A Healthier Nevada PRESENTED BY: TRIPP UMBACH 9/29/14 1

2 Introduction: Tripp Umbach o Over the past ten years, Tripp Umbach has been instrumental in 20 medical education expansion projects throughout the United States. o Since 1995 Tripp Umbach has measured the economic impact of every U.S. medical school and teaching hospital. o Since 1990, Tripp Umbach has consulted with 75 academic medical centers, more than 500 hospitals, and 250 universities in all 50 states.

3 NSHE retained Tripp Umbach to: o Develop a comprehensive business plan to expand public medical education statewide at both the undergraduate and graduate levels. Overall Study Goal: o Develop a new medical school at UNLV while growing the existing University of Nevada School of Medicine and expand GME statewide. Medical Education Expansion Study Goals (2014) the development of a second public medical school, expansion of GME, physician recruitment, and retention efforts must continue The need for more doctors in Nevada is so critical that the development of a second public medical school, expansion of GME, physician recruitment, and retention efforts must continue to produce quality physicians that will remain in the state, ensuring both public health and economic opportunity for all citizens.

Overview of Medical Education 4

In the middle nineteenth century, it was easy to become a doctor in America… o Entrance requirements to medical schools were nonexistent other than the ability to pay the fees. o The standard course of instruction in the middle nineteenth century consisted of two 4- month terms of lectures during the winter, with the second term identical to the first. o Instruction was wholly didactic: 7 or 8 hours of lectures a day, supplemented by textbook reading. o Laboratory work was sparse, and even in the clinical subjects, no opportunity to work with patients was provided. o Examinations were brief and superficial; virtually the only requirement for graduation was the ability to pay the fees. o University or hospital affiliations, in the few cases in which they existed, were nominal. 5

THREE PHASES of MEDICAL EDUCATION “A Continuum” 6 Undergraduate Medical Education (UME) o LCME (Liaison Committee on Medical Education) Graduate Medical Education (GME) o ACGME (Accreditation Council on Graduate Medical Education) Continuing Medical Education (CME) o ACCME (Accreditation Council on Continuing Medical Education)

The Continuum: A Long-Term Investment 7 K-12 Education Undergraduate/ College Medical School GME/Residency Training

8 Education Teaching Research Patient Care Educational Activities Patient Care Services Balance “Medical Education” MEDICALEDUCATION ACTIVITIES MEDICAL EDUCATION ACTIVITIES

Graduate Medical Education (GME) 9

Sponsoring Institution 10 Hospitals, medical schools, or consortium organizations may be sponsoring institutions. o ACGME-accredited residency programs must operate under the authority and control of a sponsoring institution. Hospitals, medical schools, or consortium organizations may be sponsoring institutions. o Has the primary purpose of providing educational programs and/or health care services (e.g., a university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized health care delivery system, a medical examiner’s office, a consortium, an educational foundation). o Retains responsibility for the quality of GME even when resident education occurs in other institutions.

Multi-Pronged Strategy for Developing & Expanding GME 11 Developing New University Sponsored Programs Expanding Existing University or Hospital Based Programs Teaching Health Centers/FQHC’s Hospital Consortium (501c 3) Potential GME Strategies

Federally Qualified Health Centers (FQHC’s) – Reasons to Collaborate 12 o Offers an attractive, unique training environment offering some of the best and evolving models of care. o Creates a dynamic clinical environment. o Enhances the status/reputation of each party. o Enhances physician recruitment and retention. o Stepping stone to other collaborations. o Financially and otherwise beneficial to parties and the community.

o The development of a GME Consortium model would be where hospitals and other organizations such as medical schools and public health agencies, partner to develop residency programs and act as the vehicle to expand physician training in the region. o Physicians in the future will deliver healthcare in close partnership with other health professions, such as physician assistants, nurse practitioners, and allied health professionals, it would also be the goal of the Consortium to stimulate interdisciplinary training opportunities for a wide range of health professionals. GME Consortium (501 c 3) 13

Current GME Funding 14

Income from CMS: Ranges from $50k Per Resident to as High as $180k Per Resident % of Medicare in Patient Load Ratio of Hospital Beds to Residents GME Economics 101 The Balanced Budget Amendment of 1996, in which Congress froze federal funding The Balanced Budget Amendment of 1996, in which Congress froze federal funding for established medical residency programs.

Current Funding Situation overall support for GME comes out of a number of separate public and private pots. o Although the federal government is the largest single supporter of graduate medical education, overall support for GME comes out of a number of separate public and private pots. via the Medicare program, currently provides more than $11 billion per year o The federal government, mostly via the Medicare program, currently provides more than $11 billion per year in payments to support the training of doctors who have graduated medical school. three years to develop their programs before federal funding is capped. o Newly accredited institutions have three years to develop their programs before federal funding is capped. 16

Uncertainty with GME Funding 17

o More than 40 states paid about $3.78 billion through their Medicaid programs to support GME in 2009, this amount has dropped significantly in the past 5 years as o More than 40 states paid about $3.78 billion through their Medicaid programs to support GME in 2009, this amount has dropped significantly in the past 5 years as many states have reduced their support for advanced medical training. o Private insurers support GME to a lesser degree o Private insurers support GME to a lesser degree since the enactment of the Affordable Care Act of Current Funding Situation 18

o The IOM panel calls for spending the same overall funding from Medicare over the decade, adjusted for inflation. o Distributed much differently, with a declining share providing direct subsidies to teaching programs. o An increasing share would go instead to a “GME transformation fund” that would finance new ways to provide and pay for training and fund training positions “in priority disciplines and geographic areas.” Institute of Medicine (IOM) 19

In Nevada UME + GME = Doctors 20

Benefits to Hospital Due to GME o Recruitment Cost Savings Resulting From Graduating Residents o Additional Hospital Operating Revenue (Profit) Generation Due to Graduated Residents Practicing at Hospital o Additional Hospital Operating Revenue (Profit) Generation Due to Specialty Physicians at Hospital b/c it has GME o Revenue from Quality Outcomes o Savings from Lower Utilization in Emergency Department o Image Enhancement in Key Program and Service Areas as a “Teaching Hospital” o Expansion of Potentially Profitable Programs Due to Residency Accreditation Requirements to Hire Additional Sub-Specialty Physicians o Workforce that is Closely Tied with the Culture of Both Your Hospital and Your Community 21

22 The future benefits resulting from expanding both UME and GME include: o expanding access for underserved populations; o increasing the quality of healthcare; o eliminating the need for Nevada citizens to go outside of the state for healthcare; o increasing economic development through the attraction of federal and private research dollars; and o attracting new industries who are drawn to regions with superior healthcare that could eventually lead to Nevada being a destination for advanced medicine. Making a Difference in the Community

23 o Through the expansion of UME and GME, an overall goal for the state of Nevada is to create an atmosphere of innovation and excellence in research and patient care where residents and fellows can fully realize their potential as a highly competent physician, physician-scientist, clinical investigator, or institutionally based academician. o Ultimately, the goal is to enhance the current prestige of the existing institutions and strengthen the new. Making a Difference in the Community

Success 24 o As based on national averages, students who complete both their UME and GME in Nevada have a better than 80% chance of remaining in the state. Students that only complete GME in Nevada have a 60% chance of remaining in the state. o This is why the integrated NSHE driven process is so important. The true success lies in developing pipelines, recruiting residents, and retaining graduates to an educationally enriched region.