Question: Mike, it's been a little while since we last caught up. You're one of the clearest thinkers on hospital and health system strategy I know, so I'm going to go right to the hard stuff — the "state of the union" for hospitals in 2023. It's been a rough ride, and at the risk of being hyperbolic, this is perhaps the worst 24-month period in hospital history. The issues are well-documented: persistently weak volumes, evaporated non-operating income, labor cost pressures, etc. Trinity Health hasn't been immune, and we'll get to that, but let's start higher level — what's your appraisal of the current landscape for hospitals nationally?

Slubowski: Eric, I think the first two years of the pandemic were a public health crisis and this last year and a half has transitioned into a financial crisis.

The pandemic period showed that the public health system in our country is disjointed and broken, and all things considered, I think health systems did a great job filling in the gaps. Everything was frenetic, but we had only one focus: keeping our patients and colleagues safe. Everything else took a back seat.

The wheels fell off when Omicron hit. That's when staffing vacancies rose to an all-time high and the use of agency staffing exploded. And we've continued to have weak volumes since. Generally, most health systems have been trying to dig themselves out of that hole.

As to the question of the national situation for hospitals, I'd first qualify that not everybody is facing the same level of pain right now. In our case, and maybe some other faith-based systems, we never really ran much more than one or 2% operating margins — our aspiration is 3%. So it doesn't take much to throw us into negative territory. Meanwhile, some regional systems in growth markets like Florida or in markets with good commercial insurance percentages have dropped from an 8% margin to a 5% margin, and they're running around like Chicken Little. So, I think that there's real variability across the country in terms of how health systems have suffered.

Systems that had large insurance plans were also able to cushion the blow. Specifically for Trinity, we do have a Medicare Advantage plan that originated in Columbus, Ohio and that we've replicated in five other states. But it's relatively small; it didn't help us with the body blows of financial challenges. 

Question: Your point about the "cushioned blow" — the fact that vertically-integrated health systems (the minority of health systems who own a health plan like Kaiser, Intermountain, Sentara, etc.) weathered the pandemic better than those who do not own a health plan — is key. We've indeed seen a stark divergence in operating performance between acute care-centric health systems and their more diversified counterparts. And while Trinity has a Medicare Advantage (MA) plan, as you pointed out, it's comparatively small.

I'd like to come back to this topic in greater detail later in our discussion, but first perhaps you could share what is primarily driving the operating challenges for Trinity? As a $21.5 billion enterprise, your operating losses were in-line with peers — $149 million in 2022, and $146 million in Q1 of your 2023 fiscal year.

Slubowski: The issue at hand for CEOs generally, and specifically for Trinity Health, is the nursing shortage. It's real, it's not going away, and it impacts our success as inpatient providers of care and as financially-viable organizations.

Even if we were able to recruit more nurses, many do not plan to spend the next 30 years of their careers as an inpatient bedside nurse. Some people still haven't figured that out. We need to change the model. So, at Trinity, we've implemented what I'm calling our "Moonshot," which we've named TogetherTeam.

TogetherTeam is a three-person nursing team consisting of a bedside nurse who's often a new grad or a less experienced nurse, an LPN or a certified nursing assistant, and a nurse located on-site in a monitoring area — a "virtual nurse" for lack of a better term. We like to say that we do everything at Trinity Health in threes — it's right there in our name.

This group functions as a three-person team to manage a group of patients. We piloted it at a hospital here in Michigan and have been rolling it out more widely. We have over 400 beds now covered in five markets and the results have been so strong that we're going national. By mid-summer we should have over 700 beds covered across seven markets. We've seen significant improvement in patient and family satisfaction; we've also seen significant engagement with junior nurses from having strong mentors in their "virtual nurse" counterparts. The virtual nurses are tenured nurses or nurses who have left the profession because of workload pressure and/or the physical demands, but they still want to be nurses. This team configuration allows for improved patient care, better outcomes and gives these nurses a path to stay in care delivery.

While it's still early to measure the patient outcome data, I'm convinced we're going to see fewer readmissions because the model allows more time for patient education and true discharge planning. We're also implementing prototypes of the TogetherTeam model for emergency department care.

And to your question on the state of hospital finances: we're able to do it at an 8% lower cost per patient day.

Question: Mike, let's turn from the structural nursing shortage and its outsized impact on operating margins to the other side of the coin — hospitals' non-operating margins. In other words, what I might characterize as hospitals' longstanding dependency on non-operating or portfolio income overperformance to compensate for persistent operating underperformance. As you noted, many denominational systems run 2% operating margins in a good year; this has been offset and subsidized for the past 14 years (really since the end of the Global Financial Crisis) with extraordinary appreciation in the public and private equity markets. Hospitals, with their extensive portfolio holdings, have been a beneficiary of this dynamic. I did some research at the height of the market — November 2021 — and noted that the top 25 US health systems had $455 billion in assets on their balance sheets with about half of that —more than $200 billion— in investable securities.

But no longer. With the broader market contraction, and 20% decline last year in the S&P 500, suddenly those break-even operating margins are a major problem. And the news has been grim—Mass General Brigham lost $2 billion; Kaiser lost $4.5 billion. And Trinity, the seventh largest system in the country, lost, I think $1.4 billion—in all cases largely from non-operating income. So, my question is: have we become too reliant on non-operating income? Has it atrophied our muscles when it comes to hard-nosed, operating company discipline?

Slubowski: Well, I can only speak to the Trinity viewpoint on non-operating income: we're always focused on operating margin and operating cash flow margin. It's great that we have investment income. It helps with "days cash on hand" calculations and all that good stuff. But we're totally focused on our need for generating margin and cash flow from operations and not from our investment income.

That said, investment income is the only real form of financing we have to maintain a solid bond rating. Your readers will likely know we borrow capital primarily through bonds, and bondholders want to make sure that we have sufficient liquidity to cover and service our debt, and if need be, weather foreseen and unforeseen storms. That's what it's all about. Our days cash on hand used to be in the 211 days range last fiscal year, where now it's closer to 180. And it's had an impact on our capital spending; we've had to curtail some capital spending to maintain that cash reserve. We are managing that very carefully because it's not a sustainable plan in the long run.

 I think we are, as every business is, dependent on the market and the economy in some way shape or form. In our case, it's different than an equity company, but even organizations that focus on equity must be able to generate strong operations to generate cash flow, to have investors continue to invest in them. At the end of the day, we're all dependent on the strength of our economy and the confidence of investors in our future.

Question: I like that answer and especially the dimension around bond covenants and the relentless scrutiny we get regarding days cash on hand. Do you think we've done a good enough job, as health systems, on proactively educating the public on the economic and financial realities of operating a health system? And how indispensable non-operating income is in the overall equation of health system economics?

Slubowski: It's very hard though to get the general public and even legislators to understand that you must have a strong balance sheet. Many in the public see a big investment number and ask, "Why aren't you spending that down?" The reality is that if you spend it down, you're going to go out of business because you can't borrow any money and you can't reinvest in your future unless you have a healthy balance sheet.

It's very hard for people to understand, especially when they compare not-for-profit providers to public companies with levels of cash and investment that aren't possible for us to replicate. I'm thinking here specifically about players like Big Tech, as one example.

Question: Mike let's turn to hospital M&A. Obviously, a ton of horizontal consolidation in our sector, with the top 100 health systems having aggregated almost $900 billion in revenue out of our $1.4 trillion sector. And even more concentration at the very top of the pyramid, with the 10 largest systems comprising over $300 billion. The shift over the past few years, especially with a hyper-vigilant FTC, has been around 'non-contiguous,' cross-geography tie-ups (as opposed to 'in-market' mergers). Trinity, the seventh largest system in the country, has participated in this kind of merger in the past. But not lately — most of your energy seems to be building out in-market, non-acute capabilities, and expanding your ambulatory ecosystem. Fair characterization?

Slubowski: Yes, very fair. And to your point, I would say we've focused more on non-hospital M&A.

We're the majority owner of Premier Health — a national leader in urgent care. And for us that was a two-for-one deal: it was the opportunity to turn over the day-to-day management of our urgent care offerings to make them more successful, as well as to grow our urgent care footprints in the markets that we're already in. And Premier Health also has relationships with health systems in states that we don't have any other presence in. So, if those relationships are part of their portfolio and it makes them stronger — then it makes us stronger. It was really our opportunity to recognize that urgent care is growing, that we needed more support from an expertise standpoint as well as an ability to capitalize on the growth that we need in the markets we serve.

Our hospital acquisitions have mainly been in markets we were already serving and where we thought we could make a difference by having a more complete continuum of care. But even those transactions aren't always hospital-only: MercyOne in Iowa (a $3b system boasting 430 sites, 25 affiliated hospitals, and 20K colleagues) is a diversified organization with a large medical group that includes home care, ambulatory surgery facilities, and rehab facilities. It wasn't like we were just taking on hospitals in that transaction.

We've also done some transitions and transformations of hospitals and markets, like in New Jersey or with Mercy Chicago. At Mercy Chicago, for example, there's a new owner running the acute care operation while we run the ambulatory business. There continues to be opportunities to take on continuum transformation.

We do stay in the traffic of talking to small to mid-sized Catholic systems. If a small to mid-sized Catholic system decides they want to join with us and scale up, we're very open and welcoming to that. But right now, there's nothing on the table in that regard.

Overall, I would categorize our strategy as "prudent growth." We're emphasizing more of the approach of community care versus being hospital-centric. What we're doing right now is developing an operating model and philosophy around bifurcating the organization between hospital-based services and community-based services, which are at a lower price point. Because that's where the world is going. So, in the near future you'll be hearing about some management team realignment and changes that will support that.

Question: That "bifurcation", as you describe it, between community-based and hospital-based services — with the former focused on population health and total cost of care economics, and the latter focused on specific specialty/acute interventions and unit cost economics — makes a ton of sense. That has echoes of what Marc Harrison and Intermountain structured a few years ago. At the time, he took their nine geographic divisions and sort of upended the whole thing and said, here's our community and population health side, and here's our specialty and acute care side — and there's almost a moat between the two. But that's easier to do if you have a captive health plan, as they do.

Slubowski: You got it, Eric. That's the dilemma. And yet we have to find a way to get there with or without a health plan.

I mean, we're proud of our hospital-based ambulatory surgery programs that are on campus. But if the clinicians and the payers are shifting it all to freestanding centers at a lower price point, we can either hang on to a diminishing business or retain 50% of what we got before and deliver that care in a community setting. The way I view it is, we have to go there.

For our hospital campuses, that means we must realign, downsize some of them, maybe repurpose some of the space for programs and services that are more social in nature — since we have the physical plant anyway.

And then in terms of our administrative support services, we're developing what we call "service area support" to eliminate redundant layers and support different regions of the country more directly and efficiently.

This is not the first time we've undertaken work like this. If I go back 22 years to what was then Mercy Detroit Hospital, we transformed it into the Samaritan Center. It is a multifunction community service center with everything from job training to dialysis to primary care; various faith organizations have a presence on that campus — it's purpose-built to meet the needs in that community.

We're definitely on the road to trying to convert some of our hospital campuses to what we're calling, "healthy villages," in that spirit.

Question: This notion of "healthy villages" is a great encapsulation of Trinity's strategy. Ever since Rick Gilfillan moved from CMMI to leading Trinity, your system has been a champion of moving toward VBC. And since Rick was one of the original architects of the ACO and MSSP framework, you'd expect him to be an evangelist for this in the private space.

So, when I look at Trinity with 17 CINs, dozens of MSSP partnerships and broader ACO alignments and a lot of private payers, I see Trinity at the vanguard for driving VBC in health systems.

On the other hand, a through-line in our conversation today is the challenge of not owning a fully-fledged payer function. Indeed, the average health system is still stuck at less than 1.6% full capitation, and that number has barely moved in the past decade. So, I wonder how far down the path to VBC we really are.

Slubowski: Well, first, you have a good memory, Eric. We do have 17 clinically integrated networks and we have 1.3 million attributed lives in the MA plans as well as all of the Medicare pilot programs that have been in place. I think our networks have been able to prove value in terms of both outcomes and in terms of generating savings. But they're small relative to our total size, as you point out.

Still, we believe that managing total cost of care and outcomes is a "no regret" strategy, whether you're living in a capitated or a fee-for-service arena. The reality is, we've got to make the shift, even in the fee-for-service world. Our home care, freestanding ambulatory surgery centers, physician practices, and all our urgent care operations need to operate lower price points. You have to move in that direction, and we are moving in that direction.

Do we wish that we had more opportunities to assume total cost of care and outcomes? Absolutely. Are the commercial payers open to doing that? Absolutely not.

We have a few direct-to-employer relationships, for example, and we'd like to grow that book of business, but it's an uphill battle.

Question: Trinity has an MA plan, as you noted earlier. How many lives do you have under management?

Slubowski: Forty-five thousand. The challenge with MA is that it's not a group program. You're recruiting one member at a time, so you really need your primary care physicians to be your best advocates for the plan.

It's slow going, but we felt like it was something important for us to continue doing, learning about, and growing.

Question: I hear you on the slow going. If we've learned anything about hospitals and proprietary health plans in the past few years, it's that they are super challenging to scale. In fact, if you look at the industry and the "established" provider-sponsored health plans like Kaiser, Intermountain, Geisinger, Sentara, etc. — you know what they have in common?

 It took a long time to grow and refine their health plan — in fact an average of 44 years. This is not a project for the faint of heart. So, with that rather sobering data point, what's the path forward for a health system with either a subscale payer function, or none at all?

Slubowski: You're right. Most health systems that have formidable health plans have had them for decades. We've had a plan in Columbus, Ohio for 20 years. We are moving it to places like Boise, ID or Iowa or New York, but I'd say it's still a fledgling new opportunity for us.

Having expertise around managing care within a fixed budget and doing things like connecting clinical care to social care is critical. So, any of our markets that are taking this work on as part of any kind of risk-based approach are serving as testing beds for the rest of the enterprise.

Personally, I hate the phrase "value-based care" because it lacks uniform meaning — similar to what you were saying a moment ago. But for any sort of model that includes a modicum of risk and measures outcomes based on care, it's important to learn those capabilities and skills. So, I proceed with caution, but optimism. We have to get there.

Question: And that's a great segue to some timely news that I'd love to get your take on. As of this interview, Kaiser and Geisinger have announced their merger in the form of Risant. I commend the ambition here, and it has certainly captured a lot of headlines, but I'm concerned.

We've learned over the past decades how hard it is to move from FFS to FFV at the health system level — and in fact both Kaiser and Geisinger have each had well-publicized challenges exporting their models to new geographies. Still, if any two organizations have the combined capital and best practices to make a go of it, it's these two. I'd be curious for your thoughts on that whole announcement.

Slubowski: Well, I think people want to do something and they're trying to be proactive. Your point about the time to mature capabilities holds true — the 44-year average time you referenced — and I agree with it.

The key for them is going to be, as they said in the document, "seeking the like-minded." I think they actually used the words "hospital system." So, the question is going to be if a "like-minded system" would be one that's put formidable effort into creating a primary care network or a continuum of services in the community. Or, at least, has done some rehearsal work around managing care within a fixed budget, with the ability to connect clinical care and social care.

That's critical to performance and I think they'll find some systems with group practices that are still stuck in the fee-for-service world where there's an opportunity to take on risk, given some of the expertise that they bring.

I have a soft spot in my heart for Kaiser because, as you know, I cut my teeth on managed care at Henry Ford Health system, that was my first role in healthcare. And when we were moving into managed care, when we first became part of the Health Alliance Plan of Michigan, Kaiser consulted with us to help us develop the models for managing care in a per-member per-month environment. I was fascinated by that from day one.

Question: The fundamental question is how much of Geisinger's and Kaiser's model is exportable without that activating ingredient of the premium dollar. The cynic in me worries that the answer is…not much. And I sincerely hope I'm wrong. Perhaps the smarter take is that there are teachable and translatable lessons and expertise, and as you point out Mike, it is just about finding likeminded partners. The pair say they are allocating several billion dollars to this venture in the coming years, so we shall see.

On the "exportable expertise" side, one thing I admire about Trinity is how progressive you all have been in the PACE program (Programs of All-Inclusive Care for the Elderly). You've got the largest PACE not-for-profit program in the country. Take a minute to orient us to this long-standing and commendable program that has deep connection to those VBC capabilities you mention.

Slubowski: PACE is a program for the elderly, particularly dual-eligible people (enrolled in both Medicare and Medicaid) where we take full risk for the members. The best way to describe it is as a wrap-around care program that addresses both clinical and social needs of the members. We have a transportation system that brings members to a patient daycare program where we provide both clinical and social care linkages for them, so they're in an environment with their peers where they can socialize and receive care. We carefully monitor and track their health and wellbeing, so, if they end up needing to be hospitalized or admitted to a rehab facility, they're still our member. We're fully at risk for them.

As it stands, it's a very small population that's engaged in the program, in part because there's not broad awareness about it. But I really believe with the aging of America, with the current trends with SNFs (skilled nursing facilities) in our organization being very challenged right now, there's a real unmet opportunity for these patients to be more appropriately cared for at home through a PACE program with family and social support. I think it's going to be a very important part of our future, so we're proud to have such a high-quality program.

We have 24 PACE locations right now, and we're growing. We have three or four new locations in the planning stage right now that will come alive in the next 12 to 24 months, and we've been approached by a few additional states about bringing PACE to them, because of our reputation. 

Question: PACE is a great example of an established, tenured program — the origins date back several decades — that is getting a 'second wind' from some of the technological advances over the past few years in enabling more migration of care into the home. We've seen what I might even characterize as a "Cambrian explosion" of digital health innovators over the past 36 months, with tens of billions of venture capital dollars stimulating the creation of some 13,000 startups.

Trinity has been an active participant in this ecosystem, both directly by partnering with companies and indirectly by investing in health system VC's like Heritage. I'd love to get your read, Mike, on how you think about digital innovation and capturing some of this energy at Trinity.

Slubowski: I was on a panel a couple weeks ago at Scottsdale Institute and they were asking a similar question. And I guess my first response was, I don't know about you, Eric, but everything I have — even in our health system — has a chip in it.

So digital is who we already are.

Technology is an enabler for improving care and outcomes and creating linkages and communication to patients and members. And that's only going to become more critical.

But there is a yin and yang to our movements in these arenas.

There are so many people coming forward to sell digital to us. I get calls and emails daily from yet another startup digital company that's got the latest whizzbang solution. They don't know what the problem is, but they have the solution.

So, we've been on a journey. When I came back to Trinity six years ago, we had Heinz 57 variety of EMRs. We had some facilities on Cerner, some on Epic, you name it, and we made a decision on the ambulatory side to use Athena at that point.  We were going to make another billion-dollar investment over the next four to five years, So I asked, "On the path we're on, are we going to be any more person-centric, more customer-centric than we are now?" And everybody looked at each other and said, "Well, no."

Subsequently, we made the decision to go with Epic as our common platform for EMR across the organization. We were delayed by the pandemic, but we're still on that journey of putting a common platform in place. We're about 75% of the way now and we have a single instance across the enterprise.

And I think you know Epic. They're continuing to do a lot of work on enhancing MyChart to make it much more customer-focused. They're doing some work now with their new product called Cheers for customer relationship management. So, I'm all in on what they're doing. But it's also on us to make the right choices and select investments in other digital tools. I'd refer back to our TogetherTeam "Moonshot" we discussed earlier because it illustrates what's possible when we're open to new possibilities and when we connect these investments and changes into making our work easier and more effective.

Question: AI, especially with the advent of GPTs and Large Language Models (LLMs), is all the rage across knowledge industries and specifically healthcare. I know that Trinity is a founding member of Truveta — a health system-sponsored data and analytics company — so I'd love to get some of your musings on the disruptive potential of AI in healthcare and how your partnership with Truveta amplifies Trinity's strategy.

Slubowski: Truveta is doing some really cool stuff in medical AI right now. I think you'll see a lot of breakthroughs that will come from the amount of data that they've been able to amass. They're using that now to develop their own tools that take AI to the next level. I can see applications around medical thinking because some of the AI stuff that's been out, like ChatGPT, doesn't really know how to parse and determine outcomes from the clinical data or examples you feed it. It definitely has to be nuanced.

One area I worry about with AI is that the data itself has inequities baked into it. The biases of the past on race, ethnicity, and gender are part of the utilization, cost and demographic data in our databases. So, I think we're going to have to be especially mindful of all of that as we use AI in the future. Our goal should be to eliminate care disparities based on insights we will gain from AI and advance analytics. I think there will be great power in it.

Question: I love your tongue in cheek comment about "hey, we've got the solution." And while the vendors may not always know the problems, we certainly do. There's a real clear and present threat to health systems, which is the staffing insufficiency, the geographic maldistribution of expertise, the PTSD of our frontline staff following the pandemic. Everything you started us off with.

So, I'd like to double down on the productivity front because Trinity employs 123,000 team members — one of the largest employers in healthcare. So, your workforce innovations have broader national implications because if Trinity can do this across its 26 states, it's a microcosm of the U.S. health sector.

Take nursing — you talked about Team Together and the innovations there — if you can attack the 75% of nurses' day spent in "administrivia" — documentation, chasing down DME or pharmaceuticals, walking an average of three miles per shift — we can not only mitigate burnout, reduce turnover, and perhaps even restore joy to the practice of medicine. That is a big deal. And yet hospitals are legendarily slow to embrace some of these tech insights — the average health system takes an average of 23 months to deploy a digital health solutions. Any insights here?

Slubowski: On the TogetherTeam model, we were blessed that the ideas emanated from nursing leadership. When I heard the outcome of the first pilot, I said, "Let's go national."

But we do have guilds in healthcare. And I don't want to limit that statement to just doctors or nurses. We have multiple: respiratory therapists, pharmacists, physical therapists, the list continues.

The reality is, we're going to have to do a lot more in building universal health workers to support people with the backup of both technology and sufficient competency on team-based approaches. I think we're also going to have to be more open to the concept of people taking on healthcare roles as a trade and not exclusively as an academic stream.

I'm on the board now of a public company that formerly trained people for the automotive and aeronautics industries. If you're an auto mechanic, it's likely you were trained at that company. They recently acquired a healthcare training company that trains people for LPN roles, medical assistants, dental assistants etc. They're finding people who want trade roles and finding them a home in healthcare.

Sometimes they have young people who enter training programs who previously had aspirations to move through a four-year RN baccalaureate degree, but either through testing, their ability to work and train, income reasons, or family reasons, that doesn't end up being possible. Well, you know what? It's OK that they don't have a four-year baccalaureate degree to provide and to support caregiving. So we can help channel them into another clinical profession where they can make a difference in people's lives.

We need to be more open to other ways we can provide care to our communities.

Question: Mike, I love that because the Future of Jobs report from the World Economic Forum posited that nearly 25% of jobs will be disrupted for a whole host of reasons including language models and GPTs. So, we all need to reconceptualize what it means to be a healthcare professional.

As you step back and you're appraising this potentially revolutionary force in healthcare, how are you thinking about that?

Slubowski: Well, first let me say that right now I'm focused on trying to get our sea legs back again. We're an investor in an outfit like Truveta because they've got some really bright people figuring out how to use this effectively right now in healthcare. And so we have a seat on that board and we're learning from what they're focusing on right now. And I think that's an important way to inform how we're using AI and business process automation in places like our revenue cycle management and other business processes already. We've been at it, like a lot of other people, with everything from accounts receivable to accounts payable, to you name it.

I do think it will have a profound impact. My mindset is to think and be open to the possibilities and connect it to your circumstances, to live your mission out in a better way than you're already delivering.

Question: You stepped into this role 3.5 years ago, right before the pandemic. If we were to meet up in five or 10 years, whatever the appropriate time frame, and Trinity reaches its next stage in its journey, what's that story? What's the future of Trinity?

Slubowski: Our mission is to be a transforming, healing presence, and our vision statement has been to be "the most trusted health partner for life."

It's been my goal and the goal of our board to not only be relevant in each community we serve, but to be that transforming healing presence for individuals as we go through the organizational transformation we've just described.

When I first took the CEO job, I articulated what we wanted to do as "member health." Some of our board members reacted to the word "member" because to them it meant exclusivity, and they didn't want us to be thought of as exclusive instead of inclusive.

But my intention was, how do we take an organization that, until then, had been primarily focused on episodic encounters, and translate that into a relationship where people view us as "their organization." Our vision statement says that "we will be the most trusted health partner for life."  That means we want those we serve to feel they're a member of our health system, with services across the continuum that are easy for them to access.

So, our new brand promise that we implemented a few years back is, "we listen, we partner, and we make it easy." And that's really our aspiration in terms of what we want to hear from people who receive care from us. A young person who comes to an urgent care facility may not want to have anything else to do with us at that point in their life. But how do we stay connected so that when circumstances change, we're there for them — be it preventative or interventional? That's where I'd like to see our ministry grow. We want to grow prudently and most of that growth will be in the non-inpatient arena — so in the community health division.

On the hospital side, we're being selective about what we provide. Trinity Health has one Academic Medical Center, Loyola, and then we have some higher-end community centers in places like Ann Arbor and Hartford. But at our core, we are made up of community hospitals. And community hospitals are not going to live on as currently configured. Things like orthopedics and general surgery, that's all shifting to the outpatient setting. So how do we find our points of relevance in the high tech and high touch areas of service? That's the journey we're on right now.

At the end of the day, who we are is a public trust and we're doing everything we can to make sure health care is accessible and affordable for everyone now and in the future.  I am very concerned about what's happening in our country with healthcare, and the reality is that our costs are someone else's revenues — be it the payers, the medical device suppliers, Big Pharma, Big Tech, or whomever. Providers are the ones who actually lay hands on the patient — either virtually or physically — and meet their clinical or social needs so people can live a better life.

I think the path we're on right now as a country, if we're not careful, is going to end up with much more of a two-tiered health system. And that may be where this country wants to go with some people aligned with government-sponsored Medicare/Medicaid versus some who are commercially insured. I mean, it's worked for the U.K., but on the government-sponsored side, there's definitely a more uniform way of delivering care in the public health service or the government health service.

So, I think about that a lot and our faith-based background really speaks a lot to social consciousness of society and the common good. I'm learning more and more that the "common good" is not "common," especially as we become more polarized as a nation and as a society.

We're a Catholic health system. But we think about Catholic with a small 'c,' meaning people join and people resonate with faith-based healthcare because they feel a higher purpose. At its highest level we think that our health system has to support the common good and linkages between public health and what we do. We've got to figure out how to become an extension of the public health system and connection to the social care system.

To provide human wholeness is a truly important responsibility.

Question: Let me close with the question I ask all executives in these conversations: what are you most grateful for?

Slubowski: I've been blessed in this career. I mean, there's never been a day that I've woken up when I haven't been excited about going to work, even with the hard things that we do. One of my bosses over the years always said, "It's all about the people and the work." And then another one said, "Mike, you should ask yourself periodically, are the communities better off as a result of your involvement in moving the ministry forward?"

Those are things that I ask myself a lot. Are we making the right decisions for people in communities? In faith-based healthcare and Catholic healthcare, we go through a process that we call Mission Discernment. When we make difficult decisions about either discontinuing or starting a service or exiting a community or transforming our presence in a community, it's really about looking at the impact on the community and on our colleagues.

I get really excited to see the shining eyes of people who are taking on challenging situations to make things better. I was in Albany and Syracuse about a week ago and some of the staff members were working on ways to improve patient throughput in the organization. They were very inventive and doggedly determined to solve the problems that they were experiencing. So those are things that keep me going.

These things give me a lot of energy and hope.