The Future of Pediatrics in Oregon –
the Role of the Pediatric Academic
Health Center (AHC)
H. Stacy Nicholson, MD, MPH
Chair, Department of Pediatrics
Physician-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. Now
•
•
•
•
•
1970s – 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
OHSU State Funding: 1991 - 2011
$209,531
200,000
Represents the value of 91-93
State Appropriation stated in
current dollars
150,000
$132,519
$123,553
$107,600
$107,897
$111,897
$95,978
100,000
$85,779
$82,234
$73,337
$73,311
50,000
-
91-93
93-95
95-97
97-99
99-01
01-03
State Appropriation (in Thousands)
03-05
05-07
07-09
09-11
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
– 2000
– 2005
14.1%
12.6%
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
Department of Pediatrics: ‘07 Strategic Plan
VISION:
Patient Care:
We will be the pediatric and adolescent
healthcare provider of choice for our
region.
Education:
MISSION:
To enhance the health and
well-being of children and
adolescents by ensuring
excellence in patient care,
education, research, and
advocacy.
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.
GOALS:
1) Build a sustainable educational
environment that attracts top
candidates, cultivates knowledge,
and achieves superior outcomes.
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.
4) Develop, recruit, and retain the
best faculty and staff.
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.
VALUES:
Respect & Integrity
Compassion
Innovation &
Discovery
Patient & Family
Centered
Accountability &
Transparency
Collaboration
OHSU/DCH Pediatric Residency
Nationally Competitive
>13
2011 season
as of Oct 13, 2010
New interns
for July 2011
180
Number of interviews
scheduled at OHSU
631
Number of US graduate
applications to OHSU Pediatric
residency
~2000
US 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%
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)
ABP Pediatric Training Program Pass Rates
Changing Career Choices by Grads
OHSU/DCH Pediatric Residency
Nationally Competitive
??
2011 season
as of Oct 13, 2010
New interns
for July 2011
180
Number of interviews
scheduled at OHSU
631
Number of US graduate
applications to OHSU Pediatric
residency
~2000
US applicants to pediatrics
Department of Pediatrics
Research Awards & Indirect Costs: Past 7 Years
Dept of Pediatrics - Overall Research Productivity Awards Received vs Budgeted IDC
18,000,000
3,500,000
16,000,000
3,000,000
14,000,000
10,000,000
2,000,000
8,000,000
1,500,000
6,000,000
1,000,000
4,000,000
500,000
2,000,000
0
0
FY04
FY05
FY06
FY07
FY08
FY09
FY10*
Total Awards - Direct + IDC
Budgeted IDC
*NOTE: FY10 Data is Estimated thru the end of the Fiscal Year
IDC ($)
Awards Received ($)
2,500,000
12,000,000
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 peds
Adol, Develop, Endo above
national avg
Impact of Recent Depression
on OR Families & Children
Persistent High Unemployment
July, 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%
Lower Birth Rates
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
OVERALL RANKINGS OVER TIME
0
5
10
Oregon
Washington
15
20
25
Source: 2010 Annie E. Casey Foundation Kids Count Data Book
OR CHILD HEALTH – ROADMAP TO TOP 10
Item
Current Rank
(2010)
Current Rate /
Percentage
Improvement
Needed
Infant 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
High Gains
Low Gains
Age
Low Gains
JJ Heckman, 2000
0
JJ Heckman, 2000
Age
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 nonMDs
– 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, MPH
Chair, Department of Pediatrics
Physician-in-Chief, Doernbecher
Children’s Hospital
10/16/2010