The University in American Life: The University of North Carolina Health Care System October 31, 2005

The UNC Academic Health Center Today An integral part of the University of North Carolina at Chapel Hill

Does a University need a Teaching Hospital? If yes, then why?

The Context of Health Care within the University The health care system, like the University, is a reflection of the society in which is operates. Health services have changed rapidly in the last 50 years, and the UNC Health Sciences Center reflects that change. The service role of university-based teaching hospitals is essential to the growth of educational and research programs on the part of the health science faculty. We will consider the evolution of UNC Hospitals and the UNC Health Sciences Center in that context.

The University in American Life: The 1940’s and 1950’s High rate of young North Carolina men not medically eligible for the draft - rejected from military service in WWII. Good Health Movement formed. Increased awareness of the lack of health services in North Carolina - especially in rural areas A rapidly growing nation - health manpower shortages Emerging expansion of health insurance programs “Hill Burton” funded hospitals developed with a community service obligation

The University’s Response: History and Evolution UNC School of Medicine 2 Year School Year School – 1952 North Carolina Memorial Hospital – 1952 Named as a memorial to North Carolinians who died in all wars Name changed to UNC Hospitals – also kept the NCMH NC Memorial Hospital separated organizationally from the administration of UNC-Chapel Hill Board of Directors established UNC Health Care System Formed

The University in American Life: 1960’s & 1970’s Medicare and Medicaid programs established as part of the “Great Society” (1965) – Increased access to health care by the “underserved” who were generally the poor and minority populations Improved access to outpatient services and new markets for hospitals Continuing health manpower shortages Significant growth in NIH research funding

The UNCHCS Response: Focus on Mission The Mission of the UNC Health Care System is to: – Provide high quality patient care – Educate health care professionals – Advance health and biomedical research – Serve the community

Unique Qualities of UNC Academic Health Center for North Carolinians UNC is the only University in the State of North Carolina to have all 5 health sciences schools and a major teaching hospital on one campus: – Medicine & Allied Health – Public Health – Nursing – Pharmacy – Dentistry Key links to other schools on campus, and multiple Centers, Institutes and Programs that provide both research and service Recognition of a state-wide role in health services

Medical Student Physician Assistant Nurse Practitioner AHEC* Primary Care Training Sites for Medical Students, Physician Assistants, and Nurse Practitioners * AHEC = Area Health Education Centers

North Carolina Area Health Education Centers (AHEC) Program AHEC Continuing Education Programs Source: NC AHEC Program Mountain Greensboro Coastal Northwest Southern Regional Area L Charlotte Wake Eastern Locations of Continuing Education Programs,

The University Academic Health Center Environment: 1980’s Increasing scrutiny of the cost of health services New payment schemes to control costs Concerns about an “appropriate” number of health professionals Increasing regulatory environment in health planning, service development, and quality – Certificate of Need, Accreditation, Peer Review Agencies

The University’s Response: School of Medicine Between 1970 and 1980 the number of medical students grew from 340 to its current size of 640 students and faculty grew accordingly 5,983 medical degrees awarded since the first class in 1954 Allied Health Sciences Enrollment in 2005 of 369 students (laboratory science, occupational therapy, physical therapy, radiologic science, speech and hearing, etc.) Major growth in research faculty and facilities to support their efforts that continues today.

NIH Support to U.S. Institutions of Higher Education Fiscal Year Johns Hopkins University599,151,309 2 University of Washington473,432,138 3 University of Pennsylvania464,076,925 4 UC-San Francisco438,778,831 5 Washington University388,307,875 6 University of Michigan368,176,446 7 UC-Los Angeles361,593,433 8 University of Pittsburgh360,635,035 9 Duke University343,825, Harvard University325,665, Yale University323,614, UC-San Diego304,039, Columbia University303,714, Stanford University301,733, UNC-Chapel Hill289,652, University of Wisconsin264,059, Vanderbilt251,147,207

The Academic Health Center Environment: 1990’s Rapidly changing health insurance market moving from indemnity services to “managed care” Increased emphasis on cost & questions about what quality health care might be Increasing consumerism - with attendant demands and expectations (patient’s rights) Continued growth in challenging biomedical research Recognition of the special role of Academic Health Centers and their societal contributions – Managed care entities wanted to use our “products”, but didn’t want to pay for them

The UNC Health Care System Today

Profile A system providing outpatient, inpatient, urgent, and emergent care A comprehensive health center, providing services from wellness and preventive programs to organ transplants Includes other owned or affiliated hospitals, home health and hospice services A community partner with other health care agencies and services A laboratory for teaching, and a place for clinical research A public facility, with societal obligations

The UNCHCS Vision To be the nation’s leading public academic health care system Leading. Teaching. Caring.

Special Features The first hospital in the country to provide intensive care services The only comprehensive burn center in North Carolina (between D.C. and Atlanta) A place where cutting edge research links to service – Breakthrough treatments in hemophilia, respiratory diseases, cystic fibrosis, gene therapy, AIDS, Cancer, and others Serves North Carolinians of all walks of life – 70,000 babies born since 1952

Yance y Caswell Person Granville Vance Warren Franklin Northampton Halifax Alamance Durham Wake Chatham Nash Edgecombe Wilson Johnston Wayne Lee Moore Harnett Sampson Duplin Pender Brunswick Columbus BladenRobeson Cumberland Hoke Scotland Guilford Randolph Montgomery Richmond Stokes Forsyth Davidson Rowan Stanly Anson Union Mecklenburg Cabarrus Iredell Davie Yadkin Surry Alleghan y Ashe Wilkes Alexand er Catawba Lincoln Gaston Cleveland Burke Caldwell Watauga Avery McDowell Rutherford Polk Mitchell Buncombe Henderson Transylvania Haywood Madison Swain Jackson Macon Graham Clay Cherokee Onslow Jones Lenoir Greene Pitt Martin Bertie Hertford Gates Camden Pasquotank DareTyrrellWashington Beaufort Hyde Craven Pamlico Rockingham Currituck Perquimans Chowan Carteret Orange New Hanover University of North Carolina Hospitals FY 2005 Inpatient Origin by N.C. County UNC Hospitals 1-9 cases cases cases cases cases LEGEND Total Discharges: 31, 334

University of North Carolina Hospitals - Distribution of Non-Reimbursed Care (by County of Residence – North Carolina) FY 2005 Caswell Person Granville Vance Warren Franklin Northampton Halifax Alamance Durham Wake Chatham Nash Edgecombe Wilson Johnston Wayne Lee Moore Harnett Sampson Duplin Pender Brunswick Columbus Bladen Robeson Cumberland Hoke Scotland Guilford Randolph Montgomery Richmond Stokes Forsyth Davidson Rowan Stanly Anson Union Mecklenburg Cabarrus Iredell Davie Yadkin Surry Alleghany Ashe Wilkes Alexander Catawba Lincoln Gaston Cleveland Burke Caldwell Watauga Avery McDowell Rutherford Polk Mitchel l Yancey Buncombe Henderson Transylvania Haywood Madison Swain Jackson Macon Graham Clay Cherokee Onslow Jones Lenoir Greene Pitt Martin Bertie Hertford Gates Dare Camden Tyrrell Washington Beaufort Hyde Craven Pamlico Rockingham Carteret Orange New Hanover Source: Actual 2005 charity and bad debts by residence of patients treated – UNCH’ Fiscal Services Legend for Map < $500,000 $500,000-$1M $1M - $3M > $3M Currituck Pasquotank Perquimans Chowan

Key Statistics - Fiscal Year ,322 Admissions 202,048 Inpatient Days of Care Average Length of Stay – 6.4 Days 680,689 Outpatient Physician Visits – Includes 198,091 in off-campus sites 65,894 ER, Urgent Care and Peds ER Visits 253 Transplants (heart, lung, kidney, bone marrow, liver, pancreas) 1117 Air Transports 3,574 Babies Delivered

UNC’s Clinical Support for Educational Programs 22% of active North Carolina Physicians Trained at UNC Hospitals or UNC Percent of Physicians Who Trained at UNC-CH (# of Counties) All Physicians Trained at UNC (2) 60.0% to 99.9% (3) 30.0% to 59.9% (13) 15.0% to 29.9% (44) 5.3% to 14.9% (33) No UNC-Trained Physicians (5) Percent of Active Physicians Trained by UNC/UNC-CH North Carolina, 2004 Produced by: North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Sources: Alumni Affairs Data, 2004, and North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, *Physicians included are active, instate, nonfederal, non-resident-in-training. Total Active Non-Federal Physicians = 17,349 UNC / UNCH trained physicians* =3,794 Total % of UNC Physicians in North Carolina =22% *Combines UNC graduates and UNCH residents in an unduplicated count. UNC/UNCH trained 31% of the MDs in the 10 counties with the fewest MDs Caswell Person Granville Vance Warren Franklin Northampton Halifax Wake Chatham Nash Edgecombe Wilson Johnston Wayne Lee Moore Harnett Sampson Duplin Pender Brunswick Columbus Bladen Robeson Cumberland Hoke Scotland Guilford Randolph Montgomery Richmond Stokes Forsyth Davidson Rowan Stanly Anson Union Mecklenburg Cabarrus Iredell Davie Yadkin Surry Alleghany Ashe Wilkes Alexander Catawba Lincoln Gaston Cleveland Burke Caldwell Watauga Avery McDowell Rutherford Polk Mitchell Yancey Buncombe Henderson Transylvania Haywood Madison Swain Jackson Macon Graham Clay Cherokee Onslow Jones Lenoir Greene Pitt Martin Bertie Hertford Gates Camden Pasquotank DareTyrrell Washington Beaufort Hyde Craven Pamlico Rockingham Currituck Chowan Carteret Orange New Hanover Durham Alamance Pasquotank

What is it? – An integrated health care system, owned by the State of North Carolina and based in Chapel Hill. Who is it? – UNC Hospitals and the practice plan of the School of Medicine were combined into a single system, with a single CEO – The UNCHCS was given management flexibility in purchasing, consultation, construction, and human resources activities to assure its management flexibility and competitiveness in a rapidly changing health care business environment. UNC Health Care System - Formed 1998

UNC Health Care System Why create it? – More responsive to the “marketplace”, blending the cultures of the academic base with the marketplace – Allowed for needed flexibility from State management systems How is it governed? – A Board of Directors is appointed by Board of Governors of University of North Carolina System, upon recommendation of the President – Board includes state-wide community representatives and representatives from UNC- Chapel Hill, UNC Hospitals, and the School of Medicine What is it? – UNC Hospitals, Rex Healthcare, Home Health and Hospice, etc.

The UNCHCS in Year 2005 and Beyond in Health Care’s Challenging Environment Increasing demand for services versus declining payment and increasing costs Staffing shortages – especially registered nurses Challenges in resource allocation and in priority setting for program development Capital program growth and development Heavy and costly regulation Significant emphasis on quality improvement and patient safety And on the UNC campus …Parking, Parking, Parking

Positioned to Face the Challenges New facilities developed and in planning Strong support for health science education Flexibility in response to human resource issues Severe financial challenges ahead ? Parking, parking, parking……. Growing interface between patient care and research

Carolina Roadmap to Success Multidisciplinary and Collaborative Research The National Institutes of Health have devised a new, very competitive, Roadmap program. Program is designed to transform the nation’s medical research capabilities and speed research discoveries from the bench to the bedside. Carolina garnered 8 of these prestigious grants – more than any other institution in the nation. Vanderbilt and Columbia - 6 Memorial Sloan-Kettering Cancer Center - 5 Johns Hopkins - 4 Harvard and Stanford - 3 Duke - 2

The Hospital and the University Parallel Universes

Policy & Program Opportunities Development planning and coordination – UNCHCS Facility Master Plan in University Development Plan – Adjacent facilities and future growth potential Infrastructure development and support – Parking subsidies and utility development Community relations Program development and growth – University Child Care Center – Ronald McDonald House & Family House

Day-to-Day Operations : Mission Focused Educate new health professionals and offer young people opportunities for growth Serve people statewide through the patient care provided and constantly developed while also educating and learning new things Provide a laboratory for clinical research done by the health science schools with care for protection of patients and understanding of those who participate.