The Future of Pediatrics in Oregon – the Role of the Pediatric Academic Health Center (AHC)

H. Stacy Nicholson, MD, MPH Chair, Department of Pediatrics Physician-in-Chief, Doernbecher Children’s Hospital 10/16/2010

Disclosure

• • No ties to Industry 5K12 HD 057588 (Child Health Research Center) PI: Nicholson

Pediatric Chair’s View of Reality

Chevalier, J Pediatr 151:557-558, 2007

Faculty Member’s View

Chevalier, J Pediatr 151:557-558, 2007

Academics – Then vs. Now

• • • • •

1970s – 1980s

“profess”or “teaching rounds” 3 times per week Residents and students were the primary physicians Limited supervision Solid state funding • • • • •

Today

Clinical FTE defined by subtraction ↑ Productivity demands – wRVU / CFTE – Research funding ↑ supervision ↑ direct care by faculty ↓ state funding

OHSU State Funding: 1991 - 2011 $209,531 200,000 150,000 $132,519 $123,553 $107,600 $107,897 $111,897 100,000 $95,978 Represents the value of 91-93 State Appropriation stated in current dollars $85,779 $73,337 $82,234 $73,311 50,000 91-93 93-95 95-97 97-99 99-01 01-03 State Appropriation (in Thousands) 03-05 05-07 07-09 09-11

Academic Pediatrics in USA – Issues

• • • • • ↑ part-time faculty ↑ Pressure for Increased Productivity – Tied to compensation Mission Competition: Care, teaching, research Financial – ↓ state funding – ↓endowments Resident Duty Hours / R3P – ↑ clinical work by faculty – Changing composition of ‘teams’ – ↑ ‘flexibility’ – ↓ hours (Pl1s limited to 16 hours in FY12)

Academic Pediatrics in USA

• Issues (cont’d) – Workforce • Shortage of subspecialists • Maldistribution of Providers – rural vs. urban – Reimbursement • Pediatric reimbursement lower than for adult – Medicaid reimbursement below Medicare • ‘Cognitive’ specialties have lower reimbursement • Universal Coverage / Health Care Reform – Medical Home

Decreased Funding for Ped Research

• • • Pediatric Research funded by NIH – 1994 – 2000 – 2005 14.1% 12.6% 11.3% Pediatric Research in top science journals (Science, Nature, PNAS, J Clin Invest, NEJM) – Declined by 35% from 2000 to 2006 Children are 25% of the US population

Academic Pediatrics in Oregon

• • • OHSU is Oregon’s Academic Health Center (AHC) – ‘top 20’ medical school Very Competitive Environment in Pediatrics – 4 health systems compete in metro PDX • • Competition can make you stronger (+) Fragmentation of Care (-) • • Potential negative impact on recruitment (-) Potential negative impact on payment from insurers (-) Urban vs. Rural – Distance to subspecialty pediatrics a barrier to access

OHSU – YOUR ACADEMIC HEALTH CENTER

Focusing on DCH and the Department of Pediatrics

Department of Pediatrics: ‘07 Strategic Plan

MISSION:

To enhance the health and well-being of children and adolescents by ensuring excellence in patient care, education, research, and advocacy.

VISION: Patient Care:

We will be the pediatric and adolescent healthcare provider of choice for our region.

Education:

We will be a leader for excellence in education, the cornerstone of our patient care, research, and advocacy efforts.

Research:

We will be a leading center for child health research, encompassing basic, clinical, translational, and health services research programs.

Advocacy:

We will be a strong voice for the health and welfare of children.

GOALS:

1) Build a sustainable educational environment that attracts top candidates, cultivates knowledge, and achieves superior outcomes.

2) Grow focused areas of research excellence, building upon existing research strengths in the Department and at OHSU.

3) Enhance healthcare access and improve service to patients and referring providers.

4) Develop, recruit, and retain the best faculty and staff.

5) Solidify the financial position of the Department.

6) Develop partnerships with the community to further our education, research, and patient care missions.

7) Reduce health care inequities among children and adolescents in our region.

Respect & Integrity Compassion

VALUES:

Innovation & Discovery Patient & Family Centered Accountability & Transparency Collaboration

OHSU/DCH Pediatric Residency Nationally Competitive

2011 season as of Oct 13, 2010

>13

New interns for July 2011

180

Number of interviews scheduled at OHSU

631

Number of US graduate applications to OHSU Pediatric residency

~2000

US applicants to pediatrics

DCH Residents are Great on Day 1

• Current intern class (class of 2013) – Average USMLE step 1 score = 225 • Average all peds applicants = 219 • Minimum pass = 188 – Average USMLE step 2 score = 237 • Average all peds applicants = 229 • Minimum pass = 184 – % AOA = 23 % • All peds applicants % = 12%

DCH Graduates are Great on Day 1

• American Board of Pediatrics Certification Exam – Last 2 years pass rate = 100% – Overall pass rate (2007-2009) = 98% – Of 189 programs, the number of programs with better pass rate than OHSU= 1 • Mass General = 100% pass rate (94% of eligible took exam) • Mayo Clinic = 98% pass rate (100% of eligible took exam) ABP Pediatric Training Program Pass Rates

Changing Career Choices by Grads

OHSU/DCH Pediatric Residency Nationally Competitive

2011 season as of Oct 13, 2010

??

New interns for July 2011

180

Number of interviews scheduled at OHSU

631

Number of US graduate applications to OHSU Pediatric residency

~2000

US applicants to pediatrics

Department of Pediatrics Research Awards & Indirect Costs: Past 7 Years

Dept of Pediatrics - Overall Research Productivity Awards Received vs Budgeted IDC

18 000 000 16 000 000 14 000 000 12 000 000 10 000 000 8 000 000 6 000 000 4 000 000 2 000 000 0 FY04 Total Awards - Direct + IDC Budgeted IDC FY05 FY06 FY07 FY08 FY09 FY10* 3 500 000 3 000 000 2 500 000 2 000 000 1 500 000 1 000 000 500 000 0

*NOTE: FY10 Data is Estimated thru the end of the Fiscal Year

OREGON – A FEW REMARKS ABOUT CHILD HEALTH

Healthy Kids (OR)

• • • • Insurance tax (1%): $105M over 2 years $240M in matching federal funds – 80,000 uninsured kids to get coverage by 6/11 Hospital tax (up to 5.5%): – 35,000 uninsured adults to get coverage OR – 1 of 12 states to guarantee universal coverage for kids – But…………. Coverage does not equal access.

Workforce Issues in OR

• To get OR to national numbers (#providers per 100k kids) – 7 cardiologists – 1 critical care – – 7 emergency med 3 GI – 3 Heme/Onc – 3 ID – 8 Neonatologists – – – – 1 Nephrologist 3 pulm 1 rheum 42 general peds Adol, Develop, Endo above national avg

Impact of Recent Depression on OR Families & Children Persistent High Unemployment USA Oregon Washington

July, 2009

9.4% 11.4% 9.2% Lower Birth Rates

Jan-Jun ‘08 Jul-Dec ‘08

Metro PDX Oregon 11,621 24,991 11,268 24,505

July, 2010

9.5% 10.6% 8.9%

Jan-Jun ‘09

11,181 23,892

Change

+ 0.1% - 0.8% - 0.3%

Jul-Dec ‘09

11,138 23,783

Jan-Jun ‘10

10,102 21,907

OVERALL RANKINGS OVER TIME 0 5 10 15 20 25 Oregon Washington Source: 2010 Annie E. Casey Foundation Kids Count Data Book

OR CHILD HEALTH – ROADMAP TO TOP 10

Item

Infant Mortality Rate Child Death Rate % Gaps in Family Employment % of Children in Poverty % of Children in Single Parent Homes Teen birth rate % high school dropouts % dropouts not employed

Current Rank (2010)

11 14 29 27 16 18 15 34

Current Rate / Percentage

5.8 / 1,000 17 / 100,000 29% 18% 30% 36 / 1,000 6% 9%

Improvement Needed

- 0.2 / 1,000 - 2 / 100,000 - 6% - 5% - 2% - 6 / 1,000 - 1% - 3%

High Gains Rate of Return to Investment in Human Capital High Gains Low Gains Low Gains

JJ Heckman, 2000

0

JJ Heckman, 2000

Age Age

HEALTH CARE REFORM

Real Health Care Reform

• • • • Providers work at the top of their license / training – Primary care / prevention work will be increasingly done by non MDs – PCPs will see sicker kids and take on more routine subspecialty care (CSHCN, Chronic disease, etc.) – Subspecialists • Work more closely with PCPs • Only see the most complicated patients / provide treatment Patients & Families – the most underutilized resource in healthcare – Electronic data will enable clinical decisions Systems and Networks will replace older business models Roadmap from here to there?

Christensen, Clayton, The Innovator’s Prescription, 2009

Concluding Remarks

• • Oregon – the Goldilocks State – ~ 4 million people – – ~ 1 million kids Significant barriers to care access • SES – rural & frontier populations • Geographic We can show the USA how to take better care of kids – By working together in care delivery – By working together in advocacy

The Future of Pediatrics in Oregon – the Role of the Pediatric Academic Health Center (AHC)

H. Stacy Nicholson, MD, MPH Chair, Department of Pediatrics Physician-in-Chief, Doernbecher Children’s Hospital 10/16/2010