Graduate Medical Education Reform Marc L. Boom, M.D. President & CEO The Methodist Hospital System
Overview I. Our journey II. The costs of academics III. The mismatch of residency slot allocation IV. Community based medical training 2
Selected TMHS Statistics 5 hospitals, research & educational institutes, $2.2B in revenue 1,585 operating beds and 119 OR suites 77,425 admissions 200,204 ER visits 568,772 outpatient visits 13,867 employees and 4,185 affiliated physicians Affiliated with the Texas Annual Conference of the United Methodist Church AA Bond Rating by Standard & Poor s 3
Accolades No. 1 hospital in Texas U.S. News & World Report America s Best Hospital in 13 specialties 100 Best Companies to Work For FORTUNE magazine 7 years in a row A Rating Leapfrog Group Magnet hospital American Nurses Credentialing Center 4
220 200 180 160 140 120 100 80 60 40 20 0 3 2 The Methodist Hospital Sponsored Residents 2 2 4 93 103 124 149 154 163 182 202 AY 05-06 AY 06-07 AY 07-08 AY 08-09 AY 09-10 AY 10-11 AY 11-12 AY 12-13 11 11 6 ACGME Non-ACGME Since 2005 we have created 31 ACGME programs with over 200 residents 5
Costs of Academic Medicine 2011 Direct Resident Cost/Reimbursement Fully Allocated Direct Residency Costs 26,378,068 Residents 213.60 Direct Cost Per Resident 123,493 Direct Graduate Medical Reimbursement (GME) per Resident 85,464 Uncompensated Cost Per Resident $ 38,029.07 Shortfall $ $ (8,123,009)
How we use IME funding Support Total IME Funding $ 22,783,151 IME Funds Remaining Chair Support 130,110 Program Director Support 4,452,138 Faculty Support 6,328,522 Admin Support 612,500 Total Resident Support 11,523,270 11,259,881 GME Shortfall Expenses 8,123,009 3,136,872 Library & Other Learners 1,871,966 1,264,905 Non-Funded Residents (11 @ $80k) 880,000 384,905 Cardiac Imaging, Transplant, Breast Imaging Capital Costs 500,000 (115,095) 7
An example of our infrastructure ACGME Requirements Internal Medicine support as stated in ACGME Program Requirements: The Methodist Hospital Educational Matrix 2012 Medicine Resident Education Support Chair Support 31,760 Program Director Support 428,614 Faculty Support 540,054 Administrative Support 50,000 Total Resident Support 1,050,428 Total Educational Support 1,050,428 Support per resident 35,014 Internal Medicine has 30 residents: The sponsoring institution and participating sites must: provide at least 50% salary support for the program director; o provide associate program directors (APD) based on program size. At a minimum, APDs are required at resident complements of 24 or greater according to the following parameters: Residents APDs (TMH provides 2) o provide 20 hours per week salary support for each associate program director required to meet these program requirements o provide support for core faculty based on program size, according to the following faculty to resident ratio Residents Core Faculty o A program with less than 60 residents must provide 4 core faculty members o o provide support for program administrator(s) and other support personnel required for operation of the program; (Program Coordinator) provide residents with access to training using simulation 8
Operating inefficiencies Dunn Operating Room - Teaching Costs Total Expenses 45,351,220 Cases 10,061 Teaching Cases 5,541 Expense/Case 4,508 Expense/Hour 1,610 Non Teaching Hours / Case 2.8 Teaching Hours / Case 3.1 Teaching Inefficiency Factor 9% Total Additional Teaching Hours 1,448 Total Additional Teaching Costs 2,331,836 Opportunity Costs Additional Cases - non teaching 513 Additional Charges 11,809,728 Average realization rate 24% Total Additional Net Revenue 2,834,335 9
Teaching slot allocation should follow population growth Highest Numeric Increases: Top 10 Growing States between 2000 and 2010 State Increase of People IME / GME Top 10 Reduction IME / GME Top 10 Addition Rank # Rank 1 Texas 4.3 million 5 IME, 5 GME N/A 2 California 3.4 million 2 IME, 2 GME N/A 3 Florida 2.8 million 7 IME, 7 GME 1 IME, 3 GME 4 Georgia 1.5 million N/A N/A 5 North Carolina 1.5 million N/A N/A 6 Arizona 1.3 million N/A N/A 7 Virginia 0.9 million N/A N/A 8 Washington 0.8 million N/A N/A 9 Colorado 0.7 million N/A N/A 10 Nevada 0.7 million N/A 3 IME, 1 GME Lowest Numeric Increases: Bottom 10 Increasing States between 2000 and 2010 State Increase of People IME / GME Top 10 Reduction IME / GME Top 10 Addition Rank # Rank 1 Michigan -54,804 N/A N/A 2 Rhode Island 4,248 N/A N/A 3 Vermont 16,914 N/A N/A 4 District of Columbia 29,664 N/A 5 IME 5 North Dakota 30,391 N/A N/A 6 West Virginia 44,650 N/A N/A 7 Maine 53,438 N/A N/A 8 South Dakota 59,336 N/A 10 IME 9 Louisiana 64,396 N/A 6 IME, 2 GME 10 Wyoming 69,844 N/A N/A 10
Physician shortage in Texas 1,600 people move to Texas every day Type of Trainee Retention Rate National Rank Texas already has too few doctors for its population (national rank = 46) Medical Student 58.8% 2 Doctors who train in Texas, stay in Texas Resident / Fellow 56.8% 7 Training more doctors in Texas is an important strategy for solving the shortfall in Texas doctors Combined 79.9% 4 11
Community Based Medical Training $8,000 Average amount health centers save Texas taxpayers per Medicaid patient per year 1,975 Approximate number of Medicaid patients served by Denver Harbor Clinic and Airline Children s Clinic in 2010 $15,800,000 Approximate savings to Texas taxpayers in 2010 through Denver Harbor Clinic and Airline Children s Clinic s services provided to Medicaid patients 12 (Source: Texas Association of Community Health Centers, www.tachc.org)
Community Based Medical Training We have graduated 38 residents in total since 2005, 25 of whom did all or part of their training at Denver Harbor Clinic, 13 who are currently in training including 5 who will graduate this year. At least 8 graduates have gone on to practice in an underserved or rural area 21 of 25 who have graduated practice in Texas, 15 of the 21 practice in the Houston area 13
In closing The costs of academics I. DGME & IME funding do not cover the cost of academic infrastructure II. Medicare shortfalls already exist for most hospital providers, so further reimbursement cuts will force academic hospitals to make hard decisions on their teaching missions The mismatch of residency slot allocation I. The current allocation system is not allowing the states where our population is growing to expand their teaching slots II. This will continue to place access barriers for high growth states III. There is no mechanism in the current system to address the aging population or current physician shortages in many states Community based medical training I. Further efforts should be pursued to develop more community based primary care teaching sites 14