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

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

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

4. Veterans (1922-1945) Baby Boomers (1946-1964) Generation X (1965-1980) Generation Y (1981-2000) Core ValuesRespect for authority Conformers Discipline Optimism Involvement Skepticism Fun Informality Realism Confidence Extreme fun Social FamilyTraditional Nuclear DisintegratingLatch-key kidsMerged families EducationA dreamA birthrightA way to get thereAn incredible expense Communication media Rotary phones One-on-one Write a memo Touch-tone phones Call me anytime Cell phones Call me only at work Internet Picture phones E-mail Dealing with Money Put it away Pay cash Buy now, pay laterCautious Conservative Save, save, save Earn to spend Personal and Lifestyle Characteristics by Generation

5. Veterans (1922-1945) Baby Boomers (1946-1964) Generation X (1965-1980) Generation Y (1981-2000) Work Ethic and Values Hard work Respect Authority Sacrifice Duty before fun Adhere to rules Workaholics Work efficiently Crusading causes Personal fulfillment Desire quality Question authority Eliminate the task Self-reliance Want structure and direction Skeptical What’s next Multitasking Tenacity Entrepreneurial Tolerant Goal Oriented Work is ….. An obligationAn exciting adventureA difficult challenge A contract A means to an end Fulfillment Leadership Style Directive Command-and-control Consensual Collegial Everyone is the same Challenging others Ask why *TBD Interactive Style IndividualTeam Player Loves to have meetings EntrepreneurParticipative WORKPLACE CHARACTERISTICS

6. (CONT’D) Veterans (1922-1945) Baby Boomers (1946-1964) Generation X (1965-1980) Generation Y (1981-2000) Communications Formal Memo In personDirect Immediate Email Voice mail Feedback and Rewards No news is good news Satisfaction in a job well done Don’t appreciate it Money Title recognition Sorry to interrupt but how am I doing? Freedom is the best reward Whenever I want it, at the push of a button Meaningful work Messages That Motivate Your experience is respected You are valued You are needed Do it your way Forget the rules You will work with other bright, creative people Work and Family Life Ne’er the twain shall meet No balance Work to live Balance

7. People On The Move

9. Legal Immigrants: l 1920-1961: 206,000 annually l 1961-1992: 561,000 annually l 1993-1998: 800,654 annually l 1999-2004: 879,400 annually l 2005-2008: 1,137,000 annually Refugees, Parolees, Asylees l 1961-1993: 2.1 million (65,000 annually) l 1994-1998: 428,361 (85,672 annually) l 1999-2004: 487,386 (81,231 annually) l 2005-2008: 203,642 (75,661 annually) Illegal Immigrants: l 300,000 to 400,000 annually over the past two decades l Three million granted amnesty in 1986 l 2.7 million illegal immigrants remained in U.S. after 1986 reforms l October 1996: INS estimated that there were 5 million illegal immigrants in the U.S. l August 2005: Illegal population range from 7 to 15 million. The Numbers

10. YearAll ClassesExchange Visitors Academic & Vocational Students 198111,756,903108,023 (1%)271,861 (2%) 19859,539,880141,213 (1%)285,496 (3%) 199017,574,055214,644 (1%)355,207 (2%) 199522,640,540241,364 (1%)395,480 (2%) 200033,690,082351,743 (1%)699,953 (2%) 200132,824,088389,435 (1%)741,921 (2%) 200227,907,139370,176 (1%)687,506 (2%) 200430,781,330360,777(1%)656,373(2%) 200839,381,928506,138 (1%)917,373(2%) Non-Immigrants Admitted to the United States 1981 - 2008

13. World Region of Birth for U.S. Population, 1970-2008

14. GROUP% CHANGE All Races50% Whites29% Blacks94% Native Americans109% Hispanics238% Asians/Pacific Islanders412% Population Estimates by Race/Ethnicity 1988 - 2050

15. RACE / ETHNICITY TOTAL FERTILITY RATE Hispanic2.99 Non-Hispanic White1.87 Blacks2.13 Asian2.04 Native American1.86 Total Fertility Rates of U.S. Women by Race/Ethnicity 1988 - 2050

16. America’s Color Adjustment Race/Ethnicity19952050 White73.652.8 Blacks12.013.5 Hispanics10.224.5 Asian3.38.2 American Indian0.70.9

17. Relative Distribution of U.S. Population by Race/Ethnicity, 2005 & 2050 RACE / ETHNICITY20052050 White67%47% Blacks12.8%13% Hispanics14%29% Asian5%9%

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

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

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

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

22. Percent Distribution of U.S. Births by Race/Ethnicity 1990 & 2008 RACE / ETHNICITY19902008 White66%50% Blacks17%16% Hispanics15%26% Other2%8%

23. RaceTotalMaleFemale United States 36.835.438.2 White Alone 38.337.039.6 White, Non-Hispanic 41.239.942.6 Black Alone 31.329.433.3 AIAN Alone 29.529.030.2 Asian Alone 33.632.634.6 NHPI Alone 29.929.530.3 Two or More Races 19.718.920.5 Hispanic 27.4 27.5 Median Age of U.S. Population by Race, Hispanic Origin & Gender, 2009

24. Completed Fertility for Women 40 - 44 Years Old Year Percent Childless Avg. Number of Children Percent Higher Order Births* 2006201.928 1976103.159 *Three or more Children

25. U.S. Total and Foreign Born Population Change, 1990-2000 2000 Population Absolute Change 1990 - 2000 % Change 1990 - 2000 Total 281,243,49933,323,64313.4% Foreign Born 32,989,42911,472,67653.3% Hispanic (Foreign Born) 14,410,7036,331,26478.4% Hispanic (Native Born) 20,760,7347,057,30351.5%

26. Change in Regional Distribution of Foreign Born Population, 1970 - 2008

27. Percent Change in Total and Foreign Born Population, by Region, 1990- 2000

38. Net Population Change Attributable to Non-White Population Growth, 1990 - 2000 Region 2000 Population Net Change 1990-2000 % of Net Change Due to Nonwhite Population Growth United States281,421,90632,712,03365% Northeast53,594,3782,785,149100% Midwest64,392,7764,724,14462% South 100,236,82014,790,89052% West63,197,93210,411,85069%

40. Net Population Change Attributable to Non-White Population Growth, 2000 - 2004 Region2004 Population Net Change 2000-2004 % of Net Change Due to Nonwhite Population Growth United States293,655,40412,233,49881.5% Northeast54,571,147976,769100.0% Midwest65,729,8521,337,07682.5% South 105,944,9655,708,14574.4% West67,409,4404,211,50881.0%

41. In-Migration, Out-Migration, Net Migration, and Movers from Abroad for Regions, 1990- 2000 RegionInOut Net Internal Migration Movers From Abroad Net Migration (including from abroad) Northeast3,6666,178-2,5122,222-290 Midwest6,9786,909691,6411,711 South11,7619,3572,4044,1856,588 West6,7516,731384,1854,222

42. New EnglandMidwestSouthWest -1,032-2,008+2,287+46 -346-71+376+41 -292-109+520-117 -115+42+97-27 -147-3+145+3 TOTAL Black Hispanic Elderly Foreign Born Foreign Born = Net Import = Net Export Net Migration Trends, 2000-2008

43. U.S. Population Change by Region, 2000 - 2009 Region 2009 Population Absolute Population Change, 2000-2009 Percent Population Change, 2000-2009 U.S.307,006,550248,345,9328.8% Northeast55,283,6791,616,1733.0% Midwest66,836,9112,342,9553.6% South113,317,87912,757,94012.7% West71,568,8798,117,52512.8% North Carolina9,380,8841,301,50116.1%

44. Population by Race and Hispanic Origin for the United States: 2000 RACE & HISPANIC OR LATINONUMBER% OF TOTAL Total Population281,421,906100.0% One Race274,595,67897.6% White211,460,62675.1% Black or African American 34,658,19012.3% American Indian & Alaskan Native 2,475,9860.9% Asian 10,242,9983.6% Native Hawaiian & Other Pacific Islander 398,8350.1% Some other Race 15,359,0735.5% Two or More Races 6,826,2282.4% Hispanic or Latino (of any race) 35,305,81812.5%

45. Net Population Change in the United States by Race and Hispanic or Latino Origin, 1990 - 2000 Race and Hispanic or Latino 2000 Population Net Gain 1990-2000 Percent Change Total281,421,90632,712,03313.2% White211,460,62611,774,5565.9% Black or African American34,658,1904,672,13015.6% American Indian or Alaska Native2,475,956 131.8% Asian10,242,9983,334,36048.3% Native Hawaiian and other Pacific Islander398,83533,8119.3% Some Other Race15,359,0735,554,22656.6% Hispanic or Latino (of any race)35,305,81812,951,75957.9%

46. Race2009 Population Absolute Change 2000 – 2009 Percentage Change 2000 - 2009 Total 307,806,55024,834,5398.8 Non-Hispanic 258,587,22612,057,6484.9 White 199,851,2404,088,4482.1 Black 37,681,5443,276,6619.5 AIAN 2,360,807256,56412.2 Asian 13,686,0833,233,41730.9 NHPI 448,51079,26021.5 Two or More Races 4,559,0421,123,29832.7 Hispanic 48,419,32412,776,94535.8 U.S. Population Change by Race & Ethnicity, 2000 - 2009 U.S. Population Change by Race & Ethnicity, 2000 - 2009

48. U.S. Population Turning 50, 55, 62, and 65 Years of Age, 2007 - 2015 Age 50Age 55Age 62Age 65 Average Number / Day12,34411,5419,2218,032 Average Number / Minute8.68.06.45.6

49. Absolute and Relative Change in the Gender/Age Composition of the U.S. Population, 1990 - 2000 Gender/Age 2000 Population Net Change 1990-2000 % Change 1990-2000 Total281,421,90632,712,03313.2% Male138,053,56316,814,14513.9% Female143,368,34315,897,88812.5% Age 18-3467,035,178-2,878,520-4.1% Age 35-5482,826,47920,024,49031.9% Age 55-6424,274,6843,126,76114.8% Age 65+34,991,7533,749,92212.0%

50. Age2009 Absolute Change 2000 - 2009 Percentage Change 2000 - 2009 <25104,960,2505,258,4925.3 25-4484,096,278-1,898,345-2.2 45-6479,379,43916,977,56727.2 65+39,570,5904,496,88612.8 TOTAL307,006,55024,834,5938.8 U.S. Population Change By Age, 2000 - 2009

51. Age Profile of UNC - CH Faculty, 2002 Employee TypeNumber< 4040-5960+ Average Age Tenured/Tenure Track 1,8213101,21329850.4 (%) (100)(17)(67)(16) Fixed Term 8702545704645.5 (%) (100)(29)(66)(5) Total 2,6915641,78334448.8 (%) (100)(21)(66)(13)

53. Absolute and Percent Change in U.S. Population by Age, 2005 - 2050* Age20052050% Change Total29643850.0% Age 0-177310239.7% Age 18-6418625537.1% Age 65+3781118.9%

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

55. Age20052050* Total186 million255 million Hispanic Share14%31% Foreign-born Share15%23% Change in Foreign Born and Hispanic Shares of Working Age Population (18-64), 2005 - 2050

58. In-, Out-, and Net- Migration, North Carolina, 2004-2008 YearArriving MigrantsDeparting MigrantsNet Migration 2004-05124,29395,917+28,376 2005-06139,10797,352+41,755 2006-07142,540101,273+41,267 2007-08144,936103,941+40,995

59. Major Redistributors of Population to North Carolina, 2004 - 2008 State of OriginNumber of Arriving Migrants Florida62,528 Virginia53,536 New York49,284 South Carolina39,096 Georgia28,264 California27,813 Pennsylvania23,185 New Jersey22,620 Foreign22,533

61. Per Capita Income of Arriving & Departing Migrants, North Carolina, 2004 - 2008 YearArriving IncomeDeparting IncomeDifference 2004-05 $22,464$21,124$1,522 2005-06 $23,327$22,333$ 994 2006-07 $24,576$22,422$2,154 2007-08 $25,000$23,530$1,470

63. NC Population Change by Race & Ethnicity, 2000 - 2009 2009 Population Absolute Population Change, 2000-2009 Percent Population Change, 2000-2009 Total9,380,8841,301,50116.1% White Alone8,663,222967,42912.6% White, Non-Hispanic6,267,309591,04810.4% Black Alone1,990,501253,49314.6% AIAN Alone105,5828,8929.2% Asian Alone187,86670,90560.6% NHPI Alone5,0771,76653.3% Two or More Races106,88741,32563.0% Hispanic717,662334,07287.1%

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

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

66. Population Change by Age, North Carolina, 2000 - 2009 Age 2009 Population Absolute Population Change, 2000-2009 Percent Population Change, 2000-2009 <251,560,551214,36615.9% 25-441,283,42037,6323.0% 45-641,253,434309,60732.8% 65+693,294111,30319.1%

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

68. Older Workers in U.S. Workforce 65 or Older75 or Older 2008 16.8%7.3% 1998 11.9%4.7%

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

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

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

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

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