Wilson Country Trends 2021 (Corrected)

WilsonCountyTrends

ACumberlandUniversityPublication • Fall2021

Dean’sForeword

ChrisFuller Dean,LSSTB

InThisIssue

ThankyoufortakingsometimetoreviewtotheFall2021issueofWilson CountyTrends,apublicationaboutbusinessandeconomicactivityin WilsonCounty,Tennessee.

CumberlandUniversity’sLabrySchoolofScience,Technologyand Businessispleasedtobeasponsorofthispublicationandhopesthat readerswillfinditinformative.Thankyouforyourinterestin Wilson CountyTrends.

SteveShao WCTEditor

WilsonCountyTrends containsbusinessandeconomicdataonthecountyandalsoprovides newsarticleson localindustry,businessesandspecialtopics.Thisissueprovidesupdatesonlocalbusinessactivitiesaswellason changesinWilsonCounty’seconomy.Giventheongoingnationaldiscussionanddebateconcerninghealthcare andevolvingmedicalalternatives,weincludeanindustryrecapofWC’shealthcareindustry.Alsoincluded inthisissuearerelatedarticlesontrendsintelehealthservicesandanoverviewofVanderbiltWilsonCounty Hospital.

CumberlandUniversity

Foundedin1842,CumberlandUniversityoffersa varietyofeducational,athleticandsocialexperiencestoenhancethelearningopportunitiesof thecurrentstudentbody.Theuniversityhasan exceptionalacademicprogramsteepedintheliberalarts,business,technology,nursingandmany otherfields.TheUniversity’sathleticteamsregularlycompeteforconferenceandnationalchampionships.CumberlandUniversityislocatedin Lebanon,Tennessee,30mileseastofNashville.

President ...................Dr.PaulStumb

Provost ...............Dr.C.WilliamMcKee

Dean,LabrySchool .........Dr.ChrisFuller

WilsonCountyTrendsEditor Dr.SteveShao

RecentTrends

Thissectionpresentstimeseriesandcrosssectional graphsdepictingeconomicactivityinWilsonCounty (WC),Tennessee,fromyear2019tothesecondbusinessquarterof2020.Asthefollowingdataand graphsshow,WilsonCountyishometoathriving regionaleconomy.

Population

AsofJuly1st,2019,thetotalpopulationofWilson County(WC),Tennesseewas144,657,a26.8%increaseovertheApril1st,2010federalcensuscountof 113,993.WC’spopulationgrowthinthelastdecade

1 Source:U.S.CensusBureau

isunprecedented.Incomparison,wenotethatthe populationgrowthratesofTennesseeandthenation overallwere7.6%and6.3%,respectively.1

NumberofBusinessEstablishments

In2019,WilsonCountywashometo3,087businesses,a6.23%increaseoverthe2,906residingin thecountytheyearbefore.Inthesecondquarterof 2020,thenumberofbusinessestablishmentsoperatinginWilsonCountygrewto3,211.

WCtodayisprimarilyaserviceeconomy.The county’s2019businesscommunityconsistedof472 goods-producers(15.3%ofthetotalprivateeconomy)and2,615serviceproviders(84.7%),representingincreasesof2%and7%overthepreviousyear. Wenotethatthenumberofbusinessestablishments inWCincreasedinallmajorindustrycategoriesfrom 2018to2Q2020.

Bynumberofestablishments,WC’stopindustry supersectorin2019continuestobeTrade,Transportation&Utilities2 (813firms,or26.3%ofthe privateindustrytotal)asthelargestindustrycategory.Professional&BusinessServices3 (557firms, or18%)arethenextlargest.Anearthree-way tieexistsforthirdplaceamongConstruction(320 firms,or10.3%),Leisure&Hospitality4 (308firms, or10%)andFinancialServiceProviders(306firms, or9.1%).Notably,PrivateEducationandHealth ServiceProviderswastheseventhlargestindustry category(outoftencategories)with293firms,or 9.5%ofthetotal.Interestingly,theWCindustries withthetwohighestannualchangesfromthepreviousyear(2018vs.2019)weretheInformationand Professional&BusinessServicescategories,withannualgrowthratesof13.8%and10.1%,respectively. The623totalWCfirmsinthesetwoindustrycategoriesrepresentasignificant20%ofthecounty’s totaleconomy.SeeFig.R1.

WilsonCounty’slocaleconomyisparticularlywell

2 NAICSSupersector40(Trade,transportation,andutilities)consistsofSectors42(WholesaleTrade),44-45(RetailTrade), 48-49(TransportationandWarehousing)and22(Utilities)

3 NAICSSupersector60(Professionalandbusinessservices)consistsofSectors54(Professional,Scientific,andTechnical Services),55(ManagementofCompaniesandEnterprises),and56(AdministrativeandSupportandWasteManagementand RemediationServices).

4 NAICSSupersector70(Leisure&hospitality)consistsofSectors71(Arts,entertainment,&recreation),and72(Accommodation&foodservices).

5 Source:U.S.BureauofLaborStatistics. Locationquotients areratiosthatallowanarea’sdistributionofemploymentby industry,ownership,andsizeclasstobecomparedtoareferencearea’sdistribution.TheU.S.isusedasthereferencearea forall LQsnotedinthisreport.Thereferenceindustryisalwaysthe all-industry,all-ownershipstotalforthelocalarea,andforthenation.

NumberofBusinessEstablishmentsbyIndustryinWilsonCounty TN,2018-2Q2020

Source:USDepartmentofLabor

FigureR1

AverageWeeklyWagebyIndustryinWilsonCountyTN,2018-2Q2020

Source:USDepartmentofLabor

FigureR2

representedincertainkeyindustrysectors.Thelocationquotient5 (LQ)ofWC’soverallprivateservice industry,forexample,isestimatedtobeanabove average1.08insecondquarter2020,ranking7th amongallofTennessee’s95counties.Inthesame timeperiod,WC’sLQfortheleisureandhospitality industryisahealthy1.20denotingaveryconducive environmentforbothfamilylivingandtourism.One ofWilsonCounty’sgreatesteconomicstrength’s,of course,continuestobeinthesupplychainindustries ofwarehousingandtrucking.WC’sadvantageinthis majorexpandingindustrialareaisconfirmedbythe estimated2Q2020LQofWC’strade,transportation andutilitiessectortobeanoutstanding2.10,highestofanyTennesseecountyandmorethantwicethe nationalnorm.6

Itisnotclear,however,howmuchofa‘hit’that WC’ssupplychainsectorwillexperienceduetothe nationalworkforceshortagesoccurringinlate2021.

AverageWeeklyWage

WilsonCounty’sprivatewagedataincreasedslightly from ✩808in2018to ✩837in2019,a3.6%gain. Theaverage2019weeklywageof ✩792forServiceprovidingfirmswasbelowthatforallWCbusinessesthoughthisrepresenteda4.35%increaseover 2018servicewagelevels.Paywasexpectedlyhigher inWC’sGoods-producingcategory,whichaveraged ✩1075perweek,thoughthiswithinapercentage pointofwagesforthepreviousyear.Fortheaverage weeklywagesacrossmajorWCindustrygroups,the highestwagesinWilsonCountyin2019werepaid inNaturalresourcesandmining(✩1314perweek), Financialactivities(✩1,278),Construction(✩1,091), Professional&businessservices(✩1,085),Manufacturing(✩1,065),andintheInformationsector (✩1046).Lowestaverageweeklywageswerepaid inLeisureandHospitality(✩356).SeeFig.R2.

NumberofEmployees

ThenumberofpersonsworkinginWilsonCounty’s privateindustryhasgrownsteadilyinrecentyears, from40,770workersin2018to43,002in2019,a

5.5%increaseintheregionalworkforce.Whilethe monthtomonthworkforcechangesin2019were largelypositiveincreases,fromUSDOL’spreliminary 2020employmentestimates,wenoteasignificant dropinWilsonCounty’sprivateworkforcesizefrom 44,188workersinMarch2020to40,346April2020. Ifthesegovernmentestimatesareaccurate,thesudden8.7%decreaseinWCworkersmayperhapsbe dueinparttotheCovid-19pandemicwhichbegan togripthenation’seconomyseveralmonthsearlier. SeeFig.R3.

RetailSales

TennesseeDepartmentofRevenuedatashowsthe 2019retailsalestotalforWilsonCountyTNtobe ✩2,543,680,123,downslightly1.5%from2018WC’s largestretailsalescategoriescontinuetobeAutomobiles,Boats&Aircraftat ✩678million,representing 27%ofthecounty’s2019retailsalestotal,followed byFoodStores(✩418million,or16.5%),General Merchandise(✩315million,or12.4%),Other(✩283 million,or11%),Eating&Drinking(✩257million, or10%),andBuildingMaterials(✩244million,or 9.6%).SeeFigs.R4andR6.

MonthlyretailsalesinWilsonCountyTNwere relativelystableduring2019-2Q2020,saveforalarge salesspikeinMarch2020andasmallersalesspikein December2019.TheMarchsalesspikewasmostly duetoanunusualhighof42%inthetotalmonthly salesofAutos,Boats&Aircraft,versustheindustry category’smoretypicalaverageof26%.TheDecembersalesspikewasduetoacrosstheboardholiday increasesinalmostallretailcategories.SeeFig.R5.

WC’s2019retailsalestrendswerelargelypositive incomparisonwithsalesfromthepreviousyear.Significant2019salesincreasesover2018wererecorded forGeneralMerchandise(+7.4%),ServiceStations (+5.9%),Furniture&HomeD´ecor(+26%),and Eating&Drinking(+13.7%).SalesofAutos,Boats &Aircraftregistereda16%decreasefromits2018 saleslevel.MonthlyretailsalesinWilsonCounty for2019-2Q2020largelyfollowedatypicalretailpatternwithsaleshighsoccurringduringtheNovemberDecemberholidayperiod.SeeFig.R7.

IfanLQisequalto1,thentheindustryhasthesameshareofits areaemploymentasitdoesinthenation.AnLQgreaterthan 1indicatesanindustrywithagreatershareofthelocalarea employmentthanisthecasenationwide.Forexample,LasVegaswill haveanLQgreaterthan1intheLeisureandHospitalityindustrybecausethisindustrymakesupalargershareoftheLasVegas employmenttotalthanitdoesforthenationasawhole.

6 Fordetailedinformation,seethefeaturearticle“WilsonCounty’sSupplyChainIndustry”in WilsonCountyTrends,Spring 2019Issue.

TotalPersons

PrivatelyEmployedin WilsonCounty,TN, 2019-2Q2020

Source:US DepartmentofLabor (Note:2Q2020 statisticsareUSDOL preliminaryestimates)

TotalRetail Salesby Categoryin WilsonCounty, TN

Source:TN DeptofRevenue

FigureR3

FigureR4

MonthlyTotalRetail SalesinWilson CountyTN, 2019-2Q2020

Source:TNDeptof Revenue

MonthlyAutos, Boats&Aircraft SalesinWilson County,TN, 2019-2Q2020

Source:TN DeptofRevenue

FigureR5

FigureR6

FigureR7

MonthlyRetailSalesbyCategoryinWilsonCounty,TN2019-2Q2020

Source:TNDeptofRevenue

WilsonCounty’sHealthcareIndustry

HealthcareIndustryDefined

Inthisarticle,wepresentandanalyzedataforWilson CountyTN’shealthcareandsocialassistanceindustry,asdefinedunderNAICScode62.Specifically, weconsiderWCdataascompiledbytheU.S.DepartmentofLabordata7 throughyear2019(andfor somecases,including2Q2020)forthefollowingindustrysubsectors:

❼ Ambulatory(Outpatient)Care(621)

❼ Hospitals(622)

❼ NursingandResidentialCareFacilities(623)

❼ SocialAssistance(624),and

❼ HealthcareEquipmentManufacturingand Wholesaling.

Corresponding3-digitNAICScodesforeachindustrysubsectorstudiedinthisreportarenotedabovein parentheses.Eachindustrysubsector8 canbefurther subdividedintospecificindustrygroups,asidentified by4to6digitalNAICScodes.ThehealthcareindustrygroupsclassifiedundereachindustrysubsectorarelistedinTable1.Inselectinstances,WilsonCountydataforcertainhealthcareindustrycategoriesarenotavailableduetoUSDOLdisclosure guidelines.

In2019,therewere261privatehealthcareand

7 Onlyprivately-ownedhealthcareestablishmentsandservicesareconsideredinthisanalysis.BesidestheNAICS62industry subsectors,thisanalysisalsoincludesareviewofhealthcareequipmentmanufacturingandwholesalingwhichareclassifiedunder otherNAICSsubsectors.

8 The3-digitNAICShealthcareindustrysubsectorcodesaredefinedasfollows.Industriesin AmbulatoryHealthcareServices (subsector621)providehealthcareservicesdirectlyorindirectlytoambulatorypatientsanddonotusuallyprovideinpatientservices.Healthpractitionersinthissubsectorprovideoutpatientservices,withthefacilitiesandequipmentnotusuallybeingthe mostsignificantpartoftheproductionprocess.Industriesin Hospitals (subsector622)providemedical,diagnostic,andtreatment servicesthatincludephysician,nursing,andotherhealth servicestoinpatientsandthespecializedaccommodationservicesrequired byinpatients.Hospitalsmayalsoprovideoutpatientservicesasasecondaryactivity.EstablishmentsintheHospitalssubsector provideinpatienthealthservices,manyofwhichcanonlybe providedusingthespecializedfacilitiesandequipmentthatforma significantandintegralpartoftheproductionprocess.Industriesin NursingandResidentialCareFacilities (subsector623)provide residentialcarecombinedwitheithernursing,supervisory,orothertypesofcareasrequiredbytheresidents.Inthissubsector,the facilitiesareasignificantpartoftheproductionprocessandthecareprovidedisamixofhealthandsocialserviceswith thehealth servicesbeinglargelysomelevelofnursingservices.Industriesin SocialAssistance (subsector624)provideawidevarietyofsocial assistanceservicesdirectlytotheirclients.Theseservicesdonotincluderesidentialoraccommodationservices,exceptonashort staybasis.InadditiontoNAICS62,otherhealthcarerelatedindustrygroupsincludedinthisstudyare MedicalEquipmentand SuppliesManufacturing (3391)and MedicalEquipmentMerchantWholesalers (42345).ExamplesofproductsmadebyNAICS 3391medicalequipmentmanufacturersaresurgicalandmedicalinstruments,surgicalappliancesandsupplies,dentalequipment andsupplies,orthodonticgoods,ophthalmicgoods,dentures,andorthodonticappliances.NAICS42345iscomprisedofmedical equipmentwholesalersprimarilyengagedinthemerchantwholesaledistributionofprofessionalmedicalequipment,instruments,and supplies(exceptophthalmicequipmentandinstrumentsand goodsusedbyophthalmologists,optometrists,andopticians).Source: seehttps://classcodes.com/naics-3-digit-subsector-code-list/orhttps://www.naics.com/.

ProvidenceWestMedicalCenter,Mt.Juliet,TN

socialassistanceestablishments9 operatinginWilson CountyTN,employing3,799peoplewhowereearningonaverageaweeklywageof ✩841.Compared toadecadeearlier(2009),thesenumbersindicatea healthy10yeargrowthtrendintermsofthetotal numberofhealthcareandprivatecommunityassistanceworkersemployedinWilsonCounty(+13%), thenumberofestablishments(+32%),andtheaverageweeklywage(+23%)10

Hartmann920MedicalComplex,Lebanon,TN

ThelargesthealthcareindustrysubsectorsrepresentedinWilsonCountyareambulatoryservices andnursing/residentialcarefacilities.Duringtheperiod12 2010to2019,theemploymentgrowthrate ofbothofthesesubsectorsinWCwassteadyyet modest,withtheambulatorycaresubsectorgaininganetofabout47employeesperyearandnursing/residentialcareaddingabout30annually.For thesamenineyeartimeperiod,arelativelyconstant averageweeklywagedifferentialrangingfrom ✩488 (2010)to ✩428(2019)existedbetweenthehigher paidwagesinambulatorycarevslowerpaidwages innursing/residentialcare.Inregardtothetotal

numberofestablishments,ambulatorycareproviders wereclearlydominantinWilsonCountyrepresenting afairlyconstant75%oftheentirehealthcareindustrysubsectorfrom2009to2019,addingabout5new ambulatorycentersannually.SeeFiguresH1,H2and H3.

Ambulatory(Outpatient)Care

In2019,therewere196ambulatoryserviceestablishmentsoperatinginWilsonCountyTN,employingsome1,765peoplewhowereearningonaverage aweeklywageof ✩1,045.TheseWCeconomicindicatorspointtoaveryrobust10yearcountygrowth rateforambulatorycareinWilsonCounty,interms ofthenumberofworkers(+45%),numberofestablishments(+32%)andaverageweeklywage(+10%).

PhysiciansPlaza,Lebanon,TN

AsshowninTable1,ambulatorycare(NAICS 621)canbedividedintoseven(7)industrygroups. IntermsofthenumberofambulatoryworkersinWilsonCounty,thetopthreeambulatorycategoriesin 2019werephysician’soffices(584employees),den-

9 The2019totalofNAICS62WCestablishmentsconsistsof220healthcaregroupsand41socialassistanceorganizations,or 84%vs.16%,respectively.In2009,thenumberofprivatesocialassistanceorganizationsinWCwasslightlyhigherat19% ofthe NAICS62total.NAICS62separationofhealthcarevssocialassistancegroupsisnotavailableforemployeeorwagenumbersdue toUSDOLdisclosureguidelines.

10 AccordingtoUSBureauofLaborStatistics,thepurchasingpowerof ✩1in2009wouldrequire ✩1.19in2019,acumulative priceincreaseof19.17%.Forthepurposeofwagecomparisonsthen,wecanconcludethatany10year(2009-2019)averageweekly wageincreasecitedinthisreportthatexceeds20%canmostlybeattributedtorealwagegrowthinsteadofasimplenominalwage increase.

11 NAICS6219canbefurthersub-categorizedintoAmbulanceServices(62191)andBlood&OrganBanks(621991).

12 2009nursing/residentialcaredatainWilsonCountyisunavailableduetoUSDOLdisclosureguidelines.

13 Thisindustrygroupcomprisesestablishmentsofindependenthealthpractitioners(exceptphysiciansanddentists)andincludes theofficesofchiropractors(621310),optometrists(621320),mentalhealthpractitioners(621330),physical,occupational&speech therapists,andaudiologists(621340),podiatrists(621391),andmiscellaneoushealthpractitioners(621399).

Ambulatory(Outpatient)Care(Subsector621):

OfficesofPhysicians(6211)

OfficesofDentists(6212)

OfficesofOtherHealthPractitioners(6213)

OutpatientCareCenters(6214)

MedicalandDiagnosticLaboratories(6215)

HomeHealthCareServices(6216)

OtherAmbulatoryHealthCareServices11 (6219)

Hospitals(Subsector622):

GeneralMedicalandSurgicalHospitals(6221)

PsychiatricandSubstanceAbuseHospitals(6222)

OtherSpecialtyHospitals(6223)

NursingandResidentialCareFacilities(Subsector623):

NursingCareFacilities(6231)

ResidentialMentalRetardation,MentalHealthandSubstanceAbuseFacilities(6232)

CommunityCare,AssistedLivingFacilitiesfortheElderly(6233)

OtherResidentialCareFacilities(6239)

PrivateSocialAssistance(Subsector624):

IndividualandFamilyServices(6241)

CommunityFoodandHousing,andEmergencyandOtherReliefServices(6242)

VocationalRehabilitationServices(6243)

ChildDayCareServices(6244)

OtherHealthcareRelated:

MedicalEquipmentandSuppliesManufacturers(3391)

MedicalEquipmentMerchantWholesalers(42345)

Table1: HealthcareIndustryGroupsbyNAICSCode

TennesseeSportsMedicineComplex,Mt.Juliet,TN

tist’soffices(353),andtheofficesofotherhealthcarepractitioners13 (320).Intermsofatenyear changeinthenumberofcountyambulatoryworkers(2009-2019),themostsignificantemployment changesoccurredindentist’soffices(+13%),other healthpractitioner’soffices(+20%),outpatientcare centers(+9%)andmedical/diagnosticlabs(-9%).

ThetotalofWCphysician’sofficeworkersincreased amodest2%.Intermsofthenumberofambulatory establishmentsinWC,thenumberofphysician’sand dentist’sofficeswererelativelystableoverthepast decade.Thenumberofotherhealthcarepractitioners,however,increasedbyasignificant56%.We alsonotethatthenumberofoutpatientcentersin WCtripled,from6centersin2009to18in2019.

AreviewofWC’sambulatorywagesforthepast decade2009-2019suggestssomeinterestinghealthcareindustrystabilitiesaswellaschanges.First,we notethattheaverageweeklywagesforworkersin physiciansanddentistofficesremainfirstandsecondinrankamongallWCambulatorycategories (✩1362and ✩986,respectivelyin2019).Achangeis observed,however,inWC’s homehealthcareservices14 (NAICS6216)category,however,whereits ambulatorycareaverageweeklywagerankingflips from6thplacein2009(✩548)to3rdplace(✩930)in 2019(behindphysician’sanddentist’soffices).This notedchangeinWC’shealthcareindustryportends structuralhealthcareindustrytransitionsintheyears ahead,factoringinsuchconsiderationsasagrowing seniorpopulation,changesinnationalhealthcareinsurancepolicyand,ofcourse,therecentglobalpandemic.Asonehealthcareindustryexpertrecently stated,

COVID-19hasalsohelpedtocatalyze anumberoftrendsthatwehavebeen talkingaboutforyears,including:Seniors’desire,nowgreaterthanever,to becaredforinthehome;flexibilityfrom CMSfortheutilizationoftelemedicine incareplanning;andreimbursementfor higheracuitycareprovidedinthehome.

Webelievethesetrendswillstickwell beyondthepandemicandwillonlycontinuetohighlightjusthowimportantand impactfulcareinthehomeistohealth carecostsbutalso,mostimportantly,to patientoutcomes,qualityandsafety.15

WenotethatthenumberofWCemployeesworkinginmedicalanddiagnosticlabs(NAICS6215)fell from127employeesin2009to16in2019.Wewould attributethisdropinpersonnelatdedicatedmedical andlabtestingfacilitieseithertoothertypesofmedicalservicefacilitieswhichincorporatedon-sitetesting(e.g.,hospitals)orelsetransferringsuchactivities tofacilitieslocatedoutsideofthecounty.Technologicalimprovementsintestinganddiagnosticproceduresmaybeanotherreasonforreducedpersonnel. The59%jumpinaverageweeklywageinthisindustrycategory(✩498in2009,risingto ✩793in2019) mayalsoindicatetheneedforahigherskillsetto workinmedicaltestinganddiagnosis.Wenotethat therewasaconstantfourmedicalanddiagnosticlabs operatinginWCduringtheentire2009-2019period. SeeFiguresH4,H5andH6.

14 Thehomehealthcareindustry(NAICS6216)comprisesestablishmentsprimarilyengagedinprovidingskillednursingservices inthehome,alongwitharangeofthefollowing:personalcare services;homemakerandcompanionservices;physicaltherapy; medicalsocialservices;medications;medicalequipmentandsupplies;counseling;24-hourhomecare;occupationand vocational therapy;dietaryandnutritionalservices;speechtherapy;audiology;andhigh-techcare,suchasintravenoustherapy.Source: https://secure.industriuscfo.com/industry-metrics/naics/6216-home-health-care-services

15 “HomeHealthExecutiveForecastfor2021:ReservingaSeatat theBigKids’Table”byRobertHolly,HomeHealthcareNews ,December14,2020retrievedfromhttps://homehealthcarenews.com/2020/12/home-health-executive-forecast-for-2021-reservinga-seat-at-the-big-kids-table/

TriStarSummitImagingCenter,Mt.Juliet,TN

FigureH1

AllWCHealthcareEmployees, AmbulatoryCarevsNursing& ResidentialCare,2009-2019

Source:USDepartmentofLabor

FigureH2

NumberofWCHealthcare EstablishmentsbyIndustry Group,2009-2019

Source:USDepartmentofLabor

FigureH3

AverageWeeklyWageinWC’s AmbulatoryCarevsNursing& ResidentialCare,2009–2019

Source:USDepartmentofLabor

NursingandResidentialCareFacilities

In2019,therewere20nursingandresidentialcare establishmentsoperatinginWilsonCountyTN,employingsome982peoplewhowereearningonaverageaweeklywageof ✩617.TheseWCeconomicindicatorspointtoaveryrobust9year16 countygrowth rateintermsofthenumberofnursing/residential careestablishmentworkers(+39%),numberofestablishments(+67%)andaverageweeklywage17 (+38%).

AsshowninTable1,nursingandresidentialcare facilities(NAICS623)canbedividedintofour(4) industrygroups18 .Intermsofnumberofworkers in2019,thelargestnursing/residentialcareemploymentcategoriesinWCwerenursingcarefacilities (407employees)andcommunity&assistedlivingfacilitiesfortheelderly(307employees).During20092019,itisinterestingtonoteaslightdropinthe numberofworkersemployedinWC’snursingcare facilitiesbutmorethanadoublinginthenumberof workersemployedinWC’scommunity/assistedliving centersfortheelderly.

Intermsofatenyearchangeinthenumberofnursingandresidentialcareestablishments, weobservethatthenumberofnursingcarefacilities(NAICS6231)andotherresidentialfacilities19 (NAICS6239)remainedstableat4and1facilities, respectively.However,wealsonotethatduring20092019thenumberofresidentialmentalhealthfacilitiesinWCtripled(goingfrom2to6facilities)while thenumberofeldercareassistedlivingfacilitiesalmostdoubled(goingfrom5to9facilities).

AreviewofWC’srapidlygrowingnursingand residentialcarewagesduringthepastdecade20092019confirmsthenationaltrendofincreasingdemandforthesehealthcareprofessions.Theaverage

weeklywagesforthoseemployedinWC’snursing carefacilitiesjumped62%,earning ✩475in2009and risingto ✩769in2019.Similarly,thewagesofthose employedinWC’seldercarefacilitiesincreased47%, earning ✩322in2009andincreasingto ✩474in2019. SeeFiguresH7,H8andH9.

Hospitals

Recentmovesanddevelopmentsamongmajorarea hospitalsystemsinWCarecleartestimonialstothe county’srapidgrowthinpopulationandinthelocal economy.Overtherecentpastdecade,thenumber ofhospitalsoperatinginWilsonCountyhasgrown fromonein2009tofourin2019.

ThemostnotablerecentchangeinthehospitalsoperatinginWilsonCountyhastodowith aformallargeexpansionofNashville’sVanderbiltUniversityMedicalCenter(VUMC)intoWilsonCounty.OnAugust1st,2019,VUMCacquired theLebanonTNhospitalsystemownedbyTennovaHealthcare,astatewideprivatemedicalsys-

16 2010NAICS623employmentandwagestatisticsareusedingrowthratecalculationshereascorresponding2009NAICS623 numbersareunavailableduetoUSDOLdisclosureguidelines.

17 AccordingtotheUSBureauofLaborStatistics,thepurchasingpowerof ✩1in2009wouldrequire ✩1.19in2019,acumulative priceincreaseof19.17%.Thus,any10year(2009-2019)averageweeklywageincreaseinthisreportthatexceeds20%canroughly beattributedtorealwagegrowthinsteadofasimplenominal wageincrease.

18 WageandemploymentdataforcertainNAICS623industrysubsectorsareunavailableduetoUSDOLdisclosureguidelines.

19 Thisindustrygroupcomprisesestablishmentsofresidentialcarefacilities(exceptresidentialmentalretardation, mentalhealth, andsubstanceabusefacilitiesandcommunitycarefacilities fortheelderly).Source:https://secure.industriuscfo.com/industrymetrics/naics/6239-other-residential-care-facilities

20 TennovaHealthcare’sdivestitureofitsLebanonhospitalfacilitiestoVUMCshouldnotsuggestthatthetwohospitalnetworks willalwaysoperateseparatelyfromeachanother.Forexample,itwasannouncedinfall2020thatVUMCagreedtoacquireaminority interestinTennovaHealthcare’s270-bedhospitalinClarksville.Specifically,VUMCsignedanagreementwithTennova minority partner,GHSHoldingsLLC,awhollyownedsubsidiaryofClarksvilleVolunteerHealth,Inc.,toacquireits20%minorityinterestin TennovaHealthcare-Clarksvilleandrelatedphysicianpractices.Thisactionisconsistentwitharecentspateofhospitalpartnerships,

temofhospitalsandotherhealthcareservicefacilities20 .RebrandedasVanderbiltWilsonCountyHospital(VWCH),VUMC’sTennovapurchaseconsisted ofa2-campusmedicalfacility,includingageneral inpatientserviceshospitalat1411WestBaddour Parkway,andasecondfacility,nowcalledVWCH McFarland,at500ParkAvenue.VWCHMcFarland providesspecializedbehavioralhealthandphysician rehabilitationservices21 .Notably,theVWCHMcFarlandfacilityisco-locatedwithCumberlandUniversity’sSchoolofNursing.The2019additionof VWCHsignificantlyexpandedVUMC’slocalpresenceinWC,joiningaboutadozenorsootherexistingVUMC-affiliatedclinicsandmedicalpractices. VWCHprovidesafullservicehospitalfacilityforWilsonCountyresidentsaswellasforthoselivinginthe surroundingeasternruralcountiesandbeyond. 22

Otherhospitalsystemsoperatingwithaphysical presenceinWilsonCountyincludeTriStarSummit andAscensionSaintThomasHeart.Adivisionof HCAHealth,TriStarHealthismiddleTennessee’s largest,mostcomprehensivehealthcareprovider. TriStarHealthoffersimagingandurgentcareservicesatTriStarlocationsinMtJulietandLebanon, aswellasprimarycareservicesinLebanon23 .AscensionSaintThomasHeart,aCatholichealthministry andthenation’ssecondlargestprivatehealthcareserviceprovider,offersavarietyofprimaryandspecialty careservicesinMt.JulietandLebanon24

PrivateSocialAssistanceServices

In2019,therewere41privatesocialassistanceestablishmentsinWilsonCountyTN,an11%increase overthe37establishmentsoperatinginthecounty in2009.Wealsonotein2009thattherewere702 peopleemployedinWCprivatesocialassistanceestablishments25 earninganaverageweeklywageof ✩345.

AsshowninTable1,socialassistance(NAICS 624)canbedividedintofour(4)industrygroups26 IntermsofnumberofWCworkersin2019,the largestsocialassistancecategorieswereindividual andfamilyservices(NAICS6241)andchilddaycare services(NAICS6244).Forthedecade2009-2019, wenotearatherlarge156%increaseinthenumberofWCworkersemployedinindividual/familyservices(75workersin2009risingto192workersin 2019),accompaniedbyamoderate12%increasein thenumberofdocumentedchilddaycarefacilities. Wealsonotethatwhileindividualandfamilyservicefacilitiesincreasedby44%(goingfrom9to13 duringthe10yearperiod),thenumberofregistered childdaycarefacilitiesexperiencedonlyaslight4% acquisitions,mergers,etc.takingplacewithinWilsonCounty,aswellasinthestateofTennessee,andnationally.Source:Tennova Healthcare-ClarksvilleMaySoonPartnerwithVanderbiltUniversityMedicalCenter—Newsroom(tennovaclarksville.com)

21 “IntroducingVanderbiltWilsonCountyHospital:VUMCtakes overTennovaHealthcare–Lebanon”byAndyHumbles,The Tennessean,August01,2019,retrievedathttps://www.tennessean.com/story/news/local/wilson/2019/08/01/tennova-lebanonbecomes-vanderbilt-hospital/1869272001/.

22 Alsointhisissue,seethecompanionarticleonVWCHaswellasWCT’sWho’sWhosectionforalistofspecificVUMC healthcaregroupsoperatinginWC.

23 Seehttps://tristarhealth.com/locations/forhealthcare servicesbyWClocation.

24 Seehttps://healthcare.ascension.org/locations?page=1&facility=&location=mt%20juliet&distance=50&filter=forhealthcare servicesbyWClocation.

25 2019WCemployeeandwagestatisticsareunavailableintheNAICS624industrysubsector.

26 OnlyprivatelyownedsocialassistanceestablishmentsinNAICS624areconsideredinthisanalysis.Governmentsocialassistance agenciesareexcludedfromconsideration.WageandemploymentdataforcertainNAICS624industrysubsectorsareunavailable duetoUSDOLdisclosureguidelines.

WestLebanonProfessionalMedicalCenter, Lebanon,TN

increase(goingfrom25in2009to26in2019).Interestingly,whiletheaverageweeklywagesforthose employedinWC’sindividual/familyservicefacilities increasedbyaslight7%,earning ✩391in2009and risingto ✩418in2019,thewagesofthoseemployed byWCchilddaycarefacilities27 increased35%,earning ✩278in2009andincreasingto ✩375in2019.See FiguresH10,H11,andH12.

OtherHealthcareIndustryGroups

TwoothernotablehealthcareindustrygroupsoperatinginWilsonCountyinrecentyearsaremedicalequipment&suppliesmanufacturers(NAICS 3391)andmedicalequipmentmerchantwholesalers (NAICS42345).In2019,WC’smedicalequipment manufacturingindustrywasdominatedbysmallenterprisesconsistingof5establishments,employing10 peopleintotalwhoearnedanaverageweeklywage of ✩978.Forthesameperiod,WC’smedicalequipmentmerchantwholesalerindustryconsistedof16 establishments,employing325peoplewhoearnedan averageweeklywageof ✩1271.Whileeconomicindicatorsaregenerallypositiveforthecounty’sfledgling medicalmanufacturingindustry,itsoverallsizeistoo smallatpresenttopredictwhethertheindustrygroup willhavemuchimpactonthecountyeconomyin thenearfuture.Ontheotherhand,WC’smedicalmerchantwholesalerindustryshowsmucheconomicpromiseforthecounty,notinganearterm 28%growthspurtinworkforcesize(2017to2019), an8-foldincreaseinthenumberofnewestablishments(from2009to2019),andanindustry-high wagerate.GivenWC’snationalstrengthsinsupply chainlogistics,itisnotsurprisingtoobserverecent stronglocalbusinessactivityinmedicalequipment wholesaling.SeeFigureH13.

FutureOutlook

RecenthealthcareIndustrydevelopmentsinWilson Countyhaveprovidedbothamicrocosmandanaffirmationofnationalhealthcaretrends.AsWC’spopulationhasundergoneunprecedentedgrowthduring thepastdecade,avarietyofbothsmallandlarge sizehealthcareprovidersareestablishingorexpandingtheirlocalpresenceinthecountytomeetagrowingdiversifieddemandforhealthandmedicalservices.DevelopmentsinWCoverthepastdecade haveincludednewhealthcareservicemodels,such asincreasesinhealthproviderservicestargetedat home-basedpatientcareandnewformsofambulatoryservices.Wealsonoteincreasesinthenumber specializedandindependenthealthpractitioners,as wellasintegratedhealthcareservices(e.g.,in-house diagnosisandtesting)offeredbyareahospitals.We observeincreasesinthenumberofresidentialhealthcarefacilitiesthatofferspecializedcaretospecial needsgroups,includingseniors(eldercareviaassisted livingcenters)andresidential-basedmentalhealth treatmentprograms.

Futurechallengestoadequatehealthcareservice deliveryissomewhatatypicalinWCfromthatof othercounties,inthatWCcountyincludessizable urbanandruralpopulations.HencewenoteinWC aproliferationofsmallcommunity-basedhealthcare clinicsaswellasagrowinglocalinterestintelehealth28 (mostlyInternet-based)solutions.Athenationalhealthcarescenecontinuestoundergotransitions,wemayexpectWC’shealthcarechangesofthe pastdecadetonotonlycontinuebutinsomecases intensify,drivenbybothlocalandexternalfactors, suchastheglobalpandemic,andindustryrestructuringsamonglargehealthcareproviders.

27 Whilethegeneraltopicofillegaland/orunlicenseddaycarefacilitiesisoutsidethescopeofthisreport,inadditiontochild safetyconcerns,onealsocannotignoretheeconomicsignificanceofthechilddaycareindustryitselfnoritseconomicimpacton otherindustries,includinghealthcare.Tennessee,forexample,doesnotrequireachildcareprovidertobelicensedto providecare forfewerthanfiveunrelatedchildren.SuchindustrialnuancesasthismakesacomprehensiveanalysisofthisWCindustrysubsector adifficultchallenge.(https://www.tn.gov/humanservices/for-families/child-care-services/child-care-types-of-regulated-care.html) 28 SeethesurveyarticleonTelehealthTrendsinthisissue.

FigureH4

NumberofWC Employeesin AmbulatoryServices, 2009vs2019

Source:US DepartmentofLabor

FigureH5

NumberofWC Establishmentsin AmbulatoryServices, 2009vs2019

Source:US DepartmentofLabor

FigureH6

AverageWeekly WageinWC AmbulatoryServices, 2009vs2019

Source:US DepartmentofLabor

FigureH7

NumberofWCEmployeesin Nursing&ResidentialCare, 2009vs2019

Source:USDepartmentofLabor

FigureH8

NumberofWCEstablishments inNursing&ResidentialCare, 2009vs2019

Source:USDepartmentofLabor

FigureH9

AverageWeeklyWageinWC Nursing&ResidentialCare, 2009vs2019

Source:USDepartmentofLabor

FigureH10

NumberofWCEmployeesin PrivateSocialAssistance,2009 vs2019

Source:USDepartmentofLabor

FigureH11

NumberofWCEstablishments inPrivateSocialAssistance, 2009vs2019

Source:USDepartmentofLabor

FigureH12

AverageWeeklyWageinWC PrivateSocialAssistance,2009 vs2019

Source:USDepartmentofLabor

FigureH13

NumberofWC Establishmentsin OtherHealthcare IndustryGroups,2009 vs2019

Source:US DepartmentofLabor

CumberlandUniversity’sRudySchoolofNursingandHealthProfessions,Lebanon,TN

Who’sWho:

WilsonCounty’sHealthcareIndustry

29

Apartiallistofhealthcarebusinessesresidingand operatinginWilsonCountyisgiveninTable2below.Thelistingincludeshealthcarepatientservice providers,aswellasmedicalequipmentandsupplyretailersandwholesalers.Wenotethepresenceofbothnon-profitsandfor-profitsamongWC’s healthcareserviceproviders.WilsonCounty’srobust healthcareindustrydevelopmentisimpactedbythree keyfactors,1)WC’sproximitytonationalhealthcareplayerNashville/DavidsonCounty,2)WC’sfast

growingpopulation30 andeconomy(jointindicators ofalargeattractive,andmostlyinsured,patient base),and3)structuralchangestakingplaceinthe nation’shealthcareindustry(e.g,home-basedcare, telehealth,changesinhealthcarepublicpolicy,etc). TheentryintotheWChealthcaremarketbysuch industrialheavyweightsasVUMC,HCAandAscension,hasalsoattracted,orcreated,abevyofsmall healthcareenterprisesandsupportgroups.

29 WhilegenerallynotincludedinthisWho’sWholistingbecauseoftheirrelativesmallemploymentsize,thefollowinghealth industrycategoriesarewellrepresentedinWilsonCountyandcollectivelycompriseasignificantandsizablelocalindustrycomponent -individualphysicianoffices,assistedlivingproductsand services,wellnesscenters,fitnesscenters,healthcarelegalservices,mental healthtreatmentcenters,nutritionretailers,healthinsuranceproviders,childcareservices,chiropracticservices,alcoholismand substanceabusecenters,physicaltherapycenters,ambulatoryservices,dentistoffices,pharmacies,optometry,hearingaidservices, andmedicalalarmservices.

30 Intermsofpercentagegrowth,WCwasrecentlyratedasTennessee’s8thfastestgrowingcountyandrankedthe57th fastestgrowingcountyintheUSA.Sources:seehttp://www.tnledger.com/editorial/ArticleEmail.aspx?id=126163&print=1and https://fox17.com/news/local/four-middle-tennessee-counties-among-100-fastest-growing-in-united-states

Name

AmericanFamilyCareProvidenceprimary&urgentcare,imaging MJ

AscensionSaintThomascardiovascularcareLeb

CareNowUrgentCareprimary&urgentcarewalk-insvcsLeb,MJ

CharisHealthCenterfaithbasedclinicMJ

ChampionHealthcareaddiction,psychiatry,wellnessLeb

CherryValleyFamilyCarewalk-inclinic,primary&urgentcareWtn

Children’sClinicEastwellchildcare,spirometryLeb,MJ

CommunityQuickCaremedicalclinicLeb

CumberlandSkinSurgery&DermaskincareLeb

CumberlandMentalHealthmentalhealthservicesLeb

CUSchoolofNursingnurseeducationLeb

DiasolmedicalequipmentandsuppliersWtn

DialysisClinicIncdialysisservicesLeb,MJ

DigestiveDiseaseAssociatesgastrointestinal&liverdisordersLeb

DonIngram&AssocsmedicalequipmentwholesalerLeb

Employment&AssessmentSolutionsdrugscreeningLeb

FastPaceHealthwalk-inclinic,telehealthLeb,Wtn

GPRTestandInspectionsmedicallabtestingLeb

HearingHealthCenterhearingtestsandsolutionsLeb

HometownRespiratorymedicalequip&suppliesretailerLeb

ImpactMedicalSales&Supply,LLCmedicalequipmentwholesalerLeb

InspireMedicalweightlosssvc,nutritioncounselingMJ

JacksonMedicalProducts,LLCmedicalequipmentwholesalerLeb

LebanonHealth&RehabCenterrehabilitationservicesLeb

TheLettCenterreconstructive&cosmeticsurgeryLeb,MJ

TheLittleClinicwalk-inclinic,screeningsLeb

ManorHealthcareSupplymedicalequip&suppliesretailerMJ

MartinMedicalmedicalequipmentwholesalerLeb

MedicalBillingAssocsx-rayservicesLeb

MiddleTNPeriodonticsdentalservicesLeb

PatientCenteredCareaddictioncounseling&treatmentMJ

ThePavilionrehabilitationservicesLeb

PregnancyCareCentermaternityservicesandcounselingMJ

PremierOrthopaedics&SportsMedorthopedicsurgeryLeb

QualityCenterforRehab&Healingrehabilitationsvcs,longtermcareLeb

RaiCareCenterdialysisservicesLeb

RestorativeHealthSystemsartificiallimbsLeb

SimplyCareprimarycare,skintreatmentMJ

SynderMN&AssocsnursingconsultationLeb

TNOrthopedicaorthopedicsurgeryLeb

TNSportsMed&OrthopaedicsorthopedicsurgeryMJ

TitanHealthcaremedicalbracingequipmentretailerMJ

Tri-StarEquipmentServicesmedicalequipmentretailerMJ Continuedonnextpage

Table2: Who’sWhoinWilsonCountyTN’sHealthcareIndustry,2021

Table2: (continued )Who’sWhoinWilsonCountyTN’sHCIndustry,2021

NameService(s)Location(s)

TriStarSummitimaging,primary&urgentcareLeb,MJ

VanderbiltGeneralCareprimary,women&midwives33 careMJ,Leb

Vanderbilt-IngramCancerCentermedical&radiationoncologyLeb

VanderbiltSpecialtyCare11specialtyareas34 Leb

VanderbiltSpecialtyCare3specialtyareas35 MJ

VanderbiltWalk-InClinics4locations36 Leb,MJ

VanderbiltWilsonCountyHospitalin-patientservices&surgeryLeb

VWCHMcFarlandCampusbehavioralhealth,rehabservicesLeb

WorldTestingmedicallabtestingMJ

WrightMedicalBillingmedicalbillingservicesLeb

33 MidwivescareisonlyavailableattheMt.Julietlocation.

34 VUMCspecialtyareasinLebanonincludeasthma,sinus,&allergy;eyeinstitute;gastroenterology;hearing&speechclinic; heart;neurology;physicalmedicine&rehab;surgery;urology;bariatricsurgery;andsleepdisorders.

35 VUMCspecialtyareasinMt.Julietincludeneurosurgery;orthopaedics;andsportsmedicineclinic.

36 Mt.Julietincludesachildren’safter-hoursclinic.Lebanonincludesaclinicco-locatedataWalgreens.

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GuestArticle:

VanderbiltWilsonCountyHospital

Dr.AdamHuggins isanAssistantProfessorofObstetricsandGynecologyatVanderbiltUniversityMedicalCenter.Inadditiontohisclinicalwork,healsoservesas AssociateChiefMedicalOfficerforVanderbiltWilsonandSumnerCounties.Hewas bornandraisedinBirminghamAlabama,receivedhisundergraduatedegreefromWake ForestUniversity,andcompletedmedicalschoolatUniversityofAlabamaBirmingham. Dr.HugginsdidhisresidencytraininginOBGYNatVirginiaCommonwealthUniversity.Aftergraduationfromresidency,heworkedinprivatepracticeinNashvillefor4 yearsbeforejoiningthefacultyatVUMC.Dr.HugginsalsocompletedhisMastersin ManagementofHealthcarein2016fromVanderbiltOwenSchoolofManagement.He ismarriedwithtwoyoungchildren,andinhisfreetimeenjoys playingicehockey,skiing, andflyfishing.

TraciPope istheDirectorofCommunityRelationsatVanderbiltWilsonCountyHospital.Shejoinedthehospitalin2015,withover15years’experience inthehealthcare field.TraciisagraduateofLipscombUniversityandiscurrentlycompletingaMaster ofManagementinHealthcare(MMHC)fromVanderbiltOwenSchoolofManagement. Sheisveryinvolvedinthecommunity,thecurrentchairelectforLeadershipWilson, classof2017;BoardMemberfortheMt.JulietChamberofCommerce;Rotarianwith theMt.JulietNoonRotaryClub;BoardMemberforWilsonRidesInc.; amemberof theWilsonCountyHealthCouncilandWilsonONE.Sheismarriedwithtwochildren, andinherfreetimeenjoysreading,snowskiingandexercising.

VanderbiltWilsonCountyHospital(VWCH)isa two-campushealthcarefacilitylicensedfor245beds. ItwaspurchasedbyVanderbiltUniversityMedical Center(VUMC)inAugust2019fromCommunity HealthSystems,Inc.Thefacilityhasanadultacute carehospitalaswellasaseparateinpatientphysicalrehabandinpatientpsychiatrichospital,both locatedinLebanon,Tennessee.Theacquisitionof VWCHreflectsthestrongcommitmentVUMChas tothecitizensofWilsonCountyandstrategically placesVanderbiltasthedominantproviderofhealth careservicesinoneofMetroNashville’sfastestgrowingbedroomcommunities.

MeetingWC’sHealthcareNeeds

Astheonlyfull-servicehospitalinWilsonCounty, VWCHisuniquelypositionedtomeetthehealthcareneedsofthecountyandover150,000residents.

Sincetheacquisitionin2019,withthefullsupportof VUMC,thehospitalhasaddedsignificantresources rangingfromnewmedicalservices,newalliancesand partnerships,andsignificantcapitalinvestment.New oraugmentedmedicalservicesthathavebeenadded overthepasteighteenmonthsinclude:Anesthesia,Ophthalmology,BariatricSurgery,Gastroenterology,OB/GYN,Tele-Neurology,Psychiatry,Physical MedicineandRehab,EmergencyMedicine,HospitalistInternalMedicine,CriticalCare,Radiationand MedicalOncology,PlasticSurgery,Urology,andPediatrics.Overall,morethan140providershavebeen addedtothemedicalstaffroster.ExistingemergencyserviceshavealsobeenaugmentedbyenhancingtherelationshipwithexistingEMSservicesin WilsonCountyandbyaddingVanderbiltLifeFlight ambulancesatVWCH.ThismeansVWCHisnow abletocareformorepatientswithawiderrangeof medicaldiagnosesthaneverbefore.

WC’sVanderbilt-IngramCancerCenter

OneparticularservicelineadditionthatVWCHis particularlyproudofistheopeningoftheVanderbiltIngramCancerCenter(VICC)atWilsonCounty.

VICCisoneofonly51ComprehensiveCancerCentersinthecountry.ThisCancerCenterishometo bothmedicalandradiationoncologyservices.PatientsareabletoreceivetreatmentfromVanderbilt Oncologyproviders,receivechemotherapyinfusions onsite,andreceiveradiationtherapyaswell.The VICCatWilsonCountyutilizesstateoftheartequipmenttodeliverradiationtreatmentusingtheEthos RadiotherapySystem.VWCHisoneofonlyfour centersinthecountrywiththistechnology,allowingproviderstouniquelyadapttreatmentplansto individualpatients.

“TransitioningtoVanderbilt’sEmergency MedicineDepartmentreflectsVanderbilt’sstrong commitmenttothecitizensofWilsonCountytocontinueprovidingoutstandingcaretopatientsandfamiliesthroughouttheregion,”saidR.ScottFrankenfield,MD,directorofVWCHEmergencyServices (picturedinthemiddleofphotobelow).“Vanderbilt EmergencyMedicineisoneofthemostnationallyrenownedemergencydepartments.Thecommunity willreceivethatsametop-notchcarewithouthaving toleaveWilsonCounty.Iamhonoredtoleadthe EmergencyMedicineteamatVWCH.”

VWCHTelehealthServices

AnotherinnovativewayinwhichVWCHisbringing additionalservicestoWilsonCountyisthroughtelehealth.Shortlyaftertheacquisitionofthehospi-

tal,VanderbiltNeurologybeganofferingtelemedicine consultstopatientsintheEmergencyDepartment andthoseinthehospital.Sonowpatientswithdiseasessuchasstroke,seizuredisorders,andothers canoftenbecaredforherewithoutbeingtransferred downtown.Ourtelemedicineserviceshavenowbeen augmentedbyotherspecialtiessuchas:Infectious Disease,EmergencyPsychiatry,Nursery,andPediatricED.ThePediatricEDteleconsultsareparticularlynoteworthyastheycanpotentiallysaveafamily atriptotheMonroeCarrollJuniorChildren’sHospitalforfurtherevaluationofaconditionthatcan bemanagedlocallysafely.AlloftheseservicesenableVWCHtoprovideevermorecomplicatedand comprehensivecareinahigh-qualitywayinalocal setting.

VanderbiltWilsonCountyHospital

VICCVWCH’sEthosRadiotherapySystem

RecentCapitalInvestments

Inadditiontoaddingproviderstothemedicalstaff, VWCHhasmadesignificantinvestmentsinitsunderlyinginfrastructure.Laboratoryequipmenthasbeen replacedandupgraded,thepharmacy’sserviceshave beenexpanded,andanentirelynewelectronicmedicalrecordsystemwassuccessfullyinstalledinApril 2020.Radiologyserviceshavealsoreceivedsignificantupgrades,includinganew3Dmammography machineaswellasanewMRIandnewlydesigned MRIsuite.Theoperatingsuiteshavealsoreceived significantcapitalinvestments.Theseincludeoperativeequipmentsuchas4Kvideotowersforlaparoscopicsurgery,othersurgicalinstrumentation,and theinstallationoftwonewsterilizersallowingVWCH tomoreefficientlyprocessinstrumentstocarefor morepatients.Otherupgradestothegroundsincludenewinteriorandexteriorpaintaswellasenhancementstotheparkinglotsatbothofthehospital’scampuses.

VWCHandCovid-19

SincetheacquisitionofVWCH,thehospitalhasalso playedakeyroleinthefightagainstCOVID-19. Shortlyafterthepandemicstarted,VWCHopened a17bedCOVIDUnitthatcouldbeoccupiedbyup to34COVIDpatients.Inaddition,ICUCriticalCare andMedicineproviderscaredforcriticallyillpatients intheICUandthenewlyopened12bedStepdown Unit.VUMChasbeenwidelyrecognizedasaleader inthetreatmentofCOVID-19,rangingfromresearch ontreatmenttherapiestovaccines.Thishasenabled VWCHtobeabletoprovidethelatestandmosteffectivetherapiestothepeopleofWilsonCounty.In particular,VWCHhasbeenabletoprovideCOVID19monoclonalantibodyinfusionasanearlytreat-

mentforCOVID-19,whichhasbeenshowntosignificantlyreducetheneedforhospitalization.More recently,VWCHhasplayedakeyroleinthevaccinationofprovidersandpatientsagainstCOVID-19. VWCHwasabletovaccinatenotonlyitsownstaff, butalsomanyofthecommunityprovidersandtheir staff.NowVWCHisworkingwiththeWilsonCounty HealthDepartmenttobeginthevaccinationprocess forthegeneralpublic.Withinjustweeks,VWCHwas abletoprovidevaccinationstoover2500members ofthepublic,andisinpositiontocontinueproviding thatserviceformonthstocome.

FuturePlans

Despitealloftheaccomplishmentsthusfar,VWCH iscontinuingtofocusonfuturegrowth.Thereare plansforadditionalmedicalservices,newdesignations,expandedcriticalcarecapacity,andmoreinfrastructureimprovements.Withthesupportand expertisefromVanderbiltUniversityMedicalCenter,VanderbiltWilsonCountyHospitalispositioned tocontinuetoleadthehealthcareindustryinWilsonCountythroughthehighestqualitypersonalized medicineforwhichVanderbiltHealthisknown.

TelehealthTrends

StephenShao isafacultymemberatCumberlandUniversity’sLabrySchoolof Science, TechnologyandBusiness.Dr.Shaohascollaboratedwithvarioushealthserviceorganizations,includingtheTennesseeLeaguefortheDeaf&Hardof Hearing,Tennessee RehabilitationCenter,BillWilkersonCenter,TennesseeDisabilityCoalition,VanderbiltUniversityMedicalCenter(VUMC)andothers.Hehasparticipatedinvarious telehealthinitiatives,includingserviceasadistancetrainingsupervisorforVUMC’s LeadershipEducationinNeurodevelopmentalDisabilities(LEND)programfundedby theU.S.DepartmentofHealth&HumanServices(USH&HS),andwasacontributing memberofVUMC’sScience&TechnologyEducationPartnership(STEP)fundedby theNationalInstitutesofHealth.Dr.ShaohasalsoservedonfederalgrantreviewpanelsforUSH&HS’MaternalandChildHealthBureau’sDivisionofContinuingEducation &DistanceLearning.

TelehealthDefined

Ineverydayvernacular,theterm“telehealth”may beill-defined,meaningdifferentthingstodifferent people.Dictionary.comdefinestelehealthas“asystemthatusesinternetandtelecommunicationstechnologytoprovideawiderangeofhealthcareservices,astelemedicine,education,patientcaremanagement,andremotemonitoringofvitalsigns”.This descriptionoftelehealthisfairlybroadinscope, encompassingvariouskindsofhealthcareapplications,includinghealthcareadministration,diagnosticsandtreatments,acute(shortterm)andchronic (longterm)patientcare,hospitalandambulatory care,etc.Wealsonotethatwhilethetermstelehealthandtelemedicinearesometimesusedinterchangeablywithoneanother,thelatterisactuallya subsetoftheformer.TheAcademyofFamilyPhysiciansstatesthat

telehealthisdifferentfromtelemedicine inthatitreferstoabroaderscope ofremotehealthcareservicesthan telemedicine.Whiletelemedicinerefers specificallytoremoteclinicalservices, telehealthcanrefertoremotenonclinicalservicessuchasprovidertraining, continuingmedicaleducationorpublic healtheducation,administrativemeetings,andelectronicinformationsharing

tofacilitateandsupportassessment,diagnosis,consultation,treatment,education,andcaremanagement.37

DrivingFactors

TheU.S.healthcareindustryishugeandisgetting bigger.In2019,U.S.healthcarespendinggrew4.6 percentreaching ✩3.8trillionor ✩11,582perperson.Inthesameyear,healthspendingintheU.S. accountedfor17.7percent38 ofthenation’sGDP. Whilethehealthcareindustryisthenation’slargest employer,theindustryisnotwithoutchallengesand importantrisingissues,however.Healthcareareas ofconcernhaverangedfromshortagesofdoctors, nursesandotherservicepersonnel,andlackofavailabilityofhealthservicesforruralresidentsaswell forpeoplewhoareisolatedduetorecentpandemic lockdowns.Becauseofsuchconcerns,telehealthservicesareincreasinglybecominganimportantvirtual alternativetoin-personhealthcare.Accordingtoone source,useoftelehealthservicesintheU.S.isexpectedtogrowatanannualrateof14.9%,duringtheperiod2019-202639 .Inmostcases,telehealthservicesrepresentawin-winscenario.Telehealthservicescanprovidepatientswithgreateraccesstohealthcareresourcesandmedicalprofessionals.Atthesametime,telehealthservicescanincreasehealthcareproviderproductivitybyallowing

37 https://www.aafp.org/about/policies/all/telehealth-telemedicine.html

38 https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthE xpendData/NationalHealthAccountsHistorical

39 TheFutureofTelehealthintheU.S.andAcrosstheGlobe,retrievedfromhttps://intouchhealth.com > future-telehealth-usacross-glo.

physiciansandotherhealthcareprofessionalstosee andtreatmorepatients.

Therearethreerelatedfactorsdrivingthecurrentevolutionandexpansionoftelehealthservices: 1)newandrapidadvancesininformationtechnology,2)theglobalCovid-19pandemic,and3)U.S. healthcarepublicpolicy.Inregardtothefirstfactor,informationtechnologies(IT)importanttothe provisioningoftelehealthservicesfallintotwomain categories:1)digitalhealthcaredevicesand2)computernetworkingservices(referredtoasthe“cloud” ingeneral).Inmostcaseswhendiscussingthecloud, wearetalkingaboutthepublicInternet,akatheInternetofThings,orIoT.Cloudservicetechnologyenablestelehealthservices.Withoutthecloud,weare stuckwithstand-aloneislandsofgadget-basedhealth applications,usefulintheirownrightbutnothelpingtoovercomethedistanceandisolationbarriers thatincreasinglyexistbetweenpatientandhealthcareprovider.Recentcloudaccessenhancements, e.g.,fast“broadband”Internetaccess(e.g.,fiberopticlinesor5Gwireless),coupledtogetherwithnew onlinemedicalanddiagnosticdevices,havecombined tocreateaplethoraofnewtelehealthservicealternativestotraditionalin-personhealthcare.Byone estimate,Internetconnectedmedicaldevices,electronicdiagnosticequipments,etc.,areexpectedto lowerthecostofoperationalhealthcareandclinical inefficienciesin2021by ✩100billion40 .ITadvancementspresentthehealthcareindustrywithnewopportunitiestoexpandservicecoverageandincrease efficienciesofqualityhealthcare.

Thesecondfactor,Covid-19anditsvariants,is thehardtomisselephantinthelivingroom.The globalwidepandemicimpactsthetelehealthindustryintwoways.First,wenotethatCovid-19isa healthmaladyinandofitself,onewhichthreatens everyone’spersonalhealth.Alongwithitsvariants, whileCovid-19mustbetreatedphysically(viavaccines),itcanbecontrolledbothphysically(e.g.,by maskingandsocialdistancing)andvirtually(e.g.,by extremesocialdistancingviatelehealthservices).As animmediatehealththreat,thepandemicalsoacts

asaneconomicstimulantofnewtelehealthproducts andservices,aswelladrivingforcebehindrevised telehealthpublicpolicy.

Covid-19’streatmenturgencyexertspressureon publicpolicymakerstoquicklyreviewandenactnew healthcarelawsandregulationsthataresupportive oftelehealthplatforms41 .ThisthirdfactorofrevisedU.S.healthcarepublicpolicyaddressesanobviousneedtoincludehealthinsurancecoverageof telehealth-basedpatientservices42 .Theemerging telehealthindustrycannotsucceedwithoutaguaranteedpaymentmechanism.Thereiscurrentlyno biggerfanorlobbyistoftelehealthsolutionsthanthe U.S.Government.TheU.S.DepartmentofHealth andHumanServices,forexample,statesthatduringtheCovid-19emergency,“Weencouragehealth careproviderstoadoptandusetelehealthasaway tosafelyprovidecaretoyourpatientsinappropriatesituations,including:routinehealthcare,like wellnessvisits;medicationconsultation;dermatology (skincare);eyeexams;nutritioncounseling;mental healthcounseling.”43

Anotherstepintherightdirectionisastopgaprelaxationoffederalhealthcareregulationsduringthepandemicemergency.OnMarch6,2020, CongresspassedtheCoronavirusPreparednessand ResponseSupplementalAppropriationsAct,allowing physiciansandotherhealthcareprofessionalstobill Medicarefee-for-serviceforpatientcaredeliveredby telehealthplatformsduringthecurrentcoronavirus publichealthemergency.Addedsupportforuseof telehealthservicesinMedicare,Medicaid,theAffordableCareAct,etc.,isalsoonthetableandbeing discussed.

CloudPlatforms

Fromatechnologyperspective,telehealthand telemedicineservicesareeitherbasedonasynchronousorsynchronouscloudplatforms.Asynchronousplatformsdonotrequirethesimultaneous timepresenceofbothpatientandhealthprovider, whileasynchronoustelehealthexchangedoesrequire

40 https://policyadvice.net/insurance/insights/healthcare-statistics/

41 Seeforex.,CoverageProvisionsInThe2021AppropriationsAndCOVID-19StimulusPackagebyKatieKeith,HealthAffairs, January4,2021,retrievedathttps://www.healthaffairs.org/do/10.1377/hblog20210104.961016/full/

42 See,forexample,Only15%ofFamilyPhysiciansReportUsingTelehealth;TrainingandLackofReimbursementAreTopBarriers,RobertGrahamCenterresearchpublication,January15,2016,retrievedfromhttps://www.graham-center.org/rgc/publicationsreports/publications/one-pagers/FPs-telehealth-2016.html.

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

Therearethreetypesofcloud-basedtelehealth services:store-and-forward,remotemonitoring,and videoconferences.Thefirstandthirdservicetypes areconsideredasynchronousandsynchronous,respectivelywhileremotemonitoringisusuallyprovisionedassynchronous,althoughitcanalsobeofferedasynchronously.Store-and-forward(S&F)telehealthservicesinvolveencaptureandtemporarystorageofpatientrecordswhicharelatertransmitted (forwarded)tootherservicelocationsforprocessing andevaluation.Sendingapatient’smedicalhistory, digitalX-rayfile,etc.fromaneighborhoodclinic toadiagnosticlaborhospital,isanexampleofan S&Fbasedtelehealthservice.Remotemonitoring servicesareusuallyconfiguredwitharealtimedata telemetrylinkbetweenaremotepatientmonitoring deviceandadistantfacilitythatreceives,processes, anddisplaysthemedicaldataonaterminalscreen forreviewandevaluationbyanattendingphysician, nurse,etc.WhiletelehealthservicesintheS&Fand remotemonitoringcategorieshaveexistedformany years,newonlineproductsandcloudserviceshave acceleratedtheiradoptionandusesintheU.S.Annualgrowthforecastsofdirecttelehealthlinkstohospitalsandtoat-homepatients,areexpectedtoreach 19%and19.6%,respectively,duringtheperiod20202026.44

Inresponsetodecreasingequipmentcostsand newsocialdistancingpolicies,rapidlyrisinginpopularitythenewkidonthetelehealthblockisVideoconferencing(VC)telehealthservice.VCbasedtelehealthservicesuselive2-wayaudioandvideoconferencinglinksovertheIoTtointerconnectpatients todistanthealthproviders.FromVC’suseinthe early1980sasanexpensive(andsparselyused)corporatevirtualmeetingtool,currentVCtechnology costsandqualitylevelshaveimprovedconsiderably overthepastdecade,reachingacceptablelevelsso thatVCtelehealthserviceshavebecomeaviable telehealthservicealternativeincaseswherephysical separationscannotbeavoidedorarerequired.The highlyinteractiveandinterpersonalfeaturesofvideoconferencingtechnology,alongwitheasysetupand operation,aredrivingacceptanceandadoptionlevels tonewusagelevels.Withongoingimprovementsin

quality,securityandscreenresolution,VCtelehealth servicesarebecominganindispensabletoolforremotehealthcareconsultations,examinations,andfor establishingagood,thoughvirtual,bedsidemanner.

EmergingTrends

Whatothertelehealthtrendsmayweexpectinthe nearfuture?Wehavealreadymentionedtherapid growthindevelopmentanduseofnewtelehealth gadgetry.Onemayexpectcontinueddevelopment androlloutsofnewspecialpurposetelehealthproductstofollowthedemandforspecifictelehealth services.MarketingresearchconsultingfirmGlobal MarketInsights,Inc.estimatesthattheglobalmarketfortelehealthequipmentwillexceed ✩7.9billionby2026.Anintriguingproductsubcategoryof telehealthequipmentisthenotionofageneralpurpose“telemedicinecart”,aimedatacuteremotepatientcare.Themarketfortelemedicinecartsisexpectedtogrowannuallyat17.4%fortheperiod 2020-2026.45

Complementingthegrowthofnewtypesoftelehealthequipmentareincreasesintelehealthservice offerings,asincasesofvideotele-consultationswith healthprofessionals,topicalmedicalexaminations, mentalhealthtreatment,andinsomeinstances,behaviormodification.Akeytelehealthtrendishow traditionalhealthcareinstitutionsareleveragingnew digitalandcloud-basedtechnologiestoexpandand improvethequalityoftheirownpatientcareservices.

Ina2020whitepaper,theMedicalGroupManagementAssociation(MGMA)observedthattelehealthservicesprovideprimarycarehealthorganizationssuchashospitals,withan“insourcing”opportunitytoexpandservicecoverageandcontinuing patientcareusingtheinstitution’sownphysiciansand medicalexpertsinsteadofoutsourcingcertainhealthcareresponsibilitiesto3rdpartieswhomaynotbe familiarwithinternalprotocols.Telehealthservices alsoprovidehealthinstitutionswithconnectivetools forfollowuporspecializedtreatments,allowingfor deliveryofbetterintegratedpatientcare.MGMAalso notesthegrowingimportanceoftelehealthservices assupportiveremotediagnosticandphysicianlinks betweenfirstresponders(e.g.,paramedics)andhos-

44 https://www.gminsights.com/industry-analysis/telemedicine-market

45 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

pitalswhereimmediatemedicalinterventionatthe sceneisnecessary.46

Besidesinstitutionalimpacts,emergingtelehealthservicesarehavingdirectpersonaleffectson bothhealthyandsickindividuals.TechnologynewscasterScienceX,forexample,describesabroadvarietyofemergingpersonaltelehealthproductsandservices,includingnewSmartphone-basedhealthmonitoringapps,remotebloodtestingsoftware,remote bio-sensorskinpatches,evenanartificialintelligencebasedappthatdetectsignsofpneumoniafroma person’scough.47 Theexpansionoftheso-called “mobiletelehealth”marketisexpectedtoreach ✩236 billionby2026,growingatanincredibleannualrate of44.7%.48

Forbespredictsnewtelehealthservicedemandin fourmajorareas:1)increasingadoptionoftelehealthplatformsforonlinecareofchronicdiseases, suchaslupus,autoimmunedisease,andage-related diseases;2)increasinguseofwearablehealthdevices thatcancontinuouslymonitorthingslikeheartrate, glucoselevels,andbloodpressure;3)renewedemphasisonhealthdatasecurityandprivacyduetoa post-pandemicreturntofederalhealthregulations; and4)afocusononlinementalhealthservicesand psychiatry49

GlobalhealthorganizationProjectHOPEconfirmstheexpecteddevelopmentstotakeplaceinonlinecareofchronicdiseasesstating“thattelehealth, remotemonitoring,andcareathomecanreducethe timepatientsspendinthehospitalforchronicillness management.Weanticipateproviderswillbemore savyaboutusingtelehealthtoreachat-riskpopulationsin2021.Telehealthcanextendaccessto thoselivinginruralareas,seniors,andlow-income andhigh-riskindividuals50 .”

Therealsoseemstobenotabletrendanddialogregardingincreasedhealthinsurancecoverage ofmentalhealthexamsandtreatments.Thisisa verytimelydevelopment,givenwellpublicizedissues concerningpandemic-relatedhighanxietyandstress levels,suiciderates,etc.amongthegeneralpub-

lic.GrandViewResearch,aCalifornia-basedmarketingresearchconsultancy,predictsthattheglobal “telepsychiatrymarket”valuedin2019at ✩5.5billionisexpectedtogrowatanannualrateof24.7% from2020to2027.

Chicago-basedtechnologyconsultantfirmEmpeekforeseessizablegrowthinthecontineudcurrent useoftelehealthservicesforhome-basedchroniccare patients,mentalhealthteletherapy,andnotsurprisingly,physicianteleconsultationsforCovidpatients. AccordingtoEmpeek,telehealthservicestoemerge in2021willincludetelehealthservicesintegrated withembeddedelectronichealthrecordsoftware,increaseduseofwearableIoT-basedhealthmonitoring devices,healthdatabaseanalyticsusingBigDataand artificialintelligence,augmentedrealitybasedmedicaltraining,andfinally,morestringenttelehealth datasecuritymeasures. 51

Furtherresearchrevealsthatthetypesoftelehealthservicesindevelopmentorbeingproposedare verybroadindeed.Exceptperhapsforsurgicalcases, itisalmostimpossibleinfact,tofindanareaoftraditionalhealthcareinwhichtelehealthandtelemedicine solutionsarenotbeingconsideredasviable,costefficient,serviceandtreatmentalternatives.

AfterthePandemic?

Thepandemichasputalotpressureoneveryone withavestedinterestinhealthcare-consumers, businessesandhealthcareprovidersalike,toreduce physicalin-personinteractionsandconsiderateleconsultationortele-treatmentinstead.Somepeople maybewillingtoutilizetelehealthservicesonlyas longasthethreatofCovid-19exists.Ifinthemeantimehowever,suchvirtualhealthcareexperiencesare satisfactorytobothpatientandhealthcareprovider, post-pandemictelehealthcaremayevolveintoapermanentfixtureofthenation’shealthcareinfrastructure,thoughperhapspushedalongabitbypublic policymakers.Andforgroupswhomvirtualhealthcareprovestobeparticularlyconvenientandafford-

46 https://www.mgma.com/resources/health-information-technology/the-newest-trends-in-telehealth-in-2020

47 https://medicalxpress.com/news/2020-06-remote-devices-telehealth-surge-demand.html

48 https://www.itransition.com/blog/mobile-healthcare

49 WhereTelehealthisHeadedin2021byShamaHyder,ForbesMagazine,November16,2020,retrievedat https://www.forbes.com/sites/shamahyder/2020/11/16/where-telehealth-is-headed-in-2021/?sh=5fa17aa7635e

50 Healthcarein2021:FiveTrendstoWatchbySusanDeVore,HealthAffairs,January20,2021,retrievedat https://www.healthaffairs.org/do/10.1377/hblog20210119.724670/full/.

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

able,e.g.,busyprofessionals,home-boundseniors, residentsofruralareas52 ,etc.,telehealthservices mayevenevolvefrombeinganicheorstopgapmea-

suretobecomingacommonlyusedtoolofeveryday living.

52 Wenoteaninterestingnewtrendamongsomeurbanswhodecide torelocatetoruraltownsandcommunities,dueinpartto restrictivepandemicpoliciesoflargemetropolitancities.See,forexample,AmericansLeaveLargeCitiesforSuburban Areasand RuralTownsbyKristinTate,TheHill,07/05/20,retrievedathttps://thehill.com/opinion/finance/505944-americans-leave-largecities-for-suburban-areas-and-rural-towns

CumberlandUniversity’sHeartofthePhoenix,Lebanon,TN

AppreciationandThanks areexpressedtoCUfacultyandstaff,aswellasotherindividualsandorganizations fortheirgeneralsupportandformaterialsusedinthisreport.Inparticular,wewouldliketothankthe TennesseeDepartmentofEconomic&CommunityDevelopmentandthe TennesseeDepartmentofRevenue.

TheLastWord

Asalesrep,anadministrationclerk,andthemanagerarewalkingtolunchwhentheyfindanantiqueoil lamp.TheyrubitandaGeniecomesout.TheGeniesays,‘I’llgive eachofyoujustonewish.’‘Mefirst! Mefirst!’saystheadminclerk.‘IwanttobeintheBahamas,drivingaspeedboat,withoutacareinthe world.’Puff!She’sgone.‘Menext!Menext!’saysthesalesrep.‘I wanttobeinHawaii,relaxingonthe beachwithmypersonalmasseuse,anendlesssupplyofPinaColadasandtheloveofmylife.’Puff!He’s gone.‘OK,you’reup,’theGeniesaystothemanager.Themanagersays,‘Iwantthosetwobackinthe officeafterlunch.’

Moralofthestory:Alwaysletyourbosshavethefirstsay.

WilsonCountyTrends

ACumberlandUniversityPublicationfromthe LabrySchoolofScience,Technology,andBusiness

1CumberlandSquare

LebanonTN,37087

ListofFiguresandTables

RecentTrendGraphs

HealthcareGraphs FigureH1-AllWCHealthcareEmployees,AmbulatoryCarevsNursing&ResidentialCare,2009-2019...........13