The Future of Pediatrics in Oregon – the Role of the Pediatric Academic Health Center (AHC)

1. 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

2. Disclosure • No ties to Industry • 5K12 HD 057588 (Child Health Research Center) PI: Nicholson

3. Pediatric Chair’s View of Reality Chevalier, J Pediatr 151:557-558, 2007

4. Faculty Member’s View Chevalier, J Pediatr 151:557-558, 2007

5. 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

6. OHSU State Funding: 1991 - 2011

7. 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)

8. 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

9. Decreased Funding for Ped Research • Pediatric Research funded by NIH • 1994 14.1% • 2000 12.6% • 2005 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

10. 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

11. Focusing on DCH and the Department of Pediatrics OHSU – your Academic health center

12. Department of Pediatrics: ‘07 Strategic Plan To enhance the health and well-being of children and adolescents by ensuring excellence in patient care, education, research, and advocacy. GOALS: VISION: Patient Care: We will be the pediatric and adolescent healthcare provider of choice for our region. 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. Education: We will be a leader for excellence in education, the cornerstone of our patient care, research, and advocacy efforts. MISSION: 3) Enhance healthcare access and improve service to patients and referring providers. Research: We will be a leading center for child health research, encompassing basic, clinical, translational, and health services research programs. 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. Advocacy: We will be a strong voice for the health and welfare of children. 7) Reduce health care inequities among children and adolescents in our region. VALUES: Accountability & Transparency Patient & Family Centered Collaboration Innovation & Discovery Compassion Respect & Integrity

13. OHSU/DCH Pediatric ResidencyNationally Competitive 2011 season as of Oct 13, 2010

14. 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%

15. 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

16. Changing Career Choices by Grads

17. OHSU/DCH Pediatric ResidencyNationally Competitive 2011 season as of Oct 13, 2010

18. Department of Pediatrics Research Awards & Indirect Costs: Past 7 Years

19. OREGON – a few remarks about child health

21. 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.

22. 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

23. Impact of Recent Depression on OR Families & Children Persistent High Unemployment Lower Birth Rates

24. OVERALL RANKINGS OVER TIME Source: 2010 Annie E. Casey Foundation Kids Count Data Book

25. OR CHILD HEALTH – ROADMAP TO TOP 10

26. Rate of Return to Investment in Human Capital High Gains High Gains Low Gains Age Low Gains JJ Heckman, 2000 0 Age JJ Heckman, 2000

27. Health care reform

28. Real Health Care Reform • Providers work at the top of their license / training • Primary care / prevention work will be increasingly done by non-MDs • 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

29. 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

30. 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