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 Carewithin 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 - 1879 4 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 - 1990 – also kept the NCMH

NC Memorial Hospital separated organizationally from the administration of UNC-Chapel Hill - 1971

Board of Directors established UNC Health Care System - 1998

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 ProgramsSource: NC AHEC Program

MountainGreensboroCoastalNorthwestSouthern Regional

Area LCharlotteWakeEastern

Locations of Continuing Education Programs, 2001-2002

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 University 510,005,3262 University of Pennsylvania 418,546,5103 University of Washington 405,729,0424 UC-San Francisco 365,365,9095 Washington University 343,792,0776 University of Michigan 325,786,2067 UC-Los Angeles 317,017,1818 University of Pittsburgh 308,144,8629 Yale University 289,899,94410 Duke University 277,393,16611 Harvard University 273,147,79912 Columbia University 269,844,58513 UNC-Chapel Hill 264,263,42514 Baylor College of Medicine 263,540,46015 Stanford University 247,636,170

NIH Support to U.S. Institutionsof 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 HospitalsFY 2003 Inpatient Discharges by N.C. County

Total Discharges: 29,098

Yancey

Caswell PersonGranville

VanceWarren

Franklin

Northampton

Halifax

Alamance Durham

WakeChatham

NashEdgecombe

Wilson

Johnston

Wayne

Lee

MooreHarnett

SampsonDuplin

Pender

Brunswick

Columbus

BladenRobeson

CumberlandHoke

Scotland

Guilford

Randolph

Montgomery

Richmond

Stokes

Forsyth

Davidson

Rowan

Stanly

AnsonUnion

Mecklenburg

Cabarrus

Iredell

Davie

Yadkin

SurryAlleghany

Ashe

Wilkes

Alexander

Catawba

Lincoln

GastonCleveland

Burke

Caldwell

Watauga

Avery

McDowell

Rutherford

Polk

Mitchell

Buncombe

Henderson

Transylvania

Haywood

Madison

Swain

Jackson

Macon

Graham

ClayCherokee

Onslow

Jones

Lenoir

Greene

Pitt

Martin

Bertie

Hertford

Gates Camden

Pasquotank

DareTyrrellWashington

BeaufortHyde

Craven

Pamlico

Rockingham

Currituck

Perquimans

Chowan

Carteret

Orange

New Hanover

UNC Hospitals

1-9 cases

10-99 cases

100-249 cases

250-999 cases

1000+ cases

LEGEND

Source: UNC Hospitals/HBO Trendstar Database

F:\planning\rr\unch ip origin fy 03_2.ppt

Caswell

Person

Gra

nville

Vance

Warren

Franklin

Northampton

Halifax A

lam

an

ce

Durham

Wake Chatham

Nash

Edgecombe

Wilson

Johnston

Wayne

Lee

Moore

Harnett

Sampson Duplin

Pender

Brunswick

Columbus

Bladen

Robeson

Cumberland Hoke

Scotland

Guilford

Randolph

Montgom

ery

Ric

hm

on

d

Stokes

Forsyth

Davidson

Rowan

Stanly

Anson

Union

Meckle

nb

urg

Cabarrus

Iredell

Davie

Yadkin

Surry

Alleghany

Ashe

Wilkes

Alexander

Catawba Lincoln

Gaston

Cleveland

Burke

Caldwell

Watauga

Avery

McDowell

Rutherford Polk

Mitch

ell

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

PerquimansChowan

Caswell PersonGranville

VanceWarren

Franklin

Northampton

Halifax

AlamanceDurham

Wake

Chatham

Nash

Edgecombe

Wilson

Johnston

WayneLee

Moore Harnett

Sampson

Duplin

Pender

Brunswick

Columbus

BladenRobeson

CumberlandHoke

Scotland

Guilford

Randolph

Montgomery

Richmond

Stokes

Forsyth

Davidson

Rowan

Stanly

AnsonUnion

Mecklenburg

Cabarrus

Iredell

Davie

Yadkin

Surry

AlleghanyAshe

Wilkes

Alexander

Catawba

Lincoln

GastonCleveland

Burke

Caldwell

Watauga

Avery

McDowell

Rutherford

Polk

MitchellYancey

Buncombe

Henderson

Transylvania

Haywood

Madison

Swain

Jackson

Macon

Graham

ClayCherokee

Onslow

Jones

Lenoir

Greene

Pitt

Martin

Bertie

Hertford

Gates Camden

Pasquotank

DareTyrrell

Washington

Beaufort

Hyde

Craven

Pamlico

RockinghamCurrituck

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 countSource: 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%

76-100%

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 BeyondHealth 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 UNCHCSFacility Master Plan

CancerCenter

HeartCenter

MusculoskeletalCenter 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 2003

653,473 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 MedicineDistinguishing 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 HospitalsPositioned 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…….