1. Outsourcing Medical Education from Nevada: Costs and Consequences John Hudak, Ph.D. Fellow, Center for Effective Public Management The Brookings Institution 29 September 2014 jhudak@brookings.edu @JohnJHudak

2. Requirements Outsourcing A product of value A geographic transfer – Location of origination – Destination A cost to location of origination/benefit for destination

3. Outsourcing & Medical Education Every state has healthcare needs Every state has medical training opportunities Every state has addition training capacity Supply & demand of medical professionals – Surplus of medical professionals – Shortage of medical professions Results: importing or exporting of medical professionals

4. Outline Part I. A Geographic Basis for a New Medical School Part II. A Healthcare Basis for a New Medical School Part III. A Funding Basis for a New Medical School Part IV. Conclusions

5. A Geographic Basis for a New Medical School

12. Allopathic Medical Schools Founded 2000-2013 Medical School Year of Founding Central Michigan University College of Medicine2013 Western Michigan University Homer Stryker School of Medicine2012 Oakland University William Beaumont School of Medicine (MI)2011 Frank Netter School of Medicine at Quinnipiac University (CT)2010 Florida Atlantic University Charles Schmidt College of Medicine2010 Hostra University North Shore-LIJ School of Medicine (NY)2010 Virginia Tech Carilion School of Medicine2010 The Commonwealth Medical College (PA)2008 University of California-Riverside School of Medicine2008 Texas Tech Univ. Health Sciences Center Paul Foster School of Medicine2008 Florida International University Herbert Wertheim College of Medicine2006 University of Central Florida College of Medicine2006 Cleveland Clinic Lerner College of Medicine2002 Florida State University College of Medicine2000

13. A Geographic Basis for a New Medical School Distance between New & Existing Medical Schools New Medical School Year of Founding Nearest Existing Medical SchoolDistance Central Michigan University College of Medicine2013Michigan State University68 Western Michigan University Homer Stryker School of Medicine2012Michigan State University51 Oakland University William Beaumont School of Medicine2011Wayne State University27 Frank Netter School of Medicine at Quinnipiac University (CT)2010Yale University9 Florida Atlantic University Charles Schmidt College of Medicine2010University of Miami43 Hostra University North Shore-LIJ School of Medicine2010SUNY-Downstate (Brooklyn)20 Virginia Tech Carilion School of Medicine2010University of Virginia121 The Commonwealth Medical College (PA)2008Penn State113 Univ. of California-Riverside School of Medicine2008Loma Linda University12 Texas Tech University Health Sciences Center Paul Foster School of Medicine2008 Univ. New Mexico/ TX Tech (Lubbock) 272/ 344 Florida International Univ.Herbert Wertheim College of Medicine2006University of Miami12 University of Central Florida College of Medicine2006University of South Florida85 Cleveland Clinic Lerner College of Medicine2002Case Western Reserve Univ.-- Florida State University College of Medicine2000University of Florida149

14. A Healthcare Basis for a New Medical School A shortage of medical professionals in Nevada Family Practice Doctors 47 th out of 51 (states + DC) Pediatricians46 th out of 51 Orthopedic Surgeons51 st out of 51 Ophthalmologists48 th out of 51 Psychiatrists50 th out of 51 OB/GYNs40 th out of 51 RNs50 th out of 51 **Research conducted by University of Nevada School of Medicine, rankings based on measure of medical professionals per 100,000 residents.

15. A Healthcare Basis for a New Medical School A Shortage of Medical Training in Nevada Fewest MD students per 100,000 residents* (Nevada: 9.5 / 100,000; National Average: 25.8 / 100,000) Medical residents/fellows per 100,000 residents, Nevada is 46 th. (Nevada: 8.1 / 100,000; National Average: 25.4 / 100,000) Medical residents/fellows per 100,000 residents in primary care roles, Nevada is 47 th. (Nevada 5 / 100,000; National Average: 12.2 / 100,000) *Ranking based on states with existing allopathic medical schools Note: All data drawn from 2013 State Physician Workforce Data Book from the Association of American Medical Colleges (AAMC)

16. A Healthcare Basis for a New Medical School An Opportunity for Nevada Medical Training Silver State Loyalty in Medical Training 69.2% of Nevada residents in MD programs matriculate in state Among people who attend medical school & perform residency in NV, 79% stay to practice in state. – 5 th Nationally – National mean: 66.6%

17. A Funding Basis for a New Medical School

20. GME Funding to the States – Medicare & Medicaid Programs – Assistance for Residencies and Fellowships – Largest Funding Source in US – Funding Levels Set by Congress – Bipartisan Reform Bills Tuition Dollars (Federal Subsidy) Program Plans (Private Sources) Philanthropy (Private Sources)

21. A Funding Basis for a New Medical School GME funding per capita, 2005-2009 YearNational AverageNevadaNevada's Rank (out of 46)* 2005$16.06$4.0346 2006$16.05$4.6546 2007$16.43$5.7746 2008$17.02$6.96 45 (MS) 2009$17.94$8.55 44 (NM, MS) *Includes the 45 states with allopathic medical schools + DC Note: Data drawn from the Robert Graham Center [Graham Center Data][Graham Center Data]

22. A Funding Basis for a New Medical School Results of multivariate analysis of GME funding among all states Among all states, every additional medical school graduate = +$527,000 in additional GME funds Among all states, adding a medical school = $41.4 million in additional GME funds Among all states, data suggests** the addition of a public OR private medical school is associated with a substantial increase in GME funds **those results do not achieve statistical significance

23. A Funding Basis for a New Medical School Results of multivariate analysis of GME funding among states with 3 or fewer medical schools Every additional medical school graduate is associated with an increase in additional GME funding, though results do not achieve statistical significance Every additional medical school = $26.1 million in additional GME funding Every additional public medical school = $19.8 million in additional GME funding Every additional private medical school is associated with an increase in additional GME funding, though results do not achieve statistical significance

24. A Funding Basis for a New Medical School

25. Since 2010, NIH funds to new medical schools, excluding Cleveland Clinic/Lerner School exceeds $57 million In 2013: FAU (2010): $2.25 millionFIU (2006): $3.01 million FSU (2000): $2.17 millionCMU (2013): $337,431 UCR (2008): $4.40 millionUCF (2006): $5.65 million Cleveland Clinic/Lerner School (2002): $82.19 million

26. A Funding Basis for a New Medical School

28. Additional Types of Funding – HRSA HRSA Funding per Capita, Mountain West Region StateGrant Dollars per Capita Montana$139.12 New Mexico$106.93 Idaho$79.55 Wyoming$54.68 Utah$50.67 Arizona$45.09 Nevada$24.69 Note: Includes all active grants in FY2014. Data drawn from NHRSA website.

29. CONCLUSIONS Las Vegas among the most isolated cities in the US for medical training Population, healthcare needs, geography, funding levels all suggest a need for an allopathic medical school Training doctors in Las Vegas may limit medical brain drain

30. CONCLUSIONS ACA will increase healthcare demand in Southern NV, an area already facing shortages A new medical school can create tremendous federal, private market, and private charity opportunities for Las Vegas region A new medical school likely increases research-related private market activity and FTEs

31. CONCLUSIONS Federal healthcare funding to Nevada is among the worst in the nation, fitting a trend in federal funding to the state Expanded medical training will increase opportunities for research funding Reform proposals for Medicare GME funding will help states like Nevada (growing population, political clout)

32. THANK YOU