The University in American Life: The University of North Carolina Health Care System

1. The University in American Life:The Universityof North CarolinaHealth Care System October 31, 2005

2. The UNC Academic Health Center Today An integral part of the University of North Carolina at Chapel Hill

3. Does a University needa Teaching Hospital? If yes, then why?

4. The Context of Health Carewithin the University • The health care system, like the University, 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. • 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. • We will consider the evolution of UNC Hospitals and the UNC Health Sciences Center in that context.

5. 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 programs • “Hill Burton” funded hospitals developed with a community service obligation

6. 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 Formed - 1998

7. The University in American Life:1960’s & 1970’s • 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 • Improved access to outpatient services and new markets for hospitals • Continuing health manpower shortages • Significant growth in NIH research funding

8. The UNCHCS Response:Focus on Mission • The Mission of the UNC Health Care System is to: • Provide high quality patient care • Educate health care professionals • Advance health and biomedical research • Serve the community

9. Unique Qualities of UNC Academic Health Center for North Carolinians • UNC 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

10. AHEC* Primary Care Training Sites for Medical Students, Physician Assistants, and Nurse Practitioners Medical Student Physician Assistant Nurse Practitioner * AHEC = Area Health Education Centers

11. Mountain Greensboro Coastal Northwest Southern Regional Area L Charlotte Wake Eastern North Carolina Area Health Education Centers (AHEC) Program Locations of Continuing Education Programs, 2004-2005 AHEC Continuing Education Programs Source: NC AHEC Program

12. The University Academic Health Center Environment: 1980’s • Increasing scrutiny of the cost of health services • New payment 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

13. The University’s Response:School of Medicine • Between 1970 and 1980 the number of medical students grew from 340 to its current size of 640students and faculty grew accordingly • 5,983 medical degrees awarded since the first class in 1954 • Allied Health Sciences Enrollment in 2005 of 369 students (laboratory science, occupational therapy, physical therapy, radiologic science, speech and hearing, etc.) • Major growth in research faculty and facilities to support their efforts that continues today.

14. NIH Support to U.S. Institutionsof Higher Education Fiscal Year 2004 1 Johns Hopkins University 599,151,309 2 University of Washington 473,432,138 3 University of Pennsylvania 464,076,925 4 UC-San Francisco 438,778,831 5 Washington University 388,307,875 6 University of Michigan 368,176,446 7 UC-Los Angeles 361,593,433 8 University of Pittsburgh 360,635,035 9 Duke University 343,825,304 10 Harvard University 325,665,202 11 Yale University 323,614,091 12 UC-San Diego 304,039,410 13 Columbia University 303,714,701 14 Stanford University 301,733,744 15 UNC-Chapel Hill 289,652,932 16 University of Wisconsin 264,059,408 17 Vanderbilt 251,147,207

15. The Academic Health Center Environment: 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 • Increasing consumerism - with attendant demands and expectations (patient’s rights) • Continued growth in challenging biomedical research • Recognition of the special role of Academic Health Centers and their societal contributions • Managed care entities wanted to use our “products”, but didn’t want to pay for them

16. The UNC Health Care SystemToday

17. Profile • A system providing outpatient, inpatient, urgent, and emergent care • A comprehensive health center, providing services from wellness and preventive programs to organ transplants • Includes 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 place for clinical research • A public facility, with societal obligations

18. The UNCHCS Vision To be the nation’s leading public academic health care system Leading. Teaching. Caring.

19. 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

20. University of North Carolina Hospitals FY 2005 Inpatient Origin by N.C. County Total Discharges: 31, 334 Alleghany Northampton Gates Currituck Surry Granville Camden Ashe Warren Caswell Person Stokes Rockingham Hertford Pasquotank Vance Halifax Perquimans Watauga Wilkes Yadkin Avery Forsyth Franklin Chowan Orange Bertie Mitchell Guilford Nash Caldwell Alamance Durham Yancey Alexander Davie Edgecombe Martin Washington Tyrrell Dare Madison Davidson Wake Iredell Burke Chatham Wilson Randolph Catawba McDowell Rowan Pitt Buncombe Beaufort Haywood Hyde Johnston Swain Lincoln Lee Greene Graham Rutherford Jackson Henderson Cabarrus Montgomery Harnett Wayne Cleveland Polk Stanly Moore Gaston Lenoir Craven Macon Transylvania Cherokee Mecklenburg Clay Pamlico Cumberland Jones Union Richmond Hoke Sampson Anson Duplin Onslow Carteret Scotland Robeson Bladen Pender Columbus LEGEND New Hanover 10-99 cases Brunswick 1-9 cases 100-249 cases 250-999 cases UNC Hospitals 1000+ cases

21. Camden University of North Carolina Hospitals - Distribution of Non-Reimbursed Care (by County of Residence – North Carolina)FY 2005 Alleghany Northampton Gates Currituck Warren Ashe Rockingham Caswell Surry Person Stokes Hertford Granville Vance Pasquotank Halifax Watauga Wilkes Yadkin Perquimans Avery Forsyth Orange Bertie Chowan Franklin Alamance Guilford Mitchell Nash Durham Caldwell Yancey Alexander Edgecombe Davie Martin Washington Tyrrell Dare Madison Wake Iredell Davidson Burke Randolph Chatham Wilson Catawba McDowell Pitt Rowan Buncombe Beaufort Haywood Hyde Johnston Swain Lincoln Lee Greene Graham Rutherford Cabarrus Henderson Harnett Wayne Jackson Montgomery Cleveland Polk Stanly Moore Craven Mecklenburg Gaston Lenoir Transylvania Macon Cherokee Pamlico Clay Sampson Cumberland Jones Duplin Richmond Hoke Anson Union Onslow Scotland Carteret Robeson Bladen Pender Columbus Legend for Map New Hanover < $500,000 Brunswick $500,000-$1M $1M - $3M > $3M Source: Actual 2005 charity and bad debts by residence of patients treated – UNCH’ Fiscal Services

22. Key Statistics - Fiscal Year 2005 • 31,322 Admissions • 202,048 Inpatient Days of Care • Average Length of Stay – 6.4 Days • 680,689 Outpatient Physician Visits • Includes 198,091 in off-campus sites • 65,894 ER, Urgent Care and Peds ER Visits • 253 Transplants (heart, lung, kidney, bone marrow, liver, pancreas) • 1117 Air Transports • 3,574 Babies Delivered

23. Total Active Non-Federal Physicians = 17,349 UNC / UNCH trained physicians* = 3,794 Total % of UNC Physicians in North Carolina = 22% *Combines UNC graduates and UNCH residents in an unduplicated count. 22% of active North Carolina Physicians Trained at UNC Hospitals or UNC UNC’s Clinical Support for Educational Programs Percent of Active Physicians Trained by UNC/UNC-CH North Carolina, 2004 Alleghany Camden Gates Currituck Ashe Surry Rockingham Northampton Person Warren Caswell Stokes Vance Pasquotank Granville Hertford Watauga Pasquotank Halifax Wilkes Chowan Yadkin Forsyth Avery Bertie Durham Guilford Franklin Orange Mitchell Alamance Caldwell Nash Yancey Davie Alexander Madison Edgecombe Iredell Washington Martin Tyrrell Dare Davidson Wake Burke Randolph Chatham McDowell Wilson Catawba Buncombe Rowan Pitt Haywood Swain Johnston Hyde Lincoln Beaufort Greene Rutherford Lee Cabarrus Graham Henderson Harnett Jackson Montgomery Gaston Moore Polk Stanly Mecklenburg Wayne Lenoir Transylvania Cleveland Craven Cherokee Macon Pamlico Clay Sampson Jones Cumberland Hoke Richmond Union Anson Duplin Scotland Carteret Onslow Robeson Bladen Pender Percent of Physicians Who Trained at UNC-CH Columbus (# of Counties) New Hanover Brunswick All Physicians Trained at UNC (2) 60.0% to 99.9% (3) 30.0% to 59.9% (13) 15.0% to 29.9% (44) 5.3% to 14.9% (33) Produced by: North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Sources: Alumni Affairs Data, 2004, and North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 2004. No UNC-Trained Physicians (5) *Physicians included are active, instate, nonfederal, non-resident-in-training. UNC/UNCH trained 31% of the MDs in the 10 counties with the fewest MDs

24. UNC Health Care System - Formed 1998 • 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.

25. 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 Board of Governors of University of North Carolina System, upon recommendation of the President • 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 Healthand Hospice, etc.

26. The UNCHCS in Year 2005 and Beyond in Health Care’s Challenging Environment • Increasing demand for services versus declining payment 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 • Significant emphasis on quality improvement and patient safety • And on the UNC campus …Parking, Parking, Parking

27. Positioned to Face the Challenges • New facilities developed and in planning • Strong support for health science education • Flexibility in response to human resource issues • Severe financial challenges ahead • ? Parking, parking, parking……. • Growing interface between patient care and research

28. Carolina Roadmap to SuccessMultidisciplinary and Collaborative Research • The National Institutes of Health have devised a new, very competitive, Roadmap program. • Program is designed to transform the nation’s medical research capabilities and speed research discoveries from the bench to the bedside. • Carolina garnered 8 of these prestigious grants – more than any other institution in the nation. • Vanderbilt and Columbia - 6 • Memorial Sloan-Kettering Cancer Center - 5 • Johns Hopkins - 4 • Harvard and Stanford - 3 • Duke - 2

29. The Hospital and the University Parallel Universes

30. 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

31. 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.