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

H. Stacy Nicholson, MD, MPHChair, Department of PediatricsPhysician-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. Now1970s – 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

$132,519$123,553

$107,600 $107,897 $111,897

$95,978$85,779

$73,337$82,234

$73,311

-

50,000

100,000

150,000

200,000

91-93 93-95 95-97 97-99 99-01 01-03 03-05 05-07 07-09 09-11

State Appropriation (in Thousands)

$209,531

Represents the value of 91-93 State Appropriation stated in current dollars

OHSU State Funding: 1991 - 2011

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 14.1%– 2000 12.6%– 2005 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

Patient Care:

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

region.

To enhance the health and well-being of children and adolescents by ensuring

excellence in patient care, education, research, and

advocacy.

Department of Pediatrics: ‘07 Strategic Plan

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.

VISION:

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

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

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.

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.

GOALS:

MISSION:

VALUES:

Respect & Integrity CompassionInnovation &

DiscoveryPatient & Family

CenteredAccountability & Transparency

Collaboration

OHSU/DCH Pediatric ResidencyNationally Competitive

2011 season as of Oct 13, 2010

>13New interns for July 2011

180 Number of interviews scheduled at OHSU

631Number of US graduate applications to OHSU Pediatric residency

~2000US 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%

ABP Pediatric Training Program Pass Rates

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)

Changing Career Choices by Grads

OHSU/DCH Pediatric ResidencyNationally Competitive

2011 season as of Oct 13, 2010

??New interns for July 2011

180 Number of interviews scheduled at OHSU

631Number of US graduate applications to OHSU Pediatric residency

~2000US applicants to pediatrics

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

FY04 FY05 FY06 FY07 FY08 FY09 FY10*0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

16,000,000

18,000,000

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

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

Total Awards - Direct + IDCBudgeted IDC

Aw

ards

Rec

eive

d ($

)

IDC

($)

*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 pedsAdol, Develop, Endo above

national avg

Impact of Recent Depression on OR Families & Children

Jan-Jun ‘08 Jul-Dec ‘08 Jan-Jun ‘09 Jul-Dec ‘09 Jan-Jun ‘10

Metro PDX 11,621 11,268 11,181 11,138 10,102

Oregon 24,991 24,505 23,892 23,783 21,907

Lower Birth Rates

Persistent High UnemploymentJuly, 2009 July, 2010 Change

USA 9.4% 9.5% + 0.1%

Oregon 11.4% 10.6% - 0.8%

Washington 9.2% 8.9% - 0.3%

20002002

20042006

2008

0

5

10

15

20

25

OregonWashington

OVERALL RANKINGS OVER TIME

Source: 2010 Annie E. Casey Foundation Kids Count Data Book

OR CHILD HEALTH – ROADMAP TO TOP 10Item Current Rank

(2010)Current Rate /

PercentageImprovement

NeededInfant Mortality Rate 11 5.8 / 1,000 - 0.2 / 1,000

Child Death Rate 14 17 / 100,000 - 2 / 100,000

% Gaps in Family Employment

29 29% - 6%

% of Children in Poverty 27 18% - 5%

% of Children in Single Parent Homes

16 30% - 2%

Teen birth rate 18 36 / 1,000 - 6 / 1,000

% high school dropouts 15 6% - 1%

% dropouts not employed 34 9% - 3%

Rate of Return to Investment in Human Capital

High Gains

Low Gains

0Age

JJ Heckman, 2000

High Gains

Low Gains

Age

JJ Heckman, 2000

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, MPHChair, Department of PediatricsPhysician-in-Chief,

Doernbecher Children’s Hospital

10/16/2010