Wilson Country Trends 2021 (Corrected)

Wilson County Trends

A Cumberland University Publication • Fall 2021

Dean’s Foreword Thank you for taking some time to review to the Fall 2021 issue of Wilson County Trends, a publication about business and economic activity in Wilson County, Tennessee.

Cumberland University’s Labry School of Science, Technology and Business is pleased to be a sponsor of this publication and hopes that readers will find it informative. Thank you for your interest in Wilson County Trends.

Chris Fuller Dean, LSSTB

Steve Shao WCT Editor

In This Issue Wilson County Trends contains business and economic data on the county and also provides news articles on local industry, businesses and special topics. This issue provides updates on local business activities as well as on changes in Wilson County’s economy. Given the ongoing national discussion and debate concerning healthcare and evolving medical alternatives, we include an industry recap of WC’s healthcare industry. Also included in this issue are related articles on trends in telehealth services and an overview of Vanderbilt Wilson County Hospital.

Contents Dean’s Foreword . . . . . . . . . . . . 1 In This Issue . . . . . . . . . . . . . . . . 1 Recent Trends . . . . . . . . . . . . . . 2

WC’s Healthcare Industry . . . . 9 Who’s Who in WC HC . . . . . 21 Vanderbilt WC Hospital . . . . 24

Telehealth Trends . . . . . . . . . . 27 The Last Word . . . . . . . . . . . . 31 Figures & Tables . . . . . . . . . . . 32

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Cumberland University Founded in 1842, Cumberland University offers a variety of educational, athletic and social experiences to enhance the learning opportunities of the current student body. The university has an exceptional academic program steeped in the liberal arts, business, technology, nursing and many other fields. The University’s athletic teams regularly compete for conference and national championships. Cumberland University is located in Lebanon, Tennessee, 30 miles east of Nashville.

President . . . . . . . . . . . . . . . . . . . Dr. Paul Stumb Provost . . . . . . . . . . . . . . . Dr. C. William McKee Dean, Labry School . . . . . . . . . Dr. Chris Fuller Wilson County Trends Editor Dr. Steve Shao

Recent Trends This section presents time series and cross sectional graphs depicting economic activity in Wilson County (WC), Tennessee, from year 2019 to the second business quarter of 2020. As the following data and graphs show, Wilson County is home to a thriving regional economy.

Population As of July 1st, 2019, the total population of Wilson County (WC), Tennessee was 144,657, a 26.8% increase over the April 1st, 2010 federal census count of 113, 993. WC’s population growth in the last decade 1

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is unprecedented. In comparison, we note that the population growth rates of Tennessee and the nation overall were 7.6% and 6.3%, respectively.1

Number of Business Establishments In 2019, Wilson County was home to 3,087 businesses, a 6.23% increase over the 2,906 residing in the county the year before. In the second quarter of 2020, the number of business establishments operating in Wilson County grew to 3,211.

WC today is primarily a service economy. The county’s 2019 business community consisted of 472 goods-producers (15.3% of the total private economy) and 2,615 service providers (84.7%), representing increases of 2% and 7% over the previous year.

We note that the number of business establishments in WC increased in all major industry categories from 2018 to 2Q2020.

By number of establishments, WC’s top industry supersector in 2019 continues to be Trade, Transportation & Utilities2 (813 firms, or 26.3% of the private industry total) as the largest industry category. Professional & Business Services3 (557 firms, or 18%) are the next largest. A near three-way tie exists for third place among Construction (320 firms, or 10.3%), Leisure & Hospitality4 (308 firms, or 10%) and Financial Service Providers (306 firms, or 9.1%). Notably, Private Education and Health Service Providers was the seventh largest industry category (out of ten categories) with 293 firms, or 9.5% of the total. Interestingly, the WC industries with the two highest annual changes from the previous year (2018 vs. 2019) were the Information and Professional & Business Services categories, with annual growth rates of 13.8% and 10.1%, respectively.

The 623 total WC firms in these two industry categories represent a significant 20% of the county’s total economy. See Fig. R1.

Wilson County’s local economy is particularly well

Source: U.S. Census Bureau NAICS Supersector 40 (Trade, transportation, and utilities) consists of Sectors 42 (Wholesale Trade), 44-45 (Retail Trade), 48-49 (Transportation and Warehousing) and 22 (Utilities).

3 NAICS Supersector 60 (Professional and business services) consists of Sectors 54 (Professional, Scientific, and Technical Services), 55 (Management of Companies and Enterprises), and 56 (Administrative and Support and Waste Management and Remediation Services).

4 NAICS Supersector 70 (Leisure & hospitality) consists of Sectors 71 (Arts, entertainment, & recreation), and 72 (Accommodation & food services).

5 Source: U.S. Bureau of Labor Statistics. Location quotients are ratios that allow an area’s distribution of employment by industry, ownership, and size class to be compared to a reference area’s distribution. The U.S. is used as the reference area for all LQs noted in this report. The reference industry is always the all-industry, all-ownerships total for the local area, and for the nation.

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Figure R1 Number of Business Establishments by Industry in Wilson County TN, 2018-2Q2020 Source: US Department of Labor

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Figure R2 Average Weekly Wage by Industry in Wilson County TN, 2018-2Q2020 Source: US Department of Labor

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represented in certain key industry sectors. The location quotient5 (LQ) of WC’s overall private service industry, for example, is estimated to be an above average 1.08 in second quarter 2020, ranking 7th among all of Tennessee’s 95 counties. In the same time period, WC’s LQ for the leisure and hospitality industry is a healthy 1.20 denoting a very conducive environment for both family living and tourism. One of Wilson County’s greatest economic strength’s, of course, continues to be in the supply chain industries of warehousing and trucking. WC’s advantage in this major expanding industrial area is confirmed by the estimated 2Q2020 LQ of WC’s trade, transportation and utilities sector to be an outstanding 2.10, highest of any Tennessee county and more than twice the national norm.6 It is not clear, however, how much of a ‘hit’ that WC’s supply chain sector will experience due to the national workforce shortages occurring in late 2021.

Average Weekly Wage Wilson County’s private wage data increased slightly from ✩808 in 2018 to ✩837 in 2019, a 3.6% gain.

The average 2019 weekly wage of ✩792 for Serviceproviding firms was below that for all WC businesses though this represented a 4.35% increase over 2018 service wage levels. Pay was expectedly higher in WC’s Goods-producing category, which averaged ✩1075 per week, though this within a percentage point of wages for the previous year. For the average weekly wages across major WC industry groups, the highest wages in Wilson County in 2019 were paid in Natural resources and mining (✩1314 per week), Financial activities (✩1,278), Construction (✩1,091), Professional & business services (✩1,085), Manufacturing (✩1,065), and in the Information sector (✩1046). Lowest average weekly wages were paid in Leisure and Hospitality (✩356). See Fig. R2.

Number of Employees The number of persons working in Wilson County’s private industry has grown steadily in recent years, from 40,770 workers in 2018 to 43,002 in 2019, a

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5.5% increase in the regional workforce. While the month to month workforce changes in 2019 were largely positive increases, from USDOL’s preliminary 2020 employment estimates, we note a significant drop in Wilson County’s private workforce size from 44,188 workers in March 2020 to 40,346 April 2020.

If these government estimates are accurate, the sudden 8.7% decrease in WC workers may perhaps be due in part to the Covid-19 pandemic which began to grip the nation’s economy several months earlier.

See Fig. R3.

Retail Sales Tennessee Department of Revenue data shows the 2019 retail sales total for Wilson County TN to be ✩2,543,680,123, down slightly 1.5% from 2018 WC’s largest retail sales categories continue to be Automobiles, Boats & Aircraft at ✩678 million, representing 27% of the county’s 2019 retail sales total, followed

by Food Stores (✩418 million, or 16.5%), General Merchandise (✩315 million, or 12.4%), Other (✩283 million, or 11%), Eating & Drinking (✩257 million, or 10%), and Building Materials (✩244 million, or 9.6%). See Figs. R4 and R6.

Monthly retail sales in Wilson County TN were relatively stable during 2019-2Q2020, save for a large sales spike in March 2020 and a smaller sales spike in December 2019. The March sales spike was mostly due to an unusual high of 42% in the total monthly sales of Autos, Boats & Aircraft, versus the industry category’s more typical average of 26%. The December sales spike was due to across the board holiday increases in almost all retail categories. See Fig. R5.

WC’s 2019 retail sales trends were largely positive in comparison with sales from the previous year. Significant 2019 sales increases over 2018 were recorded for General Merchandise (+7.4%), Service Stations (+5.9%), Furniture & Home Décor (+26%), and Eating & Drinking (+13.7%). Sales of Autos, Boats & Aircraft registered a 16% decrease from its 2018 sales level. Monthly retail sales in Wilson County for 2019-2Q2020 largely followed a typical retail pattern with sales highs occurring during the NovemberDecember holiday period. See Fig. R7.

If an LQ is equal to 1, then the industry has the same share of its area employment as it does in the nation. An LQ greater than 1 indicates an industry with a greater share of the local area employment than is the case nationwide. For example, Las Vegas will have an LQ greater than 1 in the Leisure and Hospitality industry because this industry makes up a larger share of the Las Vegas employment total than it does for the nation as a whole.

6 For detailed information, see the feature article “Wilson County’s Supply Chain Industry” in Wilson County Trends, Spring 2019 Issue.

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Figure R3 Total Persons Privately Employed in Wilson County, TN, 2019-2Q2020 Source: US Department of Labor (Note: 2Q2020 statistics are USDOL preliminary estimates)

Figure R4 Total Retail Sales by Category in Wilson County, TN Source: TN Dept of Revenue

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Figure R5 Monthly Total Retail Sales in Wilson County TN, 2019-2Q2020 Source: TN Dept of Revenue

Figure R6 Monthly Autos, Boats & Aircraft Sales in Wilson County, TN, 2019-2Q2020 Source: TN Dept of Revenue

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Figure R7 Monthly Retail Sales by Category in Wilson County, TN 2019-2Q2020 Source: TN Dept of Revenue

Music City Star passing through Lebanon, TN

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Wilson County’s Healthcare Industry Healthcare Industry Defined In this article, we present and analyze data for Wilson County TN’s healthcare and social assistance industry, as defined under NAICS code 62. Specifically, we consider WC data as compiled by the U.S. Department of Labor data7 through year 2019 (and for some cases, including 2Q2020) for the following industry subsectors: ❼ Ambulatory (Outpatient) Care (621) ❼ Hospitals (622) ❼ Nursing and Residential Care Facilities (623) ❼ Social Assistance (624), and ❼ Healthcare Equipment Manufacturing and Wholesaling.

Corresponding 3-digit NAICS codes for each industry subsector studied in this report are noted above in parentheses. Each industry subsector8 can be further subdivided into specific industry groups, as identified by 4 to 6 digital NAICS codes. The healthcare industry groups classified under each industry subsector are listed in Table 1. In select instances, Wilson County data for certain healthcare industry categories are not available due to US DOL disclosure guidelines.

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Providence West Medical Center, Mt. Juliet, TN In 2019, there were 261 private healthcare and

Only privately-owned healthcare establishments and services are considered in this analysis. Besides the NAICS 62 industry subsectors, this analysis also includes a review of healthcare equipment manufacturing and wholesaling which are classified under other NAICS subsectors.

8 The 3-digit NAICS healthcare industry subsector codes are defined as follows. Industries in Ambulatory Healthcare Services (subsector 621) provide health care services directly or indirectly to ambulatory patients and do not usually provide inpatient services. Health practitioners in this subsector provide outpatient services, with the facilities and equipment not usually being the most significant part of the production process. Industries in Hospitals (subsector 622) provide medical, diagnostic, and treatment services that include physician, nursing, and other health services to inpatients and the specialized accommodation services required by inpatients. Hospitals may also provide outpatient services as a secondary activity. Establishments in the Hospitals subsector provide inpatient health services, many of which can only be provided using the specialized facilities and equipment that form a significant and integral part of the production process. Industries in Nursing and Residential Care Facilities (subsector 623) provide residential care combined with either nursing, supervisory, or other types of care as required by the residents. In this subsector, the facilities are a significant part of the production process and the care provided is a mix of health and social services with the health services being largely some level of nursing services. Industries in Social Assistance (subsector 624) provide a wide variety of social assistance services directly to their clients. These services do not include residential or accommodation services, except on a short stay basis. In addition to NAICS 62, other healthcare related industry groups included in this study are Medical Equipment and Supplies Manufacturing (3391) and Medical Equipment Merchant Wholesalers (42345). Examples of products made by NAICS 3391 medical equipment manufacturers are surgical and medical instruments, surgical appliances and supplies, dental equipment and supplies, orthodontic goods, ophthalmic goods, dentures, and orthodontic appliances. NAICS 42345 is comprised of medical equipment wholesalers primarily engaged in the merchant wholesale distribution of professional medical equipment, instruments, and supplies (except ophthalmic equipment and instruments and goods used by ophthalmologists, optometrists, and opticians). Source: see https://classcodes.com/naics-3-digit-subsector-code-list/ or https://www.naics.com/ .

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social assistance establishments9 operating in Wilson County TN, employing 3,799 people who were earning on average a weekly wage of ✩841. Compared to a decade earlier (2009), these numbers indicate a healthy 10 year growth trend in terms of the total number of healthcare and private community assistance workers employed in Wilson County (+13%), the number of establishments (+32%), and the average weekly wage (+23%)10 .

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number of establishments, ambulatory care providers were clearly dominant in Wilson County representing a fairly constant 75% of the entire healthcare industry subsector from 2009 to 2019, adding about 5 new ambulatory centers annually. See Figures H1, H2 and H3.

Ambulatory (Outpatient) Care In 2019, there were 196 ambulatory service establishments operating in Wilson County TN, employing some 1,765 people who were earning on average a weekly wage of ✩1,045. These WC economic indicators point to a very robust 10 year county growth rate for ambulatory care in Wilson County, in terms of the number of workers (+45%), number of establishments (+32%) and average weekly wage (+10%).

Hartmann 920 Medical Complex, Lebanon, TN The largest healthcare industry subsectors represented in Wilson County are ambulatory services and nursing/residential care facilities. During the period12 2010 to 2019, the employment growth rate of both of these subsectors in WC was steady yet modest, with the ambulatory care subsector gaining a net of about 47 employees per year and nursing/residential care adding about 30 annually. For the same nine year time period, a relatively constant average weekly wage differential ranging from ✩488 (2010) to ✩428 (2019) existed between the higher paid wages in ambulatory care vs lower paid wages in nursing/residential care. In regard to the total

Physicians Plaza, Lebanon, TN As shown in Table 1, ambulatory care (NAICS 621) can be divided into seven (7) industry groups.

In terms of the number of ambulatory workers in Wilson County, the top three ambulatory categories in 2019 were physician’s offices (584 employees), den-

9 The 2019 total of NAICS 62 WC establishments consists of 220 healthcare groups and 41 social assistance organizations, or 84% vs. 16%, respectively. In 2009, the number of private social assistance organizations in WC was slightly higher at 19% of the NAICS 62 total. NAICS 62 separation of healthcare vs social assistance groups is not available for employee or wage numbers due to US DOL disclosure guidelines.

10 According to US Bureau of Labor Statistics, the purchasing power of ✩1 in 2009 would require ✩1.19 in 2019, a cumulative price increase of 19.17%. For the purpose of wage comparisons then, we can conclude that any 10 year (2009-2019) average weekly wage increase cited in this report that exceeds 20% can mostly be attributed to real wage growth instead of a simple nominal wage increase.

11 NAICS 6219 can be further sub-categorized into Ambulance Services (62191) and Blood & Organ Banks (621991).

12 2009 nursing/residential care data in Wilson County is unavailable due to US DOL disclosure guidelines.

13 This industry group comprises establishments of independent health practitioners (except physicians and dentists) and includes the offices of chiropractors (621310), optometrists (621320), mental health practitioners (621330), physical, occupational & speech therapists, and audiologists (621340), podiatrists (621391), and miscellaneous health practitioners (621399).

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Ambulatory (Outpatient) Care (Subsector 621) : Offices of Physicians (6211) Offices of Dentists (6212) Offices of Other Health Practitioners (6213) Outpatient Care Centers (6214) Medical and Diagnostic Laboratories (6215) Home Health Care Services (6216) Other Ambulatory Health Care Services11 (6219) Hospitals (Subsector 622): General Medical and Surgical Hospitals (6221) Psychiatric and Substance Abuse Hospitals (6222) Other Specialty Hospitals (6223) Nursing and Residential Care Facilities (Subsector 623): Nursing Care Facilities (6231) Residential Mental Retardation, Mental Health and Substance Abuse Facilities (6232) Community Care, Assisted Living Facilities for the Elderly (6233) Other Residential Care Facilities (6239) Private Social Assistance (Subsector 624): Individual and Family Services (6241) Community Food and Housing, and Emergency and Other Relief Services (6242) Vocational Rehabilitation Services (6243) Child Day Care Services (6244) Other Healthcare Related: Medical Equipment and Supplies Manufacturers (3391) Medical Equipment Merchant Wholesalers (42345) Table 1: Healthcare Industry Groups by NAICS Code

Tennessee Sports Medicine Complex, Mt. Juliet, TN

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tist’s offices (353), and the offices of other healthcare practitioners13 (320). In terms of a ten year change in the number of county ambulatory workers (2009-2019), the most significant employment changes occurred in dentist’s offices (+13%), other health practitioner’s offices (+20%), outpatient care centers (+9%) and medical/diagnostic labs (-9%).

The total of WC physician’s office workers increased a modest 2%. In terms of the number of ambulatory establishments in WC, the number of physician’s and dentist’s offices were relatively stable over the past decade. The number of other healthcare practitioners, however, increased by a significant 56%. We also note that the number of outpatient centers in WC tripled, from 6 centers in 2009 to 18 in 2019.

A review of WC’s ambulatory wages for the past decade 2009-2019 suggests some interesting healthcare industry stabilities as well as changes. First, we note that the average weekly wages for workers in physicians and dentist offices remain first and second in rank among all WC ambulatory categories (✩1362 and ✩986, respectively in 2019). A change is observed, however, in WC’s home healthcare services14 (NAICS 6216) category, however, where its ambulatory care average weekly wage ranking flips from 6th place in 2009 (✩548) to 3rd place (✩930) in 2019 (behind physician’s and dentist’s offices). This noted change in WC’s healthcare industry portends structural healthcare industry transitions in the years ahead, factoring in such considerations as a growing senior population, changes in national healthcare insurance policy and, of course, the recent global pandemic. As one healthcare industry expert recently stated, COVID-19 has also helped to catalyze a number of trends that we have been talking about for years, including: Seniors’ desire, now greater than ever, to be cared for in the home; flexibility from CMS for the utilization of telemedicine in care planning; and reimbursement for higher acuity care provided in the home.

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We believe these trends will stick well beyond the pandemic and will only continue to highlight just how important and impactful care in the home is to health care costs but also, most importantly, to patient outcomes, quality and safety.15 We note that the number of WC employees working in medical and diagnostic labs (NAICS 6215) fell from 127 employees in 2009 to 16 in 2019. We would attribute this drop in personnel at dedicated medical and lab testing facilities either to other types of medical service facilities which incorporated on-site testing (e.g., hospitals) or else transferring such activities to facilities located outside of the county. Technological improvements in testing and diagnostic procedures may be another reason for reduced personnel.

The 59% jump in average weekly wage in this industry category (✩498 in 2009, rising to ✩793 in 2019) may also indicate the need for a higher skill set to work in medical testing and diagnosis. We note that there was a constant four medical and diagnostic labs operating in WC during the entire 2009-2019 period.

See Figures H4, H5 and H6.

TriStar Summit Imaging Center, Mt. Juliet, TN

14 The home healthcare industry (NAICS 6216) comprises establishments primarily engaged in providing skilled nursing services in the home, along with a range of the following: personal care services; homemaker and companion services; physical therapy; medical social services; medications; medical equipment and supplies; counseling; 24-hour home care; occupation and vocational therapy; dietary and nutritional services; speech therapy; audiology; and high-tech care, such as intravenous therapy. Source: https://secure.industriuscfo.com/industry-metrics/naics/6216-home-health-care-services 15 “Home Health Executive Forecast for 2021: Reserving a Seat at the Big Kids’ Table” by Robert Holly, Home Healthcare News , December 14, 2020 retrieved from https://homehealthcarenews.com/2020/12/home-health-executive-forecast-for-2021-reservinga-seat-at-the-big-kids-table/

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Figure H1 All WC Healthcare Employees, Ambulatory Care vs Nursing & Residential Care, 2009 - 2019 Source: US Department of Labor

Figure H2 Number of WC Healthcare Establishments by Industry Group, 2009 - 2019 Source: US Department of Labor

Figure H3 Average Weekly Wage in WC’s Ambulatory Care vs Nursing & Residential Care, 2009 – 2019 Source: US Department of Labor

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Nursing and Residential Care Facilities In 2019, there were 20 nursing and residential care establishments operating in Wilson County TN, employing some 982 people who were earning on average a weekly wage of ✩617. These WC economic indicators point to a very robust 9 year16 county growth rate in terms of the number of nursing/residential care establishment workers (+39%), number of establishments (+67%) and average weekly wage17 (+38%).

As shown in Table 1, nursing and residential care facilities (NAICS 623) can be divided into four (4) industry groups18 . In terms of number of workers in 2019, the largest nursing/residential care employment categories in WC were nursing care facilities (407 employees) and community & assisted living facilities for the elderly (307 employees). During 20092019, it is interesting to note a slight drop in the number of workers employed in WC’s nursing care facilities but more than a doubling in the number of workers employed in WC’s community/assisted living centers for the elderly.

In terms of a ten year change in the number of nursing and residential care establishments, we observe that the number of nursing care facilities (NAICS 6231) and other residential facilities19 (NAICS 6239) remained stable at 4 and 1 facilities, respectively. However, we also note that during 20092019 the number of residential mental health facilities in WC tripled (going from 2 to 6 facilities) while the number of eldercare assisted living facilities almost doubled (going from 5 to 9 facilities).

A review of WC’s rapidly growing nursing and residential care wages during the past decade 20092019 confirms the national trend of increasing demand for these healthcare professions. The average 16

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weekly wages for those employed in WC’s nursing care facilities jumped 62%, earning ✩475 in 2009 and rising to ✩769 in 2019. Similarly, the wages of those employed in WC’s eldercare facilities increased 47%, earning ✩322 in 2009 and increasing to ✩474 in 2019.

See Figures H7, H8 and H9.

Hospitals Recent moves and developments among major area hospital systems in WC are clear testimonials to the county’s rapid growth in population and in the local economy. Over the recent past decade, the number of hospitals operating in Wilson County has grown from one in 2009 to four in 2019.

Centennial Pediatrics Plaza, Mt. Juliet, TN The most notable recent change in the hospitals operating in Wilson County has to do with a formal large expansion of Nashville’s Vanderbilt University Medical Center (VUMC) into Wilson County. On August 1st, 2019, VUMC acquired the Lebanon TN hospital system owned by Tennova Healthcare, a statewide private medical sys-

2010 NAICS 623 employment and wage statistics are used in growth rate calculations here as corresponding 2009 NAICS 623 numbers are unavailable due to US DOL disclosure guidelines.

17 According to the US Bureau of Labor Statistics, the purchasing power of ✩1 in 2009 would require ✩1.19 in 2019, a cumulative price increase of 19.17%. Thus, any 10 year (2009-2019) average weekly wage increase in this report that exceeds 20% can roughly be attributed to real wage growth instead of a simple nominal wage increase.

18 Wage and employment data for certain NAICS 623 industry subsectors are unavailable due to US DOL disclosure guidelines.

19 This industry group comprises establishments of residential care facilities (except residential mental retardation, mental health, and substance abuse facilities and community care facilities for the elderly). Source: https://secure.industriuscfo.com/industrymetrics/naics/6239-other-residential-care-facilities 20 Tennova Healthcare’s divestiture of its Lebanon hospital facilities to VUMC should not suggest that the two hospital networks will always operate separately from each another. For example, it was announced in fall 2020 that VUMC agreed to acquire a minority interest in Tennova Healthcare’s 270-bed hospital in Clarksville. Specifically, VUMC signed an agreement with Tennova minority partner, GHS Holdings LLC, a wholly owned subsidiary of Clarksville Volunteer Health, Inc., to acquire its 20% minority interest in Tennova Healthcare-Clarksville and related physician practices. This action is consistent with a recent spate of hospital partnerships,

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tem of hospitals and other healthcare service facilities20 . Rebranded as Vanderbilt Wilson County Hospital (VWCH), VUMC’s Tennova purchase consisted of a 2-campus medical facility, including a general inpatient services hospital at 1411 West Baddour Parkway, and a second facility, now called VWCH McFarland, at 500 Park Avenue. VWCH McFarland provides specialized behavioral health and physician rehabilitation services21 . Notably, the VWCH McFarland facility is co-located with Cumberland University’s School of Nursing. The 2019 addition of VWCH significantly expanded VUMC’s local presence in WC, joining about a dozen or so other existing VUMC-affiliated clinics and medical practices.

VWCH provides a full service hospital facility for Wilson County residents as well as for those living in the surrounding eastern rural counties and beyond. 22

West Lebanon Professional Medical Center, Lebanon, TN

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Other hospital systems operating with a physical presence in Wilson County include TriStar Summit and Ascension Saint Thomas Heart. A division of HCA Health, TriStar Health is middle Tennessee’s largest, most comprehensive healthcare provider.

TriStar Health offers imaging and urgent care services at TriStar locations in Mt Juliet and Lebanon, as well as primary care services in Lebanon23 . Ascension Saint Thomas Heart, a Catholic health ministry and the nation’s second largest private healthcare service provider, offers a variety of primary and specialty care services in Mt. Juliet and Lebanon24 .

Private Social Assistance Services In 2019, there were 41 private social assistance establishments in Wilson County TN, an 11% increase over the 37 establishments operating in the county in 2009. We also note in 2009 that there were 702 people employed in WC private social assistance establishments25 earning an average weekly wage of ✩345.

As shown in Table 1, social assistance (NAICS 624) can be divided into four (4) industry groups26 .

In terms of number of WC workers in 2019, the largest social assistance categories were individual and family services (NAICS 6241) and child daycare services (NAICS 6244). For the decade 2009-2019, we note a rather large 156% increase in the number of WC workers employed in individual/family services (75 workers in 2009 rising to 192 workers in 2019), accompanied by a moderate 12% increase in the number of documented child daycare facilities.

We also note that while individual and family service facilities increased by 44% (going from 9 to 13 during the 10 year period), the number of registered child daycare facilities experienced only a slight 4%

acquisitions, mergers, etc. taking place within Wilson County, as well as in the state of Tennessee, and nationally. Source: Tennova Healthcare - Clarksville May Soon Partner with Vanderbilt University Medical Center — Newsroom (tennovaclarksville.com) 21 “Introducing Vanderbilt Wilson County Hospital: VUMC takes over Tennova Healthcare – Lebanon” by Andy Humbles, The Tennessean, August 01, 2019, retrieved at https://www.tennessean.com/story/news/local/wilson/2019/08/01/tennova-lebanonbecomes-vanderbilt-hospital/1869272001/ .

22 Also in this issue, see the companion article on VWCH as well as WCT’s Who’s Who section for a list of specific VUMC healthcare groups operating in WC. 23 See https://tristarhealth.com/locations/ for healthcare services by WC location.

24 See https://healthcare.ascension.org/locations?page=1&facility=&location=mt%20juliet&distance=50&filter= for healthcare services by WC location.

25 2019 WC employee and wage statistics are unavailable in the NAICS 624 industry subsector.

26 Only privately owned social assistance establishments in NAICS 624 are considered in this analysis. Government social assistance agencies are excluded from consideration. Wage and employment data for certain NAICS 624 industry subsectors are unavailable due to US DOL disclosure guidelines.

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increase (going from 25 in 2009 to 26 in 2019). Interestingly, while the average weekly wages for those employed in WC’s individual/family service facilities increased by a slight 7%, earning ✩391 in 2009 and rising to ✩418 in 2019, the wages of those employed

by WC child daycare facilities27 increased 35%, earning ✩278 in 2009 and increasing to ✩375 in 2019. See Figures H10, H11, and H12.

Other Healthcare Industry Groups Two other notable healthcare industry groups operating in Wilson County in recent years are medical equipment & supplies manufacturers (NAICS 3391) and medical equipment merchant wholesalers (NAICS 42345). In 2019, WC’s medical equipment manufacturing industry was dominated by small enterprises consisting of 5 establishments, employing 10 people in total who earned an average weekly wage of ✩978. For the same period, WC’s medical equipment merchant wholesaler industry consisted of 16 establishments, employing 325 people who earned an average weekly wage of ✩1271. While economic indicators are generally positive for the county’s fledgling medical manufacturing industry, its overall size is too small at present to predict whether the industry group will have much impact on the county economy in the near future. On the other hand, WC’s medical merchant wholesaler industry shows much economic promise for the county, noting a near term 28% growth spurt in workforce size (2017 to 2019), an 8-fold increase in the number of new establishments (from 2009 to 2019), and an industry-high wage rate. Given WC’s national strengths in supply chain logistics, it is not surprising to observe recent strong local business activity in medical equipment wholesaling. See Figure H13.

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Future Outlook Recent healthcare Industry developments in Wilson County have provided both a microcosm and an affirmation of national healthcare trends. As WC’s population has undergone unprecedented growth during the past decade, a variety of both small and large size healthcare providers are establishing or expanding their local presence in the county to meet a growing diversified demand for health and medical services. Developments in WC over the past decade have included new healthcare service models, such as increases in health provider services targeted at home-based patient care and new forms of ambulatory services. We also note increases in the number specialized and independent health practitioners, as well as integrated healthcare services (e.g., in-house diagnosis and testing) offered by area hospitals. We observe increases in the number of residential healthcare facilities that offer specialized care to special needs groups, including seniors (eldercare via assisted living centers) and residential-based mental health treatment programs.

Future challenges to adequate healthcare service delivery is somewhat atypical in WC from that of other counties, in that WC county includes sizable urban and rural populations. Hence we note in WC a proliferation of small community-based healthcare clinics as well as a growing local interest in telehealth28 (mostly Internet-based) solutions. A the national healthcare scene continues to undergo transitions, we may expect WC’s healthcare changes of the past decade to not only continue but in some cases intensify, driven by both local and external factors, such as the global pandemic, and industry restructurings among large healthcare providers.

While the general topic of illegal and/or unlicensed daycare facilities is outside the scope of this report, in addition to child safety concerns, one also cannot ignore the economic significance of the child daycare industry itself nor its economic impact on other industries, including healthcare. Tennessee, for example, does not require a childcare provider to be licensed to provide care for fewer than five unrelated children. Such industrial nuances as this makes a comprehensive analysis of this WC industry subsector a difficult challenge. (https://www.tn.gov/humanservices/for-families/child-care-services/child-care-types-of-regulated-care.html) 28 See the survey article on Telehealth Trends in this issue.

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Figure H4 Number of WC Employees in Ambulatory Services, 2009 vs 2019 Source: US Department of Labor

Figure H5 Number of WC Establishments in Ambulatory Services, 2009 vs 2019 Source: US Department of Labor

Figure H6 Average Weekly Wage in WC Ambulatory Services, 2009 vs 2019 Source: US Department of Labor

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Figure H7 Number of WC Employees in Nursing & Residential Care, 2009 vs 2019 Source: US Department of Labor

Figure H8 Number of WC Establishments in Nursing & Residential Care, 2009 vs 2019 Source: US Department of Labor

Figure H9 Average Weekly Wage in WC Nursing & Residential Care, 2009 vs 2019 Source: US Department of Labor

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Figure H10 Number of WC Employees in Private Social Assistance, 2009 vs 2019 Source: US Department of Labor

Figure H11 Number of WC Establishments in Private Social Assistance, 2009 vs 2019 Source: US Department of Labor

Figure H12 Average Weekly Wage in WC Private Social Assistance, 2009 vs 2019 Source: US Department of Labor

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Figure H13 Number of WC Establishments in Other Healthcare Industry Groups, 2009 vs 2019 Source: US Department of Labor

Cumberland University’s Rudy School of Nursing and Health Professions, Lebanon, TN

Labry School of Science, Technology, and Business

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Who’s Who: Wilson County’s Healthcare Industry29 A partial list of healthcare businesses residing and operating in Wilson County is given in Table 2 below. The listing includes healthcare patient service providers, as well as medical equipment and supply retailers and wholesalers. We note the presence of both non-profits and for-profits among WC’s healthcare service providers. Wilson County’s robust healthcare industry development is impacted by three key factors, 1) WC’s proximity to national healthcare player Nashville/ Davidson County, 2) WC’s fast 29

growing population30 and economy (joint indicators of a large attractive, and mostly insured, patient base), and 3) structural changes taking place in the nation’s healthcare industry (e.g, home-based care, telehealth, changes in healthcare public policy, etc).

The entry into the WC healthcare market by such industrial heavyweights as VUMC, HCA and Ascension, has also attracted, or created, a bevy of small healthcare enterprises and support groups.

While generally not included in this Who’s Who listing because of their relative small employment size, the following health industry categories are well represented in Wilson County and collectively comprise a significant and sizable local industry component - individual physician offices, assisted living products and services, wellness centers, fitness centers, healthcare legal services, mental health treatment centers, nutrition retailers, health insurance providers, childcare services, chiropractic services, alcoholism and substance abuse centers, physical therapy centers, ambulatory services, dentist offices, pharmacies, optometry, hearing aid services, and medical alarm services.

30 In terms of percentage growth, WC was recently rated as Tennessee’s 8th fastest growing county and ranked the 57th fastest growing county in the USA. Sources: see http://www.tnledger.com/editorial/ArticleEmail.aspx?id=126163&print=1 and https://fox17.com/news/local/four-middle-tennessee-counties-among-100-fastest-growing-in-united-states

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Table 2: Who’s Who in Wilson County TN’s Healthcare Industry, 2021 Name31 American Family Care Providence Ascension Saint Thomas CareNow Urgent Care Charis Health Center Champion Healthcare Cherry Valley Family Care Children’s Clinic East Community Quick Care Cumberland Skin Surgery & Derma Cumberland Mental Health CU School of Nursing Diasol Dialysis Clinic Inc Digestive Disease Associates Don Ingram & Assocs Employment & Assessment Solutions Fast Pace Health GPR Test and Inspections Hearing Health Center Hometown Respiratory Impact Medical Sales & Supply, LLC Inspire Medical Jackson Medical Products, LLC Lebanon Health & Rehab Center The Lett Center The Little Clinic Manor Healthcare Supply Martin Medical Medical Billing Assocs Middle TN Periodontics Patient Centered Care The Pavilion Pregnancy Care Center Premier Orthopaedics & Sports Quality Center for Rehab & Healing Rai Care Center Restorative Health Systems SimplyCare Synder MN & Assocs TN Orthopedica TN Sports Med & Orthopaedics Titan Healthcare Tri-Star Equipment Services

31 32

Services Location(s)32 primary & urgent care, imaging MJ cardiovascular care Leb primary & urgent care walk-in svcs Leb, MJ faith based clinic MJ addiction, psychiatry, wellness Leb walk-in clinic, primary & urgent care Wtn well childcare, spirometry Leb, MJ medical clinic Leb skin care Leb mental health services Leb nurse education Leb medical equipment and suppliers Wtn dialysis services Leb, MJ gastrointestinal & liver disorders Leb medical equipment wholesaler Leb drug screening Leb walk-in clinic, telehealth Leb, Wtn medical lab testing Leb hearing tests and solutions Leb medical equip & supplies retailer Leb medical equipment wholesaler Leb weight loss svc, nutrition counseling MJ medical equipment wholesaler Leb rehabilitation services Leb reconstructive & cosmetic surgery Leb, MJ walk-in clinic, screenings Leb medical equip & supplies retailer MJ medical equipment wholesaler Leb x-ray services Leb dental services Leb addiction counseling & treatment MJ rehabilitation services Leb maternity services and counseling MJ Med orthopedic surgery Leb rehabilitation svcs, long term care Leb dialysis services Leb artificial limbs Leb primary care, skin treatment MJ nursing consultation Leb orthopedic surgery Leb orthopedic surgery MJ medical bracing equipment retailer MJ medical equipment retailer MJ Continued on next page

Please send additions, deletions, or corrections to wilsoncountytrends@cumberland.edu .

Abbreviations: Leb=Lebanon, MJ=Mt. Juliet, Wtn=Watertown

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Table 2: (continued) Who’s Who in Wilson County TN’s HC Industry, 2021 Name TriStar Summit Vanderbilt General Care Vanderbilt-Ingram Cancer Center Vanderbilt Specialty Care Vanderbilt Specialty Care Vanderbilt Walk-In Clinics Vanderbilt Wilson County Hospital VWCH McFarland Campus World Testing Wright Medical Billing

Service(s) imaging, primary & urgent care primary, women & midwives33 care medical & radiation oncology 11 specialty areas34 3 specialty areas35 4 locations36 in-patient services & surgery behavioral health, rehab services medical lab testing medical billing services

Location(s) Leb, MJ MJ, Leb Leb Leb MJ Leb, MJ Leb Leb MJ Leb

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Midwives care is only available at the Mt. Juliet location.

VUMC specialty areas in Lebanon include asthma, sinus, & allergy; eye institute; gastroenterology; hearing & speech clinic; heart; neurology; physical medicine & rehab; surgery; urology; bariatric surgery; and sleep disorders.

35 VUMC specialty areas in Mt. Juliet include neurosurgery; orthopaedics; and sports medicine clinic.

36 Mt. Juliet includes a children’s after-hours clinic. Lebanon includes a clinic co-located at a Walgreens.

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Master of Business Administration (MBA) Degree Cumberland University’s MBA Our MBA is a great choice for anyone wishing to advance their business acumen, skills, knowledge, and abilities in order to grow and prosper professionally in these unique times.

Our business programs at Cumberland are accredited by the American Council of Business Schools and Programs (ACBSP), which bases its standard of excellence on the Baldrige Education Criteria for Performance Excellence.

Cumberland University MBA Mission Statement The Master of Business Administration program at Cumberland University empowers our graduates to become strategic leaders with management skills and knowledge to ensure their professional and personal success as twenty-first century global leaders.

How and when are MBA classes offered? The three semesters (spring, summer, and fall) are split into two eight-week terms (A and B). MBA courses are offered each term in a variety of formats: traditional classes meeting one evening per week or online courses; students may complete the program entirely online, entirely on campus, or choose a combination of those two options.

How long will it take to graduate? Students may complete the program in as little as one year, or they may choose to complete the program in two years taking only one course at a time.

What are the Core Courses? Required classes include Managerial Accounting, Corporate Financial Analysis, Computer Information Systems, Marketing Management, Managerial Economics, Applied Statistics, Organizational Behavior & Theory, Strategic Management, and Leadership.

Is there the opportunity to specialize? Students will concentrate in one of the following specializations: General Management, Leadership, Human Resource Management, Marketing, and International Management.

More questions? Contact MBA Program Director, Dr. Paul Percy (ppercy@cumberland.edu) or for more information visit http://www.cumberland.edu/mba-flipbook To apply for the MBA program, visit www.cumberland.edu/applynow

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Cumberland University

Guest Article: Vanderbilt Wilson County Hospital Dr. Adam Huggins is an Assistant Professor of Obstetrics and Gynecology at Vanderbilt University Medical Center. In addition to his clinical work, he also serves as Associate Chief Medical Officer for Vanderbilt Wilson and Sumner Counties. He was born and raised in Birmingham Alabama, received his undergraduate degree from Wake Forest University, and completed medical school at University of Alabama Birmingham.

Dr. Huggins did his residency training in OBGYN at Virginia Commonwealth University. After graduation from residency, he worked in private practice in Nashville for 4 years before joining the faculty at VUMC. Dr. Huggins also completed his Masters in Management of Healthcare in 2016 from Vanderbilt Owen School of Management. He is married with two young children, and in his free time enjoys playing ice hockey, skiing, and fly fishing.

Traci Pope is the Director of Community Relations at Vanderbilt Wilson County Hospital. She joined the hospital in 2015, with over 15 years’ experience in the health care field. Traci is a graduate of Lipscomb University and is currently completing a Master of Management in Healthcare (MMHC) from Vanderbilt Owen School of Management.

She is very involved in the community, the current chair elect for Leadership Wilson, class of 2017; Board Member for the Mt. Juliet Chamber of Commerce; Rotarian with the Mt. Juliet Noon Rotary Club; Board Member for Wilson Rides Inc.; a member of the Wilson County Health Council and Wilson ONE. She is married with two children, and in her free time enjoys reading, snow skiing and exercising.

Vanderbilt Wilson County Hospital (VWCH) is a two-campus healthcare facility licensed for 245 beds.

It was purchased by Vanderbilt University Medical Center (VUMC) in August 2019 from Community Health Systems, Inc. The facility has an adult acute care hospital as well as a separate inpatient physical rehab and inpatient psychiatric hospital, both located in Lebanon, Tennessee. The acquisition of VWCH reflects the strong commitment VUMC has to the citizens of Wilson County and strategically places Vanderbilt as the dominant provider of health care services in one of Metro Nashville’s fastest growing bedroom communities.

Meeting WC’s Healthcare Needs As the only full-service hospital in Wilson County, VWCH is uniquely positioned to meet the healthcare needs of the county and over 150,000 residents.

Since the acquisition in 2019, with the full support of VUMC, the hospital has added significant resources ranging from new medical services, new alliances and partnerships, and significant capital investment. New or augmented medical services that have been added over the past eighteen months include: Anesthesia, Ophthalmology, Bariatric Surgery, Gastroenterology, OB/GYN, Tele-Neurology, Psychiatry, Physical Medicine and Rehab, Emergency Medicine, Hospitalist Internal Medicine, Critical Care, Radiation and Medical Oncology, Plastic Surgery, Urology, and Pediatrics. Overall, more than 140 providers have been added to the medical staff roster. Existing emergency services have also been augmented by enhancing the relationship with existing EMS services in Wilson County and by adding Vanderbilt LifeFlight ambulances at VWCH. This means VWCH is now able to care for more patients with a wider range of medical diagnoses than ever before.

Labry School of Science, Technology, and Business

Vanderbilt Wilson County Hospital

WC’s Vanderbilt-Ingram Cancer Center

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tal, Vanderbilt Neurology began offering telemedicine consults to patients in the Emergency Department and those in the hospital. So now patients with diseases such as stroke, seizure disorders, and others can often be cared for here without being transferred downtown. Our telemedicine services have now been augmented by other specialties such as: Infectious Disease, Emergency Psychiatry, Nursery, and Pediatric ED. The Pediatric ED teleconsults are particularly noteworthy as they can potentially save a family a trip to the Monroe Carroll Junior Children’s Hospital for further evaluation of a condition that can be managed locally safely. All of these services enable VWCH to provide ever more complicated and comprehensive care in a high-quality way in a local setting.

One particular service line addition that VWCH is particularly proud of is the opening of the VanderbiltIngram Cancer Center (VICC) at Wilson County.

VICC is one of only 51 Comprehensive Cancer Centers in the country. This Cancer Center is home to both medical and radiation oncology services. Patients are able to receive treatment from Vanderbilt Oncology providers, receive chemotherapy infusions onsite, and receive radiation therapy as well. The VICC at Wilson County utilizes state of the art equipment to deliver radiation treatment using the Ethos Radiotherapy System. VWCH is one of only four centers in the country with this technology, allowing providers to uniquely adapt treatment plans to individual patients.

“Transitioning to Vanderbilt’s Emergency Medicine Department reflects Vanderbilt’s strong commitment to the citizens of Wilson County to continue providing outstanding care to patients and families throughout the region,” said R. Scott Frankenfield, MD, director of VWCH Emergency Services (pictured in the middle of photo below). “Vanderbilt Emergency Medicine is one of the most nationallyrenowned emergency departments. The community will receive that same top-notch care without having to leave Wilson County. I am honored to lead the Emergency Medicine team at VWCH.”

VWCH Telehealth Services Another innovative way in which VWCH is bringing additional services to Wilson County is through telehealth. Shortly after the acquisition of the hospi-

VICC VWCH’s Ethos Radiotherapy System

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Recent Capital Investments In addition to adding providers to the medical staff, VWCH has made significant investments in its underlying infrastructure. Laboratory equipment has been replaced and upgraded, the pharmacy’s services have been expanded, and an entirely new electronic medical record system was successfully installed in April 2020. Radiology services have also received significant upgrades, including a new 3D mammography machine as well as a new MRI and newly designed MRI suite. The operating suites have also received significant capital investments. These include operative equipment such as 4K video towers for laparoscopic surgery, other surgical instrumentation, and the installation of two new sterilizers allowing VWCH to more efficiently process instruments to care for more patients. Other upgrades to the grounds include new interior and exterior paint as well as enhancements to the parking lots at both of the hospital’s campuses.

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ment for COVID-19, which has been shown to significantly reduce the need for hospitalization. More recently, VWCH has played a key role in the vaccination of providers and patients against COVID-19.

VWCH was able to vaccinate not only its own staff, but also many of the community providers and their staff. Now VWCH is working with the Wilson County Health Department to begin the vaccination process for the general public. Within just weeks, VWCH was able to provide vaccinations to over 2500 members of the public, and is in position to continue providing that service for months to come.

VWCH and Covid-19 Since the acquisition of VWCH, the hospital has also played a key role in the fight against COVID-19.

Shortly after the pandemic started, VWCH opened a 17 bed COVID Unit that could be occupied by up to 34 COVID patients. In addition, ICU Critical Care and Medicine providers cared for critically ill patients in the ICU and the newly opened 12 bed Stepdown Unit. VUMC has been widely recognized as a leader in the treatment of COVID-19, ranging from research on treatment therapies to vaccines. This has enabled VWCH to be able to provide the latest and most effective therapies to the people of Wilson County. In particular, VWCH has been able to provide COVID19 monoclonal antibody infusion as an early treat-

Future Plans Despite all of the accomplishments thus far, VWCH is continuing to focus on future growth. There are plans for additional medical services, new designations, expanded critical care capacity, and more infrastructure improvements. With the support and expertise from Vanderbilt University Medical Center, Vanderbilt Wilson County Hospital is positioned to continue to lead the healthcare industry in Wilson County through the highest quality personalized medicine for which Vanderbilt Health is known.

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Telehealth Trends Stephen Shao is a faculty member at Cumberland University’s Labry School of Science, Technology and Business. Dr. Shao has collaborated with various health service organizations, including the Tennessee League for the Deaf & Hard of Hearing, Tennessee Rehabilitation Center, Bill Wilkerson Center, Tennessee Disability Coalition, Vanderbilt University Medical Center (VUMC) and others. He has participated in various telehealth initiatives, including service as a distance training supervisor for VUMC’s Leadership Education in Neurodevelopmental Disabilities (LEND) program funded by the U.S. Department of Health & Human Services (US H&HS), and was a contributing member of VUMC’s Science & Technology Education Partnership (STEP) funded by the National Institutes of Health. Dr. Shao has also served on federal grant review panels for US H&HS’ Maternal and Child Health Bureau’s Division of Continuing Education & Distance Learning.

Telehealth Defined In everyday vernacular, the term “telehealth” may be ill-defined, meaning different things to different people. Dictionary.com defines telehealth as “a system that uses internet and telecommunications technology to provide a wide range of healthcare services, as telemedicine, education, patient care management, and remote monitoring of vital signs”. This description of telehealth is fairly broad in scope, encompassing various kinds of healthcare applications, including healthcare administration, diagnostics and treatments, acute (short term) and chronic (long term) patientcare, hospital and ambulatory care, etc. We also note that while the terms telehealth and telemedicine are sometimes used interchangeably with one another, the latter is actually a subset of the former. The Academy of Family Physicians states that telehealth is different from telemedicine in that it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote nonclinical services such as provider training, continuing medical education or public health education, administrative meetings, and electronic information sharing 37

to facilitate and support assessment, diagnosis, consultation, treatment, education, and care management.37

Driving Factors The U.S. healthcare industry is huge and is getting bigger. In 2019, U.S. healthcare spending grew 4.6 percent reaching ✩3.8 trillion or ✩11,582 per person. In the same year, health spending in the U.S. accounted for 17.7 percent38 of the nation’s GDP. While the healthcare industry is the nation’s largest employer, the industry is not without challenges and important rising issues, however. Healthcare areas of concern have ranged from shortages of doctors, nurses and other service personnel, and lack of availability of health services for rural residents as well for people who are isolated due to recent pandemic lockdowns. Because of such concerns, telehealth services are increasingly becoming an important virtual alternative to in-person healthcare. According to one source, use of telehealth services in the U.S. is expected to grow at an annual rate of 14.9%, during the period 2019-202639 . In most cases, telehealth services represent a win-win scenario. Telehealth services can provide patients with greater access to healthcare resources and medical professionals. At the same time, telehealth services can increase healthcare provider productivity by allowing

https://www.aafp.org/about/policies/all/telehealth-telemedicine.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthE xpendData/NationalHealthAccountsHistorical 39 The Future of Telehealth in the U.S. and Across the Globe, retrieved from https://intouchhealth.com > future-telehealth-usacross-glo .

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physicians and other health care professionals to see and treat more patients.

There are three related factors driving the current evolution and expansion of telehealth services: 1) new and rapid advances in information technology, 2) the global Covid-19 pandemic, and 3) U.S. healthcare public policy. In regard to the first factor, information technologies (IT) important to the provisioning of telehealth services fall into two main categories: 1) digital healthcare devices and 2) computer networking services (referred to as the “cloud” in general). In most cases when discussing the cloud, we are talking about the public Internet, aka the Internet of Things, or IoT. Cloud service technology enables telehealth services. Without the cloud, we are stuck with stand-alone islands of gadget-based health applications, useful in their own right but not helping to overcome the distance and isolation barriers that increasingly exist between patient and healthcare provider. Recent cloud access enhancements, e.g., fast “broadband” Internet access (e.g., fiber optic lines or 5G wireless), coupled together with new online medical and diagnostic devices, have combined to create a plethora of new telehealth service alternatives to traditional in-person healthcare. By one estimate, Internet connected medical devices, electronic diagnostic equipments, etc., are expected to lower the cost of operational healthcare and clinical inefficiencies in 2021 by ✩100 billion40 . IT advancements present the healthcare industry with new opportunities to expand service coverage and increase efficiencies of quality healthcare.

The second factor, Covid-19 and its variants, is the hard to miss elephant in the living room. The global wide pandemic impacts the telehealth industry in two ways. First, we note that Covid-19 is a health malady in and of itself, one which threatens everyone’s personal health. Along with its variants, while Covid-19 must be treated physically (via vaccines), it can be controlled both physically (e.g., by masking and social distancing) and virtually (e.g., by extreme social distancing via telehealth services). As an immediate health threat, the pandemic also acts 40

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as an economic stimulant of new telehealth products and services, as well a driving force behind revised telehealth public policy.

Covid-19’s treatment urgency exerts pressure on public policy makers to quickly review and enact new healthcare laws and regulations that are supportive of telehealth platforms41 . This third factor of revised U.S. healthcare public policy addresses an obvious need to include health insurance coverage of telehealth-based patient services42 . The emerging telehealth industry cannot succeed without a guaranteed payment mechanism. There is currently no bigger fan or lobbyist of telehealth solutions than the U.S. Government. The U.S. Department of Health and Human Services, for example, states that during the Covid-19 emergency, “We encourage health care providers to adopt and use telehealth as a way to safely provide care to your patients in appropriate situations, including: routine health care, like wellness visits; medication consultation; dermatology (skin care); eye exams; nutrition counseling; mental health counseling.”43 Another step in the right direction is a stopgap relaxation of federal healthcare regulations during the pandemic emergency. On March 6, 2020, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, allowing physicians and other health care professionals to bill Medicare fee-for-service for patient care delivered by telehealth platforms during the current coronavirus public health emergency. Added support for use of telehealth services in Medicare, Medicaid, the Affordable Care Act, etc., is also on the table and being discussed.

Cloud Platforms From a technology perspective, telehealth and telemedicine services are either based on asynchronous or synchronous cloud platforms. Asynchronous platforms do not require the simultaneous time presence of both patient and health provider, while a synchronous telehealth exchange does require

https://policyadvice.net/insurance/insights/healthcare-statistics/ See for ex., Coverage Provisions In The 2021 Appropriations And COVID-19 Stimulus Package by Katie Keith, Health Affairs, January 4, 2021, retrieved at https://www.healthaffairs.org/do/10.1377/hblog20210104.961016/full/ 42 See, for example, Only 15% of Family Physicians Report Using Telehealth; Training and Lack of Reimbursement Are Top Barriers, Robert Graham Center research publication, January 15, 2016, retrieved from https://www.graham-center.org/rgc/publicationsreports/publications/one-pagers/FPs-telehealth-2016.html .

43 https://www.hhs.gov/coronavirus/telehealth/index.html 41

Labry School of Science, Technology, and Business

it.

There are three types of cloud-based telehealth services: store-and-forward, remote monitoring, and videoconferences. The first and third service types are considered asynchronous and synchronous, respectively while remote monitoring is usually provisioned as synchronous, although it can also be offered asynchronously. Store-and-forward (S&F) telehealth services involve encapture and temporary storage of patient records which are later transmitted (forwarded) to other service locations for processing and evaluation. Sending a patient’s medical history, digital X-ray file, etc. from a neighborhood clinic to a diagnostic lab or hospital, is an example of an S&F based telehealth service. Remote monitoring services are usually configured with a real time data telemetry link between a remote patient monitoring device and a distant facility that receives, processes, and displays the medical data on a terminal screen for review and evaluation by an attending physician, nurse, etc. While telehealth services in the S&F and remote monitoring categories have existed for many years, new online products and cloud services have accelerated their adoption and uses in the U.S. Annual growth forecasts of direct telehealth links to hospitals and to at-home patients, are expected to reach 19% and 19.6%, respectively, during the period 20202026.44 In response to decreasing equipment costs and new social distancing policies, rapidly rising in popularity the new kid on the telehealth block is Videoconferencing (VC) telehealth service. VC based telehealth services use live 2-way audio and videoconferencing links over the IoT to interconnect patients to distant health providers. From VC’s use in the early 1980s as an expensive (and sparsely used) corporate virtual meeting tool, current VC technology costs and quality levels have improved considerably over the past decade, reaching acceptable levels so that VC telehealth services have become a viable telehealth service alternative in cases where physical separations cannot be avoided or are required. The highly interactive and interpersonal features of videoconferencing technology, along with easy setup and operation, are driving acceptance and adoption levels to new usage levels. With ongoing improvements in 44

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quality, security and screen resolution, VC telehealth services are becoming an indispensable tool for remote healthcare consultations, examinations, and for establishing a good, though virtual, bedside manner.

Emerging Trends What other telehealth trends may we expect in the near future? We have already mentioned the rapid growth in development and use of new telehealth gadgetry. One may expect continued development and rollouts of new special purpose telehealth products to follow the demand for specific telehealth services. Marketing research consulting firm Global Market Insights, Inc. estimates that the global market for telehealth equipment will exceed ✩7.9 billion by 2026. An intriguing product subcategory of telehealth equipment is the notion of a general purpose “telemedicine cart”, aimed at acute remote patientcare. The market for telemedicine carts is expected to grow annually at 17.4% for the period 2020-2026.45 Complementing the growth of new types of telehealth equipment are increases in telehealth service offerings, as in cases of video tele-consultations with health professionals, topical medical examinations, mental health treatment, and in some instances, behavior modification. A key telehealth trend is how traditional healthcare institutions are leveraging new digital and cloud-based technologies to expand and improve the quality of their own patientcare services.

In a 2020 white paper, the Medical Group Management Association (MGMA) observed that telehealth services provide primary care health organizations such as hospitals, with an “insourcing” opportunity to expand service coverage and continuing patientcare using the institution’s own physicians and medical experts instead of outsourcing certain healthcare responsibilities to 3rd parties who may not be familiar with internal protocols. Telehealth services also provide health institutions with connective tools for follow up or specialized treatments, allowing for delivery of better integrated patientcare. MGMA also notes the growing importance of telehealth services as supportive remote diagnostic and physician links between first responders (e.g., paramedics) and hos-

https://www.gminsights.com/industry-analysis/telemedicine-market https://www.globenewswire.com/news-release/2020/04/22/2019866/0/en/Telehealth-Devices-Market-to-cross-USD-7-9-Bnby-2026-Global-Market-Insights-Inc.html 45

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pitals where immediate medical intervention at the scene is necessary.46 Besides institutional impacts, emerging telehealth services are having direct personal effects on both healthy and sick individuals. Technology newscaster Science X, for example, describes a broad variety of emerging personal telehealth products and services, including new Smartphone-based health monitoring apps, remote blood testing software, remote bio-sensor skin patches, even an artificial intelligencebased app that detect signs of pneumonia from a person’s cough.47 The expansion of the so-called “mobile telehealth” market is expected to reach ✩236 billion by 2026, growing at an incredible annual rate of 44.7%.48 Forbes predicts new telehealth service demand in four major areas : 1) increasing adoption of telehealth platforms for online care of chronic diseases, such as lupus, autoimmune disease, and age-related diseases; 2) increasing use of wearable health devices that can continuously monitor things like heart rate, glucose levels, and blood pressure; 3) renewed emphasis on health data security and privacy due to a post-pandemic return to federal health regulations; and 4) a focus on online mental health services and psychiatry49 .

Global health organization Project HOPE confirms the expected developments to take place in online care of chronic diseases stating “that telehealth, remote monitoring, and care at home can reduce the time patients spend in the hospital for chronic illness management. We anticipate providers will be more savy about using telehealth to reach at-risk populations in 2021. Telehealth can extend access to those living in rural areas, seniors, and low-income and high-risk individuals50 .”

There also seems to be notable trend and dialog regarding increased health insurance coverage of mental health exams and treatments. This is a very timely development, given well publicized issues concerning pandemic-related high anxiety and stress levels, suicide rates, etc. among the general pub46

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lic. Grand View Research, a California-based marketing research consultancy, predicts that the global “telepsychiatry market” valued in 2019 at ✩5.5 billion is expected to grow at an annual rate of 24.7% from 2020 to 2027.

Chicago-based technology consultant firm Empeek foresees sizable growth in the contineud current use of telehealth services for home-based chronic care patients, mental health teletherapy, and not surprisingly, physician teleconsultations for Covid patients.

According to Empeek, telehealth services to emerge in 2021 will include telehealth services integrated with embedded electronic health record software, increased use of wearable IoT-based health monitoring devices, health database analytics using Big Data and artificial intelligence, augmented reality based medical training, and finally, more stringent telehealth data security measures. 51 Further research reveals that the types of telehealth services in development or being proposed are very broad indeed. Except perhaps for surgical cases, it is almost impossible in fact, to find an area of traditional healthcare in which telehealth and telemedicine solutions are not being considered as viable, cost efficient, service and treatment alternatives.

After the Pandemic?

The pandemic has put a lot pressure on everyone with a vested interest in healthcare - consumers, businesses and healthcare providers alike, to reduce physical in-person interactions and consider a teleconsultation or tele-treatment instead. Some people may be willing to utilize telehealth services only as long as the threat of Covid-19 exists. If in the meantime however, such virtual healthcare experiences are satisfactory to both patient and healthcare provider, post-pandemic telehealthcare may evolve into a permanent fixture of the nation’s healthcare infrastructure, though perhaps pushed along a bit by public policymakers. And for groups whom virtual healthcare proves to be particularly convenient and afford-

https://www.mgma.com/resources/health-information-technology/the-newest-trends-in-telehealth-in-2020 https://medicalxpress.com/news/2020-06-remote-devices-telehealth-surge-demand.html 48 https://www.itransition.com/blog/mobile-healthcare 49 Where Telehealth is Headed in 2021 by Shama Hyder, Forbes Magazine, November 16, 2020, retrieved at https://www.forbes.com/sites/shamahyder/2020/11/16/where-telehealth-is-headed-in-2021/?sh=5fa17aa7635e 50 Healthcare in 2021: Five Trends to Watch by Susan DeVore, Health Affairs, January 20, 2021, retrieved at https://www.healthaffairs.org/do/10.1377/hblog20210119.724670/full/ .

51 https://empeek.com/5-trends-driving-telemedicine-market-forecast-through-2021/ 47

Labry School of Science, Technology, and Business

able, e.g., busy professionals, home-bound seniors, residents of rural areas52 , etc., telehealth services may even evolve from being a niche or stopgap mea-

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sure to becoming a commonly used tool of everyday living.

52

We note an interesting new trend among some urbans who decide to relocate to rural towns and communities, due in part to restrictive pandemic policies of large metropolitan cities. See, for example, Americans Leave Large Cities for Suburban Areas and Rural Towns by Kristin Tate, The Hill, 07/05/20 , retrieved at https://thehill.com/opinion/finance/505944-americans-leave-largecities-for-suburban-areas-and-rural-towns

Cumberland University’s Heart of the Phoenix, Lebanon, TN

Appreciation and Thanks are expressed to CU faculty and staff, as well as other individuals and organizations for their general support and for materials used in this report. In particular, we would like to thank the Tennessee Department of Economic & Community Development and the Tennessee Department of Revenue.

The Last Word A sales rep, an administration clerk, and the manager are walking to lunch when they find an antique oil lamp. They rub it and a Genie comes out. The Genie says, ‘I’ll give each of you just one wish.’ ‘Me first!

Me first!’ says the admin clerk. ‘I want to be in the Bahamas , driving a speedboat, without a care in the world.’ Puff! She’s gone. ‘Me next! Me next!’ says the sales rep. ‘I want to be in Hawaii , relaxing on the beach with my personal masseuse, an endless supply of Pina Coladas and the love of my life.’ Puff! He’s gone. ‘OK, you’re up,’ the Genie says to the manager. The manager says, ‘I want those two back in the office after lunch.’

Moral of the story: Always let your boss have the first say.

Wilson County Trends A Cumberland University Publication from the Labry School of Science, Technology, and Business 1 Cumberland Square Lebanon TN, 37087

List of Figures and Tables Recent Trend Graphs Figure R1 - Number of Business Establishments by Industry in Wilson County TN, 2018-2Q2020 . . . . . . . . . . . . . . . . . . . . 3 Figure R2 - Average Weekly Wage by Industry in Wilson County TN, 2018-2Q2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Figure R3 - Total Persons Privately Employed in Wilson County, TN, 2019-2Q2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Figure R4 - Total Retail Sales by Category in Wilson County, TN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Figure R5 - Monthly Total Retail Sales in Wilson County TN, 2019-2Q2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Figure R6 - Monthly Autos, Boats & Aircraft Sales in Wilson County, TN, 2019-2Q2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Figure R7 - Monthly Retail Sales by Category in Wilson County, TN 2019-2Q2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Healthcare Graphs Figure H1 - All WC Healthcare Employees, Ambulatory Care vs Nursing & Residential Care, 2009 - 2019 . . . . . . . . . . . 13 Figure H2 - Number of WC Healthcare Establishments by Industry Group, 2009 - 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Figure H3 - Average Weekly Wage in WC’s Ambulatory Care vs Nursing & Residential Care, 2009 – 2019 . . . . . . . . . . 13 Figure H4 - Number of WC Employees in Ambulatory Services, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure H5 - Number of WC Establishments in Ambulatory Services, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure H6 - Average Weekly Wage in WC Ambulatory Services, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure H7 - Number of WC Employees in Nursing & Residential Care, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure H8 - Number of WC Establishments in Nursing & Residential Care, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure H9 - Average Weekly Wage in WC Nursing & Residential Care, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure H10 - Number of WC Employees in Private Social Assistance, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Figure H11 - Number of WC Establishments in Private Social Assistance, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Figure H12 - Average Weekly Wage in WC Private Social Assistance, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Figure H13 - Number of WC Establishments in Other Healthcare Industry Groups, 2009 vs 2019 . . . . . . . . . . . . . . . . . . . 20

Tables Table 1 - Healthcare Industry Groups by NAICS Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 2 - Who’s Who in Wilson County TN’s Healthcare Industry, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22