UNC Hospitals The University in American Life: The University of North Carolina at Chapel Hill October 13, 2003

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 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. Consider the evolution of UNC Hospitals and the UNC Health Sciences Center in that context. 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.

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 “Hill Burton” funded hospitals developing - 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

The University in American Life: 1960’s & 1970’s Increased development of health insurance and increased availability to the public 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 Increased access to outpatient services and new markets for hospitals Continuing health manpower shortages Significant growth in NIH research funding

The University’s Response: Focus on Mission UNC Hospitals is a public academic teaching hospital operated by and for the people of North Carolina. Our Mission is to: – Provide high quality patient care – Educate health care professionals – Advance health and biomedical research – Provide community service

Unique Qualities of UNC Health Science Center for North Carolinians UNC at Chapel Hill 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 in American Life: 1980’s Increasing scrutiny of the cost of health services New reimbursement 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. 5,391 medical degrees awarded over the years Allied Health Sciences Enrollment in 2001 of 354 students (laboratory science, occupational therapy, physical therapy, radiologic science, speech and hearing, etc.) Major growth in research faculty and facilities to support their efforts

1 Johns Hopkins University510,005,326 2 University of Pennsylvania418,546,510 3 University of Washington405,729,042 4 UC-San Francisco365,365,909 5 Washington University343,792,077 6 University of Michigan325,786,206 7 UC-Los Angeles317,017,181 8 University of Pittsburgh308,144,862 9 Yale University289,899, Duke University277,393, Harvard University273,147, Columbia University269,844, UNC-Chapel Hill264,263, Baylor College of Medicine263,540, Stanford University247,636,170 NIH Support to U.S. Institutions of Higher Education Fiscal Year 2002 (Go HEELS!!!)

The University in American Life: 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 Questions about limits to health services – rationing care Increasing consumerism - with attendant demands and expectations (patient’s rights) Continued growth in challenging biomedical research Recognition of the special roll of Academic Health Centers and their societal contributions – Managed care entities wanted to use our “products”, but didn’t want to pay for them

What is UNC Hospitals Today? A facility providing outpatient, inpatient, urgent, and emergent care A comprehensive health center, providing services from wellness and preventive programs to organ transplants A “system” including 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 locus for clinical research A public facility, with societal obligations

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 – Some with early challenges

University of North Carolina Hospitals FY 2003 Inpatient Discharges by N.C. County Total Discharges: 29,098 Yancey 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 Alleghany Ashe Wilkes Alexander 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 UNC Hospitals 1-9 cases cases cases cases cases LEGEND Source: UNC Hospitals/HBOTrendstarDatabase F:\planning\rr\unch iporiginfy03_2.ppt

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 University of North Carolina Hospitals - Distribution of Non-Reimbursed care (by County of Residence – North Carolina) FY 2003 Source: Actual 2003 charity and bad debts by residence of patient schedule - UNCH finance Legend for Map < $500,000 $500,000-$1M $1M - $3M > $3M Currituck Pasquotank Perquimans Chowan

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 Mitchell Yancey Buncombe Henderson Transylvania Haywood Madison Swain Jackson Macon Graham Clay Cherokee Onslow Jones Lenoir Greene Pitt Martin Bertie Hertford Gates Camden Pasquotank Dare Tyrrell Washington Beaufort Hyde Craven Pamlico Rockingham Currituck Perquimans Chowan Carteret Orange New Hanover UNC’s Clinical Support for Educational Programs 23% of active North Carolina Physicians Trained at UNC Hospitals or UNC Total Active Non-Federal Physicians =13,782 UNC / UNCH trained physicians* =3,164 Total % of UNC Physicians in North Carolina =23% * Combines UNC graduates and UNCH residents in an unduplicated count Source: Alumni Affairs Data, 2/14/96 and NC Health Professions Data System: 1996 Physicians, Sheps Center. UNC/UNCH trained 50% of the MDs in the 10 counties with the fewest MDs Active Physicians Trained by UNC/UNCH Percentage by County 0% 1-15% 16-30% 31-45% 46-60% 61-75% % Legend for Map

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 President of University of North Carolina System – 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 University in American Life: Year 2000 and Beyond Health Care’s Challenging Environment Increasing demand for services versus declining reimbursement 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 And on the UNC campus …Parking, Parking, Parking

NC Children’s and Women’s Hospitals

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

UNC Hospitals and UNCHCS Facility Master Plan Cancer Center Heart Center Musculoskeletal Center and Ambulatory Care

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.

ROLE of one PHYSICIAN in Academic Health Care Center When you’ve seen one MD at an AMC, you’ve seen one MD at an AMC

Context UNC BS in Zoology 1977 Didn’t get into MD first time applied UNC MD 1982 UNC Ob Gyn Residency 1986 UNC Maternal Fetal Medicine Fellowship 1988

Assistant Professor 1988 Associate Professor 1994 Professor 2001

Four Legged Stool of Academic Medical Center MD Clinical Research Teaching Administration

CLINICAL Private High Risk Obstetrics Practice – 2 ½ days per week Consultative Ultrasound Practice – 2 ½ days per week High Risk Obstetrics Practice – 1 ½ day per week In House Night Call – 3 nights per month Phone Night Call – 3 nights per month

Research 40% TIME AT THE NIH IN WASHINGTON COLLABORATOR ON MANY PROJECTS LOCALLY EASIEST TO QUANTIFY IN PROMOTION AND TENURE DECISIONS

TEACHING TEACHING PORTFOLIO AT RISK WITH CURRENT CLIMATE VARIOUS DEFINITIONS – CLASS ROOM TEACHING – WARD TEACHING – CLINIC TEACHING – MENTORING – LABORATORY STUDIES – RESEARCH MENTORS – ADVISING

ADMINISTRATION No longer included in Promotion and Tenure decisions – Committee work – Medical director ambulatory clinics Ob Gyn: > 50% of revenues – Program director fetal therapy program

An AMC on a University Campus? Major advantage to recruiting new dean/CEO/ Vice Chancellor for Health Affairs for the University Joint departments that interrelate – Genetics – Biology – Pharmacy – Nursing – Public Health Orange Cardiovascular Foundation

Important issues facing AMC’s Changing demographics – Cultural competency – Geriatrics No money, no mission – “Provide health care for the people of NC”

The School of Medicine of UNC at Chapel Hill is dedicated to: Improving the health and life quality of North Carolinians by: 1. Educating medical students, residents, practicing physicians, and pre- and post- doctoral basic and allied health science students. 2. Providing care to all patient presenting o UNC Health Care System regardless of their ability to pay.

3. Conducting scholarly investigation in biomedical, behavioral, and social sciences 4. Stimulating economic development in the state through bio-technical innovation 5. Providing leadership in all of these areas Priority project focus on prevention, detection and treatment of prevalent illnesses and disabilities of the states’ citizens.,….

Key Statistics - Fiscal Year ,473 Outpatient Physician Visits – Includes 162,711 in off-campus sites 42,243 ER Visits 977,414 Total Outpatient Visits Hospital-Wide 29,129 Admissions 190,596 Inpatient Days of Care Average Length of Stay – 6.6 Days 4,826 Newborn Days of Care 216 Transplants (heart, lung, kidney, bone marrow, liver, pancreas) 925 Air Transports 3,100 Deliveries 25,902 Home Health Visits 3,896,610 Laboratory Tests Provided

UNC-CH School of Medicine Distinguishing Feature: Bimodal Medical Schools Ranked in top 20% by AAMC in production of primary care physicians and in receiving research grants from NIH. UNC-Chapel Hill UC-San Diego UC-San Francisco U. of Washington

UNC Hospitals Positioned to Face the Challenges New facilities developed and in planning Strong support for health science education Flexibility in response to human resource issues ? Parking, parking, parking…….