture. I think back to the question that Dr. Fraleigh answered, I think that's ultimately how we get through any tough circumstances, burnout or whatever you call it. We've got a very can-do, strive-for-the-best culture, and that means we're investing a lot in our people, and they, in turn, invest a lot into the customers and patients that we take care of.

Colovin: I have the honor and opportunity to work with a team that walks into a patient or family's home, typically at one of the worst moments of their life. I had the honor over the last couple of years to work with all of our operations teams and see up-close the work that they do. My current role was a recent transition into Experience and Insights and Innovation. I'm proud and excited to have the opportunity to work with them as partners now and look at their experience as an employee and collaborate with our community and our partners, our payers from an experience standpoint, because they're sometimes forgotten. How can we partner with them. They have deliverables as well. Also, ultimately, at the end of the day, it's to treat our patients. I think we've got to think outside box of the experience of the patient being tied into all those pieces. So, I'm excited to pool all that together and collaborate and ultimately, caring for our patient population.

Fraleigh: I'm most proud of our mission. St. Francis, Bon Secours. Our mission is to extend the compassionate healing ministry of Jesus, of caring for the poor, underserved, and dying. And I can honestly say that I feel that every single day with our providers, our physicians, with our associates. And we're continually striving to figure out how do we continue to meet those needs, whether it's within the community, within the clinic, within the hospital. 

Q. When faced with a new challenge, what's your decision-making process? Where do you turn for trusted information or advice?

Fraleigh: From a medical group perspective, we strongly believe in being physician-led, so each of our specialties has what we call a dyad structure, where we have a physician medical director that's helped leading, looking at the guidelines, looking at strategy, and working together with the administrator. And really my goal, and my dyad is our Chief Clinical Officer, is really to remove obstacles and be a resource to our team. We need to allow physicians to do what they do best, and that's to treat patients and help remove some of those barriers around that. So, we felt from our group that that was the most important thing, was to ensure that the physicians are truly driving what care looks like.

Colovin: I think for me, it starts with our employees, our clinicians, our therapists, but also our patients, and how are we pulling them in to what that looks like and following that journey of what those needs are? I would say that and then trusted experts in the field, or at least folks that are trying to forge that path, reaching out to them, because we all know we don't know all the answers, and we all know we didn't show up here today in this role that we're in. I think just not being fearful of reaching out to folks saying, Hey, I'm new to this, and can you help me navigate this? I've got some thoughts, but we'd love your thoughts as an expert in the industry.

Jenkins: I would say much the same. We have a leadership council from the community. I lean on those leaders and the community a lot. The patient experience as well, understanding where the challenges are, the bottlenecks. I'm a recovering engineer, so I draw a lot of things out on the board, and I think about the ripple effect of decision making, not just immediate, but also that second and third ripple effect to the community, to the patient, to the health system, to our students and our faculty and staff. And so that's usually my points of engagement diagram when I get into a lot of complexity. And I've just been blessed with a lot of mentors, really great mentors in my life that I can reach out and ask for advice and guidance. And I pray. I pray about it.

Kouskolekas: For me, I'm highly collaborative by nature, so it's collaboration. … Whether that collaboration involves my boss, peers across the system, or people that I work directly with, and other leaders in our system, we've worked hard to try to push decision-making down. But when there are new things, there's almost always some gray in health care. Short of living and dying, there's some gray. And so, trying to avoid unintended consequences, really through collaboration is how we try to do that.

Q. Talk a little bit about cybersecurity and privacy. You deal with a lot of sensitive information. I've been told many times that the hackers are way ahead of us. Obviously, it's an issue. You see it as a controllable issue, and how are you trying to control the privacy frontier?

Fraleigh: It's one of the top security threats, any type of data breach, data privacy. It all starts with us and ensuring what we let in to the internet. It's frustrating having to change those passwords, and they seem to be longer, and now you have to put different special characters. But understanding the why, why that is, is important. … We have continuous exercises where we're sending out different emails to ensure we know how to catch them, to where we have respond back that that's phishing or whatnot. 

Jenkins: I'm married to an IT guy, so I hear a lot about that. And then my information has been leaked from a wireless carrier, and when I applied to FDA, the federal government, it was leaked as well. So, there's a lot of challenges out there. It's a two-edged sword. We've talked about the electronic health record, right? And I can get on MyChart right now and look at all my scans and results and my meds, and send messages to my doctor. That carries with it a level of risk. As a physician, and my entire family and our patients at Prisma Health, I know that I feel very comfortable that Prisma Health is doing second-, third-, and fourth-level security to prevent data breaches, and so our information is safe. … When you have organizations that really focus on that as a top priority, then you can feel secure that your information and your family's health information is secure.

Fraleigh: I'll say that's a firm yes. And with that, I look at it as zero harm. We have to do our part. I'm very confident we're doing the measures necessary for what we know now on how to protect. But things are constantly evolving, which means we're going to have to keep evolving on how these hackers are trying to get in.

Jenkins: I can think about 30,000 employees who are getting emails that say, You've just won a $50 or $100 Amazon gift card. Just click on this link. And so, you have to have a lot of education of your employees who have access to that system. I think that it's just a constant, daily top-of-mind thing to make sure that we are doing it well.

Kouskolekas: We’re all doing … many of the same things. … The phishing that Dr. Fraleigh mentioned, we have tests that come out. I've gotten pretty good at diagnosing, this doesn't look right. But I think other things that organizations are doing, limiting access to certain components on certain servers so that you can't get into an entire system when perhaps you hack into one component. Multifactor authentication is another. Do I think that we'll ever fully stay ahead of the hackers? Unfortunately, probably not. Health care data is incredibly valuable to these people. You've got banks and credit card companies that, unfortunately, have invested a lot of money because they've had to, but there still are issues there. How many times has your own card perhaps been compromised? But health care, unfortunately, is a financial win to hackers. The real key is going to be, how do we stay ahead? I think in general, what I'm hearing from them, our teams do a great job having the right levels of things in place to try to mitigate anything that can happen, and quick shutoffs when they do happen. 

Colovin: I think we have to remain highly vigilant but not be fearful. Because I think it can create fear. I think that health care has operated in that. That's why we're behind from a technology standpoint. It's definitely a delicate balance. You talked about AI and generative AI. It's under our feet right now, and it has the potential to drive tremendous efficiencies for our care providers. It also has the potential to do a lot of harm. So, we've got to remain vigilant, and we have to have the systems in place. My poor IT gets emails from me all the time. I'm like, Is this real?... It's easy to become relaxed around it because you see it so much and you're exposed to it. And just helping our teams understand the why when they're typing in that 800-letter password, that it's to protect their patients, which is why they're there. 

Q. Last question. Let me ask each of you, if you were in charge of the nation's health care system and can go back and do one thing differently, what would that be? 

Kouskolekas: This might shock a lot of people, but I'm not sure I would have created Medicare. I think when you look at the investments that governments in general … make, some have good intentions, things become bloated. Medicare drives a lot of things. It's not all bad, and the program itself for the consumer can be quite good. But that trust fund has been depleted many times over. There's been multiple concerns about it running dry. What are we going to do? Because of the payments we get, which generally don't even cover the cost, those that are commercially insured pay much more than the cost. And so, I would have, again, with benefit of hindsight, tried to push more things to individual states, let them figure it out if that's something that they want to do rather than a one-size-fits-all solution around Medicare. 

Jenkins: I think I would have put in a little more checks and balances. I think there is a segregation of power from payers and third parties and health systems and patients who are trying to access care. However you feel about this question, I think you have to ask yourself the question, is it a right of being a citizen to have health care access? As someone who, growing up, never had the opportunity to go to the physician, I mean, basically, it was my grandfather popsicle-sticking my finger or slinging from a torn-up T-shirt, our arm ... I think we need to address that question.

Fraleigh: No matter what the numbers say, I still think we have the best health care system in the world as far as providing the care and compassionate docs and so forth. But I would almost switch it to what we're getting into now, right? What if we focused on value-based care, preventive medicine, coming out the gates. And yeah, there's going to be busier docs and so forth. And you can still give great value, but then maybe incentivize somewhat on that. But because we came out of the gates incentivizing based on volume, It's hard to turn the pendulum saying, OK, you mean I'm going to make how much more less now if we switch? So, I think there's some of that aspect. I think if we would have started with the value equation, we would have stayed more focused on the patient, and we would still have that patient-physician relationship that I think we've all come to love. And that would probably would have stayed at the forefront.

Kouskolekas: I agree with Dr. Fraleigh. There's no other place I would choose to get health care outside of America. We've got warts, but this is unequivocally, in my opinion, the best health care provider system. We don't have a nationalized system, but in terms of the delivery of care here, it's superior. Not that other places don't have good outcomes, but I think we have the best providers in the world. That's why many come here to train and why many wealthy people from other places come here when they need something.

Jenkins: I agree, and I think here in the Upstate, we have excellent delivery of care.

Colovin: You took the words out of my mouth on the value side. I think that's the piece is that when we set that in motion around fee-for-service, we started to create buildings and facilities and locations and then the driver of reimbursement. We've got to pay for our providers who’ve gone to school for years and years. You create this fee for service where there's a churn. So, if they're not seeing their patient, there's not payment. And so, we missed the boat on that because now providers have literally their feet in two places based on the payer that the patient has coming in, and it dictates a lot of their care. And we missed the mark on the outcome piece, really looking at what that experience is. There is typically a lower cost setting of care for a patient, the education, the early interventions. Those are the pieces that we don't really focus on here. Unfortunately, it's the beast of the system that's been set forth.

Q. I want to thank each of you for your time this morning. It's been a great conversation on a very important topic.