UNC Hospitals

1. UNC Hospitals The University in American Life: The University of North Carolina at Chapel Hill October 13, 2003

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

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

4. 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.

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 • “Hill Burton” funded hospitals developing - 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 - 1998

8. 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

9. 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

10. 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

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

12. Mountain Greensboro Coastal Northwest Southern Regional Area L Charlotte Wake Eastern North Carolina Area Health Education Centers (AHEC) Program Locations of Continuing Education Programs, 2001-2002 AHEC Continuing Education Programs Source: NC AHEC Program

14. 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

15. 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

16. NIH Support to U.S. Institutionsof Higher Education Fiscal Year 2002 1 Johns Hopkins University 510,005,326 2 University of Pennsylvania 418,546,510 3 University of Washington 405,729,042 4 UC-San Francisco 365,365,909 5 Washington University 343,792,077 6 University of Michigan 325,786,206 7 UC-Los Angeles 317,017,181 8 University of Pittsburgh 308,144,862 9 Yale University 289,899,944 10 Duke University 277,393,166 11 Harvard University 273,147,799 12 Columbia University 269,844,585 13 UNC-Chapel Hill 264,263,425 14 Baylor College of Medicine 263,540,460 15 Stanford University 247,636,170 (Go HEELS!!!)

17. 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

18. 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

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 – Some with early challenges

21. University of North Carolina Hospitals FY 2003 Inpatient Discharges by N.C. County Total Discharges: 29,098 Alleghany Northampton Gates Currituck Camden Surry Granville Ashe Warren Caswell Pasquotank Person Stokes Rockingham Hertford Vance Perquimans Halifax Watauga Wilkes Yadkin Avery Forsyth Franklin Chowan Orange Bertie Mitchell Guilford Nash Alamance Caldwell 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 LEGEND Scotland Robeson Bladen Pender 1 - 9 cases 10 - 99 cases Columbus New Hanover 100 - 249 cases Brunswick 250 - 999 cases 1000+ cases UNC Hospitals Source: UNC Hospitals/HBO Trendstar Database F: \ planning \ rr \ unch ip origin fy 03_2. ppt

22. Camden University of North Carolina Hospitals - Distribution of Non-Reimbursed care (by County of Residence – North Carolina)FY 2003 Alleghany Northampton Gates Currituck Ashe Warren Caswell Surry Person Stokes Rockingham Granville Hertford Vance Pasquotank Halifax Watauga Wilkes Yadkin Perquimans Avery Forsyth Orange Bertie Chowan Guilford Alamance Franklin Mitchell Nash Durham Caldwell Yancey Alexander Edgecombe Davie Martin Washington Tyrrell Dare Madison Wake Iredell Davidson Burke Chatham Randolph Wilson Catawba McDowell Pitt Rowan Buncombe Beaufort Haywood Hyde Johnston Swain Lincoln Lee Greene Graham Rutherford Cabarrus Henderson Harnett Wayne Montgomery Jackson Cleveland Polk Stanly Moore Craven Gaston Mecklenburg Lenoir Transylvania Macon Cherokee Pamlico Clay Sampson Cumberland Jones Duplin Hoke Richmond Anson Union Onslow Scotland Carteret Robeson Bladen Pender Legend for Map < $500,000 Columbus New Hanover $500,000-$1M Brunswick $1M - $3M > $3M Source: Actual 2003 charity and bad debts by residence of patient schedule - UNCH finance

23. UNC’s Clinical Support for Educational Programs Legend for Map 0% 1 - 15% 16 - 30% 31 - 45% 46 - 60% 61 - 75% 76 - 100% 23% of active North Carolina Physicians Trained at UNC Hospitals or UNC Active Physicians Trained by UNC/UNCH Percentage by County Alleghany Camden Currituck Northampton Gates Granville Ashe Warren Surry Caswell Person Stokes Rockingham Vance Halifax Pasquotank Hertford Wilkes Perquimans Watauga Orange Bertie Yadkin Forsyth Chowan Guilford Franklin Mitchell Alamance Nash Avery Durham Yancey Caldwell Edgecombe Davie Alexander Tyrrell Madison Martin Washington Wake Dare Iredell Davidson Burke Randolph Chatham Wilson McDowell Pitt Rowan Buncombe Beaufort Catawba Haywood Johnston Hyde Swain Greene Lincoln Lee Rutherford Cabarrus Harnett Moore Graham Wayne Montgomery Jackson Cleveland Henderson Craven Polk Gaston Stanly Lenoir Macon Transylvania Mecklenburg Cherokee Pamlico Sampson Cumberland Clay Richmond Jones Union Duplin Hoke Anson Scotland Onslow Carteret Robeson Bladen Pender Total Active Non - Federal Physicians = 13,782 UNC / UNCH trained physicians* = 3,164 Columbus Total % of UNC Physicians in North Carolina = 23% New Hanover Brunswick * Combines UNC graduates and UNCH residents in an unduplicated cou nt Source: Alumni Affairs Data, 2/14/96 and NC Health Professions D ata System: 1996 Physicians, Sheps Center. UNC/UNCH trained 50% of the MDs in the 10 counties with the fewe st 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 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.

26. 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

27. NC Children’s and Women’s Hospitals

28. The Hospital and the University Parallel Universes

29. 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

30. UNC Hospitals and UNCHCSFacility Master Plan Heart Center CancerCenter MusculoskeletalCenter andAmbulatory Care

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.

33. ROLE of one PHYSICIAN in AcademicHealth Care Center When you’ve seen one MD at an AMC, you’ve seen one MD at an AMC

34. 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

35. Assistant Professor 1988 • Associate Professor 1994 • Professor 2001

36. Four Legged Stool of Academic Medical Center MD • Clinical • Research • Teaching • Administration

37. 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

38. Research • 40% TIME AT THE NIH IN WASHINGTON • COLLABORATOR ON MANY PROJECTS LOCALLY • EASIEST TO QUANTIFY IN PROMOTION AND TENURE DECISIONS

39. TEACHING • TEACHING PORTFOLIO • AT RISK WITH CURRENT CLIMATE • VARIOUS DEFINITIONS • CLASS ROOM TEACHING • WARD TEACHING • CLINIC TEACHING • MENTORING • LABORATORY STUDIES • RESEARCH MENTORS • ADVISING

40. 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

42. 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

43. Important issues facing AMC’s • Changing demographics • Cultural competency • Geriatrics • No money, no mission • “Provide health care for the people of NC”

44. 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.

45. 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.,….

47. 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

48. 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

49. 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…….