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THOT GME Vital Signs Final Used Version w/o Health Affairs 1.14.16

No HA version
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maureen milligan

on 26 April 2017

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Transcript of THOT GME Vital Signs Final Used Version w/o Health Affairs 1.14.16

62
ECG
bpm
Thank You!
Vital Signs -- for
Graduate Medical Education (GME)

Why is GME so hard?

For a start...because:
It affects Article II
It affects Article III
It's provided through partnerships -- with Medical School Faculty & Hospitals as well as other clinical settings (directors??)
There's no one "Go To" state agency that includes all GME stakeholders??
It involves funding from: Federal, State, local and private sources
It makes Medicaid financing look not so bad...

Three Legged Stool
Patient Care
Research

Education

Trivia # 6:
What do: Conan O'Brien, Christina Aguilera, Russell Crowe & Mark Zuckerberg have in common with:
Drs. Helen Hobbs (UTSW) and Jim Allison (MD Anderson)??
Research
Patient Care
Economic Development & Health System Savings

Texas Research has impacts

Locally, in Texas, Nationally and Around the World
Critical Mass of
Research, Education, and Patient Care:

Creates a Synergy -
Draw great faculty; students; residents; attracts more grants, more research & more achievements
;
Public Health
The mission of the Galveston National Laboratory
is to assist the National Institute of Allergy and Infectious Diseases and the nation in the development of an improved means for the
prevention, diagnosis and treatment of potentially life-threatening diseases caused by
naturally emerging and purposefully disseminated
infectious agents.

Like....
Medical School
Graduates
Residencies
Practice?
Trivia # 2
THOT members
represent what percent of all hospital based
residency programs in Texas?
a) 0 - 25%
b) 25- 50%
c) 50 - 75%
d) 75 - 100%
Texas Physician Shortage:
12,819 additional physicians needed to meet national average: 226 physicians per 100,000
1:1.1 Ratio Requires 240 more Residencies (2018-2019) THECB
$180,000 x 30 = $5.5 M Lost
Tie Breakers

2A: Medicare - largest payer of GME -- pays something for all bona fide GME residents. True..or...False?

2B: Medicare pays about what % of GME costs for residents it pays for:
a) less than 25%
b) between 25- 50%
c) between 50 - 75%
d) over 75%
The Pipeline
Good job -- Medical School Capacity & Graduates
Challenge: Enough Residency Positions
Goal 1 Grad to 1.1 Residency positions
More Likely to Stay in TX
SB 18
First: What are the costs for GME?
And..... where are those costs?
THOT Break to Educate
Graduate Medical Education & Research
January 12, 2016
with Dr. Ben Raimer

Senior Vice President, Health Policy & Legislative Affairs, UTMB
&
Maureen Milligan - THOT

@TeachingHospTX

#THOTEducate


What is GME?
GME is...

Trivia #2

To practice in Texas, does an M.D. need to complete a residency? (Yes or no)

To be "Board Certified" does an M.D. need to complete a residency? (yes or no)

Texas Physician Shortage:
12,819 additional physicians needed to meet national average: 226 physicians per 100,000
1:1.1 Ratio Requires 240 more Residencies (2018-2019) THECB
The ^ Pipeline
We've done a good with job
Medical School Capacity & Graduates
#2: Challenge: Residency Positions
#3:Goal 1 Grad to 1.1 Residency positions
SB 18
Trivia # 1
THOT members
represent what percent of all hospital based
residency programs in Texas?
a) 0 - 25%
b) 25- 50%
c) 50 - 75%
d) 75 - 100%
Tie Breakers

2A: Medicare - largest payer of GME -- pays something for all bona fide GME residents. True..or...False?

2B: Medicare pays about what % of GME costs for residents it pays for:
a) less than 25%
b) between 25- 50%
c) between 50 - 75%
d) over 75%
Ensuring Adequate Workforce
Supporting
Patient Care
Research
Community Services
Creating Synergy....
Why is GME Important ??
What's the Big Deal?
Shortage
Trivia # 2

In just one year, over $34 Billion in hospital charges in Texas were related to which three top 10 chronic diseases?


Heart Disease, Cancer, Stroke
Harris conty public health and environmental services



for a start....
Enough Dedicated Faculty
Sufficient volume and diversity of patients and conditions
Appropriate Clinical Facilities
Maintenance of appropriate credentials
3) Partnership and Negotiation
between
medical schools and hospitals
Medical School Costs:
Faculty costs to teach
residents during GME
Estimated Costs: $18,000 per resident/year
Funding Source:
GME Formula Funding: about $6,266 per resident
per year in 2016/2017
Unfunded Cost: about $11,734 per resident per year
Hospital Costs:

Direct Costs
for Resident Salaries and Benefits +
Direct Costs
for Malpractice Insurance

Indirect Costs
Work Slow Down
Extra Services (labs, etc.)
Specialized services & treatment programs
$89,000 per resident/year average

Who Pays for Hospital Costs of GME?

Medicare Texas Hospital Average: $21,600 PRPY*
For about 17% of Texas residents,
Medicare Pays Zero
Unfunded Average
Direct
Costs:
$89,000 PRPY
And of course -- there's Patient Care
Trivia #3:
THOT members include how many children's hospitals??
THOT Members' Avg GME Medicare Payment per Resident is less than other hospitals
Avg. Unfunded Per Resident Direct Cost for Medicare-Covered Residents: $67,400 PRPY
Ethics
Scholarship & Lifelong learning
Communication Skills
Medical Practice issues
Personal & Professional Development
Clinical inpatient & ambulatory training
teamwork
AAMC 2015 State Physician Workforce Databook
(2014 Data)
Texas Population: 30,000,000
Total Active Physicians: 57,502
Primary Care Physicians: 19,234
Female Physicians: 18,674
Medical Students: 7,441
Total Residents: 7,835
Texas physicians/100,000 population and TX national rank
active patient care physicians: 191 Rank: 42
active patient care - primary care: 65 Rank: 47
active patient care - general Surgeons 5.6 Rank: 48

% of active patient care physicians >/= 60 yrs old 26.4% Rank: 42
% of physicians retained from UME: 59.7% Rank: 2
% of Physicians retained from GME: 58% Rank
% retained with both Texas UME & GME: 80.6% Rank: 3
Texas Retention
Related Trends
Increase Pressure*

But...Need more Residencies
#1: Med School
Grads
But...Why is there a shortage??
1) Funding
2) Qualified Programs & Sites
3) Partnerships
+
What you need
to provide GME includes:
For about 83% of Texas residents, Medicare pays on average less than 25% of direct GME costs.
What about Medicaid payments???
Medicaid pays a portion of Medicaid-related
indirect GME costs
(based on Medicare cost reports).

Medicaid no longer pays for GME
Direct
costs for Medicaid patients (except state hospitals).

Medicaid paid its share of
direct
GME costs until about 2001, but eliminated payments to address budget issues.



THOT estimates that if Medicaid were to pay for direct GME costs in 2017/2018 GR costs would be $150M but result in all funds GME payments of $346.2 M.
who ^ pays?

Hospitals --
counties,
Med School Faculty Practice Plans
Else
Trivia #1
THOT members
represent what percent of all hospital based
residents in Texas?
a) 0 - 25%
b) 25- 50%
c) 50 - 75%
d) 75 - 100%
Who are we again...?
But our hospitals AND health systems do more...
Like...Trauma care....
"Jorie Klein, director of
trauma and disaster preparedness at Parkland,
discusses her
experience in keeping North Texas ready for anything,
especially
during large events like the Super Bowl."

But THOT hospitals and health systems do more...
InterGovernmental Transfer IGT

How does all this get Paid for??
Medicaid Claims - 50% costs
Uninsured Care


Supplemental Payments
DSH (Disproportionate Share)
UC, DSRIP
Medicaid Shortfall
HSL, IGT
DSH CAP?
Haircuts?
THOT members: Significant Financing Partner
Unsustainable


Budget crisis....
hum....
Hospitals 40% of Medicaid acute care..we use GR for rates...let's cut payments some...
Rates less than costs??
Oh -- new supplemental programs can help us
If we use our County taxes to supplement GR for Medicaid rates

Today: supplemental funds provide more than half of Hospital Medicaid funding
IGT: Unsustainable
Uninsured
Uninsured
Medicaid
Back to ...You
Interim Work
HAC - Reimbursement, Trauma, Waiver, Historical Program Growth, Cost Trends
SHHS - Waiver, Medicaid Reform & State Innovation; Telemedicine
HPH - Trauma Systems & Financing; Telemedicine; Preparedness for public health threats
S Transportation: DRP & alternatives
H Higher Ed - Review 84th & SB 18 for GME funding



Who Cares About Hospitals...& Health Systems?
And....Patient Care

THOT:
5%
of Texas hospitals
23%
of all Medicaid Days

30%
of all Outpatient Visits***

36%
of all Unfunded Care
THOT Members provide a
DISPROPORTIONATE SHARE OF
Medicaid, Outpatient and Uninsured Care
And of course -- there's Patient Care
48%
of all reported Uncompensated Trauma Care

16%
of all Texas Hospital Patient Days
Trivia #3:
THOT members include how many children's hospitals??
Shared State Goals:
Quality healthcare
Trauma & disaster management
Healthcare Workforce - GME
quality healthcare

public health & disease prevention,
clinical research, development and improvements in care
healthcare infrastructure & innovation
economic and local development
sustainable healthcare financing
Medicaid Claims - 50% costs
Uninsured Care


Supplemental Payments
DSH (Disproportionate Share)
UC, DSRIP
Medicaid Shortfall
HSL, IGT
DSH CAP?
Haircuts?
THOT members: Significant Financing Partner
Unsustainable


Ebola: Parkland, UTSW, UTMB
“The goal of
these facilities is to
rival the most
advanced facilities
in the world.”
The mission of the
Galveston National Laboratory
is to assist the National Institute of Allergy and Infectious Diseases and the nation in the development of an improved means for the prevention, diagnosis and treatment of potentially life-threatening diseases caused by naturally emerging and purposefully disseminated infectious agents.
And...Public Health...
.............including
prevention
And lots of outpatient care
Within a Vertically-Integrated System of Care

Preventive
Primary
Specialty
Chronic Care
vertically integrated healthcare
Did we mention the nobel laureates?
THOT Members Serve as 11 of the 20 Waiver Anchors


Like...

Like....
Medical School
Graduates
Residencies
Practice?
Trivia # 2
THOT members
represent what percent of all hospital based
residency programs in Texas?
a) 0 - 25%
b) 25- 50%
c) 50 - 75%
d) 75 - 100%
Texas Physician Shortage:
12,819 additional physicians needed to meet national average: 226 physicians per 100,000
1:1.1 Ratio Requires 240 more Residencies (2018-2019) THECB
$180,000 x 30 = $5.5 M Lost
Tie Breakers

2A: Medicare - largest payer of GME -- pays something for all bona fide GME residents. True..or...False?

2B: Medicare pays about what % of GME costs for residents it pays for:
a) less than 25%
b) between 25- 50%
c) between 50 - 75%
d) over 75%
The Pipeline
Good job -- Medical School Capacity & Graduates
Challenge: Enough Residency Positions
Goal 1 Grad to 1.1 Residency positions
More Likely to Stay in TX
SB 18
Research & Innovation
WHY ?? Because THOT does more uninsured & Medicaid and less Medicare
Trivia #3
How much of the
Direct
costs of GME does Medicaid pay in Texas?
a) 0 - 25% of PRPY
b) 25- 50% of PRPY
c) 50 - 75% of PRPY
d) 75 - 100% of PRPY
Questions? Thoughts?
Discussion?

2) What else do you need for a GME Program?
wait a minute...!
What about all the $$
your residents earn
seeing patients???
Questions? Thoughts?
Discussion?
uh-oh: surgery

103 degree fever & rash? ED visit


what do hospitals have to do with me?

Someone in the family had a stroke?
Summary:
2.6% of visits: Inpatient
7.6% of visits: ED
89.8 % of visits: outpatient prevention, primary, specialty
Biocontainment
Public Health
Translational Science driving cures
GME!
Long
Source: TMA
Chronic Disease
Don't lose our investments!
Projected Shortage
Where are the Costs:
1) Medical School Faculty
2) Hospitals/clinical sites
"Formal Medical Eduction, Usually
Hospital-based,
after an MD degree, needed for state licensure & Board certification"
Clinical & Other experience, needed to be able to practice independently.

Texas Needs More Residencies to Keep our Grads here, Bring More Grads
to Texas, & have more docs, ya'll!
If you lose 30 Grads
-- you lose $5.5 M in
TX $ ($180,000 x 30) thecb
Who Pays for
GME
Hospital
Costs?
IOM Financing Graphic
does this help?
the largest payer for GME BUT
Which Means -- Texas gets Less Medicare GME $ than the Northeast

Mullan F, Chen C, Steinmet E, The Geography of Graduate Medical Education, Health Affairs 2013 Nov:32(11):1914-1921.
Medicare
Covered or capped positions Medicare will pay for are biased to the Northeast
And Per Resident and per population GME payments are biased to the Northeast.
GME "Profit Center?"
Each Residency Program Different
Jointly managed and financed by local medical schools and affiliated teaching hospitals
Programs consider community needs (physicians needed), clinical capacity, and mission values
When no Medicare funds are available--
requires more difficult service offset and payment decisions
Negotiate:
greatest areas of need
what residency areas to create and commit to (over the term of the residencies: this is a marriage--not dating)
How to fund residencies
SB 18: landmark GME legislatation
to increase Residencies in Texas
Planning and Partnership: $3.5M in 16/17
Unfilled Position Grants: $9.75 M in 16/17
New and Expanded 1st Year Residency Positions @ $75,000 PRPY: $39.75M
A Great Investment -- And
We'll need continued increases, in particular to support Existing Residencies positions with
direct
losses ranging from $67,000 - $89,000 PRPY
Sustainability of Existing Programs & Capacity for New Positions
Clincal Data, sociodemographic data, doctor's notes-- Predictive Modeling and Effective Interventions Improve care

THOT: 10 of 17 Level 1 Trauma Centers in Texas
Look at Your Match Results and See Your Future!
Match Day!!!
See Handout!!
Avg. Unfunded Per Resident Direct Cost for THOT's Medicare Covered Residents: $77,000
Breakthrough Achievements in
the Life Sciences
"The body of science is assembled over centuries. Yet a single mind can extend it immensely."
Breakthrough: Immunotherapy for Cancer
New non-surgical intervention to treat lung disease
Three Legged Stool
Patient Care
Research

Education

Delivery System Innovation
Translational
Science
Direct Patient Care
Why
do we do it?

Mission
Trivia

#1: THOT members respresent what percent of all hospital based residents in Texas?
63% so: c) 50 - 75% is the correct answer.

#2: To practice in Texas, does an MD need to complete a residency?
NO

To be "Board Certified" does an MD need to complete a residency?

Yes

#3 How much of the Direct Costs of GME does Medicaid pay in Texas?
Zero. The correct answer is a) 0 - 25%

#4 For a Medicare covered residency, Medicare payments are what percent of direct residency costs?
Less than 25%. The correct answer is a) 0 - 25%.

#5: Texas, like other states, is facing a shortage in primary care physicians only. Luckily we have all the specialists we need.
FALSE

#6 What do Conan O'Brien, Christina Aquilera, Russell Crowe and Mark Zuckerberg have in common with Drs. Helen Hobbs (UTSW) and Jim Allison (MD Anderson)??
A: they are all involved in the Breakthrough prize.


Trivia # 4
For a Medicare-covered residency, Medicare payments are what Percent of Direct Residency Costs?

a) 0 - 25%
b) 25 - 50%
c) 50 - 75%
d) 75 - 100%
Trivia

#1: How many THOT Level 1 Trauma Centers in Texas?
10
How many Level 1 Centers in all of Texas?
17

#2: What percentage of all Texas Hospital Based Residencies are at THOT facilities?
C: 50 - 75%
It's actually
63%

Tiebreakers --
2A: Does Medicare pay something for all bona fide GME residents?
FALSE
-- No way (pay something for about
83%
of Texas residents)

2B: What % of costs on average of covered resident costs does Medicare pay for?
A: less than 25%
Only
19%


# 3 How many Children's Hospitals are THOT Members??
2
(Dell Children's and Children's Health System)

#4 On average how much funding goes to Alzheimer's research?
$480 million/year.
THOT Members
See Handout!
Trivia #5
Texas, like other states, is facing a shortage in primary care physicians only. Luckily -- we have all the specialists we need.
True or False??
THOT Members have provided care to patients from all 254 Texas counties




Medicaid Financing & Other Key Hospital
Financing Pressures,

Wednesday,
March 9, 2016.
With Dr. Fred Cerise -- Parkland CEO
Introduction -- 12:30
Advanced -- 3:00



Quality and Quality Measures,

Thursday, April 7, 2016 11:30


Trauma Systems and Trauma Funding,
Tuesday, May 3, 2016 11:30

Save these dates for our
remaining sessions!
Full transcript