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Desert Companion

A healthy discussion

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Panel Discussion
Portraits by Brent Holmes

Barbara Atkinson, Renee Coffman and Shelley Berkley

In a wide-ranging roundtable interview, the leaders of Southern Nevada’s three medical schools talk about the state of medical education, how to fix the doctor shortage, the challenges of fundraising, and what’s better, cadavers or robots

As long as anybody can remember, Nevada healthcare has been in trouble. This year, America’s Health Rankings put the state at 35th in the nation overall, and that’s 12 slots higher than in 2010. A lack of doctors is a big part of the problem: Nevada ranks 47th in number of physicians per capita. But something is happening that might change that: Two new medical schools are opening, joining the one that’s already here. What will this emerging academic medical community mean to you? We invited the heads of all three schools to the Desert Companion offices to talk about it. They are Barbara Atkinson, Renee Coffman, and Shelley Berkley.

Barbara Atkinson is the founding dean of the UNLV School of Medicine, the region’s only publicly funded medical school. It officially came about in 2014 when the state’s higher education board approved a two-year budget and applied for national accreditation, but Atkinson had been hired earlier that year to lead the process. She’s raising funds for a new building on Shadow Lane, and the school’s first class of 60 students began classes in July. (After this interview, Atkinson was admitted to the hospital after suffering a ruptured intestine and subsequent infection; she remains hospitalized as of press time.)

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Renee Coffman is cofounder and president of Roseman University of Health Sciences, a private nonprofit, with campuses in both Henderson and Summerlin and roots in the 17-year-old Nevada College of Pharmacy. Like UNLV, Roseman has applied for accreditation to offer M.D. degrees — in addition to the dental, pharmacy and nursing degrees it offers already — and expects to enroll its first class of medical students in 2019.

Shelley Berkley has been the CEO and senior provost of Touro University Western Division since December 2013. Touro University Nevada, a private nonprofit that offers Doctor of Osteopathic Medicine (D.O.) degrees, opened its Nevada campus in Henderson in 2004 and has a total current enrollment of 1,400. That includes students in nursing, as well as occupational and physical therapy, and medical education.

This interview has been edited for length and clarity.

 

Heidi Kyser: What’s Nevada’s most pressing healthcare need right now, and how will this more robust academic medical community that you’re developing address it?

Barbara AtkinsonBarbara Atkinson, UNLV: [pictured right] Well, we just need more doctors, and we need more of every kind — primary care doctors, specialty doctors — and we need to build some medical programs that don’t exist in Las Vegas at all. But really, right now, access is the hardest part: too-long waits, and we just need more doctors.

Shelley Berkley, Touro: I would echo that. We have a tremendous doctor shortage in the state of Nevada, particularly in Southern Nevada, but in the rural areas, they are struggling as well. I welcome the new medical schools; I think it’s very important, and I think we are part of a very exciting time in healthcare in this community and in this country, and we are educating healthcare providers for a system that will be dramatically different a decade from now. But, you could have one new medical school or 10 new medical schools, but until we get graduate medical education, which is residencies — which is, after your four years of medical school, you’ve got three years of residency before you can practice. Until we have the requisite number of residency programs to keep these future doctors in the state, they’re going to have to leave, because they have to leave in order to get the residency.1 Interesting statistic: 70 percent of doctors end up practicing where they do their residencies. We don’t have the residency programs here, they’re leaving, and 70 percent of them are not coming back.

Renee Coffman, Roseman: I’d echo what Shelley said. The medical school is one piece of it, but the residency-creating is hugely important. If we don’t have that coupled with growing the M.D.-granting or D.O.-granting degree programs, we’re going to be stuck where we’re at. Just to add to what Shelley said, too, one out of every four physicians in Nevada is 60 or older, so we’d have to create 2,000 new positions in Nevada just to be average. So, if you think about that and couple that with the one-fourth who are 60 or older and getting to retirement age, we need to really ramp up production.

 

Kyser: Barbara used the word “access,” and I know you’re all doing specific things to address that — the mobile clinics from Touro and the telemedicine program at UNLV are a couple of examples. What are some of other specific programs you’re developing to fill gaps in access?

Coffman: Well, we have a couple already in existence, even though our medical school is still moving toward accreditation. Our pharmacy program, in particular, does a lot of outreach with immunization programs, where we go out and immunize, along with the health district, not only in Southern Nevada, but also in surrounding communities, particularly around Pahrump and Mesquite — some of those outlying areas where access is hugely an issue, even more intense than it is here in the Las Vegas Valley. When our medical school gets up and running, one program we’ll be developing is called the Lens Program, where our medical students will be serving those underserved communities, learning what the stressors are for the patients in those communities to help make our students much more aware of that, moving through school.

ChartBerkley: I would say that Touro University is in a unique position, because we don’t only have our medical, our doctor program — and we are the largest medical school in the state of Nevada; we graduate 135 future doctors every year — but under the same roof are our physician assistants. We’re going from 60 to 80 in the next couple of years. We received accreditation for that. We have a very robust nursing program and we’re expanding our nurse practitioner program. Why? Because in the Legislature’s infinite wisdom, they have determined that nurse practitioners don’t have to be supervised by a doctor, and they could write prescriptions. I’m thinking that nurse practitioners are the next hot thing in healthcare, and we want to be on the cusp of that.* We have our physical therapy doctorate, our occupational therapy doctorate. With all those programs, we do a lot of inter-professional education, so that they are learning together, because that’s how they’re going to be practicing. In addition to those academic programs, we do have two mobile clinics that go out, one to Opportunity Village, where we take care of a very fragile medical population, and (one to) Shade Tree, U.S. Vets Veterans Village, Catholic Charities. And we just received funding for a third. So, we’re very excited about our outreach. In addition to that, we have our on-site medical clinic. We have 2,100 patient visits a month. We have our autism center, and we have a partnership with the Southern Nevada Health District that has their facilities on our campus. And so, we believe in outreach to the community.

[*According to the Bureau of Labor Statistics, employment of nurse practitioners is expected to grow 31 percent from 2014 to 2024; employment of physician assistants is expected to grow 30 percent in the same time span. The expected growth is due to increased demand for healthcare services among aging Baby Boomers, and an industry shift toward focusing on preventive care.]

Atkinson: The outreach is really important, and I think the teamwork involved in a lot of different specialties is very important. At UNLV, we’re trying to foster that as well. We have a strong nurse practitioner program, too. And then on the access and community service part, I just have to comment on our dental school, which does 60,000 dental visits a year — anywhere from free to, on a sliding scale, up to whatever somebody can afford to pay. As a community service, it is amazing what they can do.

Berkley: And I was on the Board of Regents when we approved the dental program, and I’m as proud of it as Barbara is.

Atkinson: We’re working on a lot of different things. We have our students starting to become EMTs, so they’ll be out in the community doing that. They’ll continue that throughout the four years, but while they’re doing that, they’re going to be doing some public health. It sounds a lot like Renee’s program where they’ll be in a community, looking for the things that make a community unhealthy: How many kids graduate from high school? How many liquor stores are there compared to stores that sell vegetables? How many parks? What is there for kids to do? They’ll be assessing that right from the beginning and then starting to work with that ZIP code. We picked the 10 worst health-outcome ZIP codes in Las Vegas, and that’s where they’re going to be.

But then I just have to talk about the telemedicine, too. So, we’ve piloted that with our autism program. We also have a very strong autism program, for both treatment and diagnosis. We now are seeing kids from Pahrump and all over. And it really is a program where you need to have the patient there for the first diagnosis, but you can do a treatment plan where a lot of the activities can actually happen by video teleconferencing, and it really saves coming into town from somewhere distant, and we think it will be good for a lot of things.*

[*Telemedicine technology allows a doctor to see a rural patient without either of them having to travel. Using a computer equipped with specialized software and videoconferencing hardware, he can zoom in to look at a patient’s eyes, take a blood pressure reading, and perform other tests. The UNLV School of Medicine will include telemedicine appointments in its clinical rotations, practical studies that are done during the final phase of an MD program.]

So, we’re partnering with the Cleveland Clinic and UMC on really expanding those programs, and I have to say they’re good for urban areas too, because they don’t have transportation or parking is a problem. So, for post-op visits and things like that, it’s really valuable in an urban setting, but particularly necessary for rural.

 

Andrew Kiraly: Barbara, you mentioned that EMT training is part of the curriculum. Can each of you give us a picture of what the modern medical education classroom looks like? I think most people still imagine a classroom with a guy in a lab coat and the plastic skeleton.

Atkinson: Well, we’re just designing our new building right now, so I can tell you that it’s going to have a variety of different things. It is going to have one lecture hall that you can work on from two levels and goes in a gradual slope, but we needed something that would hold about 300 students at one time, so it is going to have a lecture hall. It’s going to have a lot of small-group activities. We’re doing a lot of small-groups — six to seven people in a group. We also have 20-person group rooms, and we have two 30-person rooms that can come together. So, a lot of different sizes for different kinds of activities. But probably the most exciting is the simulation part and the clinical skills part. Simulation is where you have either robots that act like people and respond to direct ...

Berkley: They bleed.

Atkinson: They bleed, they talk, they say, “I can’t breathe,” things like that. Or, it’s actual patients who are actors pretending to have a disease. Those we use for really teaching skills the hard way and then testing to see whether the students can really interact with their patient or not. Those patients are tough. They grade the students, and they’re tough. And we also have a room that’s being developed as a 3-D video kind of room, I mean, they have these video goggles now that you put your cell phone on the back of, and you can see things happening.

Coffman: So, our classrooms, rather than being stadium seating or students facing one way, and the faculty facing in the other, the faculty is in the center, and the seats go all the way around in a hexagonal shape.4 Because in education today, it’s no longer that you have a professor professing at the front of the classroom. It’s much more interactive. If you look at the studies on how students learn best, they’re learning best by interacting, so it’s designed so that the faculty is very close to the student, and the students can see one another, so that they can interact with one another. Highly technologically integrated. We have six big screens around the segments of the hexagon, so that the faculty can project anything they want — something from the internet, it even does 3-D.4 It basically can capture something on the table and project it up so that everyone can see it. You can do demonstrations very easily that way.

Roseman University

A typical Roseman University classroom is a hexagon with the instructor and six projector screens in the center.

And then, as Barbara mentioned, around the perimeter of the classroom, we have small breakout rooms so that when they break up into the smaller groups, to learn from each other, to help each other, to teach one another. Again, it’s really underpinned by a lot of the research on how students learn best, and it’s also about trying to foster the type of graduate you want. You want a student who’s going to be able to interact, in the health professions, with other health professionals. And if you can foster that by creating opportunities for them to work together in teams, they’ll translate that into the work environment as well.

Berkley: At Touro, when you show up your first day, we give you a laptop. In the laptop is everything you’re going to need to know, because the library is a thing of the past. And we keep reloading it as required. We also, thanks to a very generous private donation — because we don’t receive any state money, any taxpayer money — we are building our sim lab. We have money for the equipment, and I have a woman who gives birth every 20 minutes when we need her to, and that’s very, very helpful. (Laughter)

Touro

A class at Touro University

Atkinson: Can I just comment on one technological thing that is different than other schools? We don’t have the big, smelly formaldehyde lab, where you dissect the body. We have virtual anatomy, and that’s one of the things that we’ve been sharing with Shelley’s people.

Berkley: I love those cadavers! And when somebody operates on me, I want them to have already been inside somebody else. (Laughter) So, we’re not getting rid of our cadaver lab, although we will be moving more and more to virtual-reality cadavers. But, frankly, I want students to see what’s inside.

 

Kiraly: I had read that bioethics is going to be a strong component of the curriculum at the UNLV School of Medicine. Barbara, can you talk about that, and why that’s important?

Atkinson: It’s something I’m very passionate about. Bioethics is how you think about medical problems. Sometimes it’s end of life, and when is the right time to say, “Enough is enough”? Sometimes the most controversial part has been reproductive rights and abortions and things like that. But there are all kinds of other issues in really taking care of patients. It can be things like how much surgery to do on a child. Or, is this treatment better than that one, or should somebody go to some other physician to get a referral. And then there are scientific things, too. I was on President Barack Obama’s Bioethics Commission, and we dealt with things like, when should you test a pediatric anthrax vaccine on kids? They need to be tested on normal kids to get the dose, but the rule on experimentation on kids is, never experiment unless it has the chance of helping the kid, and there’s no way you could ever predict that testing an anthrax vaccine could help a kid. So, there are those issues, and I think it’s important that students start thinking about them relative to patients right from the beginning. So we’re embedding bioethics into patient cases, and we’ll be discussing it with them as they have their own cases, when they’re third- and fourth-year students.*

[*During the inter-sessions of their first three years, UNLV School of Medicine students will take interdisciplinary seminars, including one on bioethics titled, “Do the Right Thing: Ethics in Medicine and Beyond; Personalized and Consumer-Driven Medicine.” Here’s a sampling of other bioethics seminars being taught in U.S. medical schools: Cross-Cultural Perspectives on Brain Death (Harvard Medical School); Literature and Medicine (Northwestern University); The Responsible Conduct of Research (Stanford Medicine); The Environmental Ethics of Health Care (University of Minnesota); Designing Humans: A Human Rights Approach (NYU); The Problem of Evil: Philosophical, Biological, and Social Dimensions (Stony Brook University)

Coffman: What Barbara mentions is really important. The typical medical student is a very high achiever, and they’ve been used to being very successful academically. But real life is much more nuanced than that, and the decisions that are made in the medical field often have to be a lot more nuanced than that. So, you’ll see, in all of our curricula, exposure to more real-life situations is important, whether it’s actually placing students in under-served communities — because sometimes, you know, the best medication is the most expensive, and if the patient can’t pay for it, then, how are we helping the patient? So, it’s those nuanced decisions that we get by putting students in much more real-life situations that helps to mold their decision-making skills to be much more comprehensive, not so black and white.

Berkley: And I think it’s very important to note that what Barbara and Renee are talking about should remain within the purview of the medical community, and not our politicians. And I say that as a recovering politician. I’ll give you the perfect example: I was on the (U.S. Congressional) Ways and Means Committee, Healthcare Subcommittee, during the year-long debate on the Affordable Care Act. And somehow, paying doctors for their time to discuss end-of-life options turned into “death panels.” And it had nothing to do with death panels, and it had to do with compensating a doctor for the time they’re going to spend with an elderly patient discussing their options — what they want at the end of their lives.

 

Kyser: Let’s talk money. Barbara, you’ve said in the past that the new medical school building on Shadow Lane is going to cost $100 million.

Atkinson: We started out saying it was going to be $100 million. (Laughter)

Kyser: Okay, what’s it up to now?

Atkinson: It’s up to somewhere about $200 million, but that’s if we build it out to its full extent.

Kyser: So you just recently got the $25 million anonymous donation, and then I believe Governor Sandoval said the state has put $80 million toward the school. So, where are you in terms of your goal?

Atkinson: We’re at $50 million toward the  capital campaign goal right now, but we have a lot of people whom we’re talking to, and that we’re hoping we’ll be able to get to it, and I’d certainly like to be able to break ground by the end of this year. It might be not until spring, but ...

 

Kyser: Whether it’s government moShelley Berkleyney, philanthropists, or tuition, funding is always a challenge. So, I wonder if the two of you, Shelley and Renee, have some secrets for squeezing blood out of that turnip, so to speak?

Berkley: [Pictured right] I don’t want Barbara to respond to this, but when I was a senior at UNLV, they created — Howard Hughes passed away in that timeframe — a medical school at UNR. Now, in those days, UNLV was barely a branch of UNR, so Reno was the appropriate place to put a medical school. We are now many, many years later, and UNR’s medical school really has not expanded as it was supposed to, and we spend $60 million a biennium to keep it going. I don’t think this state, knowing that our citizens, our fellow citizens, are very careful with the taxpayers’ money, that they will want to sustain two medical schools, one that we’re spending $60 million a biennium (on) and the expenses of UNLV. When I was on the Board of Regents, I was very vocal in bringing that school down here. Now eventually, we’re going to need to make a decision, and the Legislature’s going to have to make that decision, that the resources are going to come down here to Southern Nevada where they should be. Seventy percent of the population is here. This is where our medical practice is growing dramatically, if the Medical District expands or is finally created and expands and does what it is supposed to do. But I think Barbara would have another $60 million if we reallocated those resources, and eventually we’re going to have to, because this state doesn’t have a whole lot of tax money to spread around, and tough choices are going to have to be made. And the sooner we make the tough choices, the better off we’re going to be as a state, not as Southern Nevada, but as the state of Nevada.*

[*We asked Thomas Schwenk, dean of the University of Nevada School of Medicine in Reno, to respond to Berkley’s comment. He replied: “To advantage one part of the state in support of medical education at the expense of another does not seem appropriate. The patient population in the north, including rural Nevada, where we do much of our training, has an equal need for primary care doctors. Medical education is expensive, and the Legislature has to make some very difficult decisions, but I would not want to de-emphasize the need for physicians in the north.”]

 

Kiraly: A shot across the bow!

Coffman: Well, it is expensive to run a medical school. That’s what you’re hearing from both of them, really. It’s much more than just the educational mission. In order to maintain accreditation with LCME (Liaison Committee on Medical Education), in particular, the research mission is incredibly important, and you can’t really get accreditation and maintain accreditation without a strong research program. Research programs are very expensive to run. We’re looking to raise about the same amount that Barbara’s talking about, between $25 and $30 million per year. We’re in the midst of a $66 million campaign so we can get up and running. It’s all nice and well to say that we need a medical school, we want a medical school, but it’s expensive. 

 

Kiraly: Your three schools have collaborated to address the problem of the lack of graduate medical education; that is, residency positions in local hospitals that keep graduates in the community as they transition to their careers. How would you assess the current state of graduate medical education (GME) in the valley?

Berkley: Pathetic! I mean, last legislative session, we did work together, although it was not a tough sell. Governor Sandoval got it, and he created his Governor’s Task Force on GME. He requested $10 million. The Legislature appropriated the $10 million. All of the schools have representatives on the GME task force. This year, $10 million. And it barely created a ripple. I mean ... 

 

Kyser: How many residency positions came out of that, finally?

Atkinson: Actually, there were a lot that came out if you count all the years’ worth, a couple hundred. But, it takes a while. It takes a year or two to start. So, UNLV is taking over from Reno additional psychiatry residents, so we’re adding six residencies a year for four years, so there’ll be 24 ultimately, but there’s six right now. We’re also expanding the OB-Gyn residencies by, I think, five a year. And that’s, again, for four years until you get 30 residencies.

Berkley: You don’t get the money and tomorrow you have a residency program. They’re expensive to start, and a number of the hospitals in town are capped, meaning that they cannot, they do not, qualify for GME, so we’re working with our partners to remedy that situation, but it’s not an easy process. When we were doing the Affordable Care Act, in the House version — and I know because a congresswoman from Pennsylvania, Allyson Schwartz, and I, introduced legislation to include GME — it doesn’t take a genius to figure out that, if you are providing access to 30 million more Americans that you might need some more doctors to take care of them. And so, we had the money to create GME, and it comes out of the Medicare fund, in the House version. The Senate version did not include graduate medical education, and (it was) the bill that was passed because Barack Obama didn’t want the cost of the ACA to go above a certain number. The Senate jettisoned the GME and other funding to get to that magic number that the president wanted. So, the Senate bill came back to the House for the final vote. So, when we voted for it, we were voting for expanding medical care to 30 million more Americans with no additional resources to train doctors. How shortsighted is that?

 

Kiraly: When you’re out in the community talking to prospective donors, do each of you have a unique selling proposition, a certain angle?

Berkley: I’m not ashamed to say that I have traded on lifelong friendships, and brought people to Touro who had no idea. The operative sentence, after I give them a tour, is, “We had no idea what was going on here.” Or, “We pass Touro on U.S. 95 going to Boulder City, and we never knew what was here.” But it is a gem of a school, and I find that if I bring someone on campus, and they have the wherewithal and the disposable income to give, that they will be inclined to support such a worthy endeavor. And, you know, we never had scholarship money before. That, to me, was a number one priority. My students need scholarships. This is an expensive education. They graduate, sometimes, with about $200,000 worth of debt. My stepdaughter, who practices here — she’s a family-practice physician, and she comes from an affluent family — she did it on her own, and she owed $200,000 when she graduated medical school. It is pretty standard. So, if I can do anything to help these students, so that they can have a quality of life while they’re in medical school, and not have such a large burden when they get out, I’m going to do it. If you can show what the money is going for, and bring a donor into your vision and your goal, I think you have a much better chance of success.

Coffman: Our position is fairly similar. There wasn’t a lot of knowledge about who we are and what we do in the community. The University of Nevada system is kind of the 10,000-pound gorilla. So, as a private not-for-profit in a state that really does not have a complementary private educational system —  I’m from Ohio originally, and you really cannot throw a stone without hitting a private school in Ohio — even where I got my pharmacy degree, the town had 5,000 people, and it supported a university. So, there’s a disconnect, I think, in Nevada, in particular, not understanding what a private, not-for-profit (college) is.

So, if potential donors first understand what a private school is, and that we don’t take any state funding, so your tax dollars are not supporting us — we have to support that through good business sense, for one thing, with the money we do get, but then philanthropy is a second point — but then also, as a not-for-profit, not lumping us in with some of the for-profit schools that have had such a bad reputation throughout the United States, whether it’s the University of Phoenixes or whatever. When we get excess revenue, it doesn’t line somebody else’s pocket. It goes into developing and building out programs and expanding what we do have to serve our communities.

Atkinson: I sort of go at it a little bit differently. In the very beginning the case that was made to make a public medical school in Las Vegas was actually an economic one. It wasn’t the need for doctors, or healthcare, or things missing on the healthcare front. It was simply economic. Public medical school, in 15 years, should generate $1.2 billion of economic impact. And if it was put — which it is going to be — in the Medical District, then together, the two of them, it’s a $3.6 billion a year economic impact and 22,000 new jobs. So, that was the selling point. But that’s not what I use when I go to potential donors. I use that with the Legislature and with some businesspeople who want to hear that piece, too.

But the real piece that I use is that we have a real innovative education, that I really planned it thinking about what a doctor who’s going to practice for 50 years is going to need. The technology is going to be really important, as is outpatient medicine and care for whole populations of people — it’s not going to be fee-for-service medicine. So, we’ve built all of those things in. We have a third year that’s all outpatient instead of in a hospital. Patients in the hospital are too sick. They’re taken care of by hospitalists. It’s a different business now, and what these students need to learn is outpatient medicine and keeping people healthy and out of hospitals.

Berkley: And that’s what I love about osteopathic medicine. My stepdaughter’s a D.O. and my husband’s an M.D. When I tell my husband Larry I have a headache, he’ll give me a pill. When I tell Dr. Stephanie I have a headache, she’ll start rubbing me over here, or ask me what I had for dinner last night, or knowing that my headache may not be in my head, and I like that approach with osteopathic medicine. But, look, public health is a very important part of this, as 70 percent of chronic illnesses are related to three things: smoking, obesity, lack of exercise. We have it in our (capability) to lower our healthcare costs. We choose, as a society, not to. So one of these days we’re going to have to change the paradigm of how we deliver healthcare, go to early detection and prevention of disease, instead of spending 70 percent of our healthcare dollars in the last sixth months of life. Now that is not a death panel, but that is exactly what we are doing. So if we change the paradigm, we can live longer, healthier lives and spend much less taxpayers’ dollars on our healthcare system, which, frankly, is unsustainable at its current pace.

 

Kiraly: If the Affordable Care Act is repealed and replaced, how do you anticipate this affecting the educational institutions you’re building, and medical education in general?

Berkley: Both the House version and the proposed Senate version, which no one has seen yet (as of interview time), are so dangerously bad and preposterous for people throughout the United States, but particularly here in the state of Nevada, it will devastate us. One of the reasons that I ultimately voted for the Affordable Care Act, all flaws known to me, is at the time, there were 600,000 uninsured Nevadans. And Medicaid-eligible, I would say. Being uninsured doesn’t mean you don’t get sick. It means you wait until you’re really, really, really sick and you end up in the emergency room of the hospitals. There was no accident that out of the 33 hospitals that we have in Nevada, 20 of them were operating in the red, particularly UMC. Seventy million dollars in the red. They’re not operating in the red anymore, because they’re getting compensated by Medicaid for these patients. If we eliminate that, you are going to uncompensated care, and someone is paying for this! And it’s all the people in the state of Nevada who are going to be paying for these Medicaid patients. So the idea that we are cutting it, or eliminating it, or changing it, is an outrage, and dangerous to the health and well-being of our citizens.

 

Kyser: I’m curious, though, how that specifically affects your schools. Can you give some examples?

Atkinson: We will have a lot more trouble making money in our practice to pay the salaries of the doctors, which means we’ll cut back on the number of faculty we have. We won’t be able to afford to do some of the higher-profile things, the liver transplants and the bone-marrow transplants, and the stuff that needs to be added in this town, because you can’t afford to give those kinds of care away for free. UMC won’t have enough money to pay for all of the care that it gives, so it’s going to go back in debt if it loses a substantial amount of the Medicaid enrollment, and it will. It’ll actually lose more under the Senate bill than it loses under the House bill. The Senate bill is actually tougher than the House bill, and that one was outrageous.

Berkley: It is meaner. Meaner.

Atkinson: Sunrise Hospital will have the same problems. Sunrise is very good at taking care of underserved people. They’ve done much better under this Medicaid program, but they’ll go back to being uncompensated care. Over half of the deliveries in the country — over 40 percent of them, anyway — are Medicaid cases now. Sunrise and UMC is probably more like 70 to 80 percent of all the deliveries are Medicaid deliveries. So, that care goes away. The prenatal part of that care goes away, which means the babies are sicker, they end up in the NICU (neonatal intensive care unit) forever, there are all kinds of complications that are unexpected if the woman hasn’t had any prenatal care going into it. It’s bad for education in every kind of way, because all you see are really sick people. You don’t actually get to take care of chronic disease. People go off things like kidney dialysis, and cancer care, and they really won’t be able to afford it.

Renee CoffmanCoffman: [Pictured right] Barbara pointed out something really important. A lot of people don’t realize that as you’re building a medical school, it receives sources of revenue other than tuition, and one is the clinical enterprise. If the physicians who are part of the clinical enterprise of the medical school aren’t getting compensated, you hire fewer physicians. That means you have fewer students, because  there’s a certain ratio the accrediting agency is looking for, for faculty-to-students.

On the positive side, though — I’ll be the Pollyanna in the group — there may be opportunities for other healthcare professionals like nurse practitioners, like pharmacists, to fill some of the gaps in some of those areas that were normally held by physicians that they can do within the scope of their care. So there may be some more demand, particularly on the nurse practitioner/physician assistant side for some of those services compensated at a lower rate than what a physician would have.

Berkley: Let me answer your question in a really direct way. Our second mobile clinic where we have a partnership with Opportunity Village, all of the Opportunity clients that we see as patients are Medicaid-eligible, and while we receive a grant to pay for the mobile clinic, the reality is, in the future, what we were counting on is getting all of the Medicaid-eligible patients into our system, and paying Medicaid rates is not a huge payer, but it would be enough for us to break even, to continue delivering services to a very fragile patient population. If that Medicaid money goes away, all of these Opportunity Village clients are going to be without healthcare.

 

Kiraly: On an institutional level, do you feel a responsibility to engage students in the discussion about fixing healthcare in America, or is medical school just about training doctors?

Atkinson: There’s a health policy piece that is really important. We have a community health sciences school that is moving toward becoming a public health school. I think it’s extremely important that we really teach every level of student about our healthcare, about where the costs are and what the costs are. Again, I think population health management is the way to ultimately save money, by spending more time with patients up front, finding out about the patient themselves, setting a treatment plan, either for normal and healthy patients, or for a chronic disease like hypertension or diabetes, and working out those details by spending up-front time. It’s the only way we’re going to really cut costs — that and being really careful about when you order what tests and why.

Coffman: Shelley talked earlier about those in healthcare having the ability to weigh in on these healthcare policy issues, as opposed to politicians. But it’s something we have to integrate in the curriculum and inculcate in the students, because we’re so focused on making sure they get the anatomy, and they get the clinical practice, and they get all of that piece of it, that when they graduate, they are maybe not as in tune (with the policy dimension). How do they weigh in? How do they make their voices heard? But it’s a real challenge. Our curricula are packed as they are.

 

Kiraly: Are there health policy classes at Roseman?

Coffman: We don’t have specific policy classes. We have tracks that will allow students to get some exposure to that. We send students to the state Legislature every session so that they can see what’s going on.

Berkley: At Touro, they go to Carson City. My students go to Washington, D.C., too, in their white coats, and they look very impressive when they’re walking the halls of either the United States Congress or the Legislature in Carson City.

Kyser: Can each of you describe your single greatest challenge and how you overcame it?

Coffman: Money. Roseman did go through the accreditation process, and out of the 93 elements the LCME looked at, the reason we weren’t able to advance on the timeline we wanted to was because they said we needed more funding. Unfortunately, we didn’t have a Legislature giving us dollars to support us, so that is the biggest challenge. We talked about some of the challenges and people not recognizing all the elements that make medical school and GME funding so expensive, but then you layer on top of that just being an educational institution in and of itself. We are one of the most highly regulated types of industries in the United States, with the federal government weighing in, with layers of regulations. And then healthcare on top of education means there’s a lot of time and effort that goes into just maintaining that component. 

Atkinson: I agree it’s money, because I have to go out to the Legislature and ask for it, and then get it. But higher for me was actually the infrastructure. You had a healthcare infrastructure that already existed because of your other healthcare schools. But UNLV had never had a medical school. I think they thought it was going to be a lot easier than it was. And they certainly didn’t expect it to be as expensive! They really didn’t expect it to be as expensive or us to move as fast. They wanted it to happen fast, so I made it happen fast. But believe me, we’re going through the throes now of adding 750 employees on July 1 to UNLV, almost a quarter the size of UNLV. And their HR was not ready. It’s a good thing we had built our own HR structure to work with theirs, to be able to begin to do it. The total dollar amount is going to be a $130 million operation on July 1. We’re talking real money. And if we don’t bill on time, we’ll lose over a million dollars a week. There’s just a lot that has to come together, and a lot of it is infrastructure. And UNLV had pared its infrastructure down during the recession, and hadn’t really built it back up again yet. It’s working and they’ve been incredibly supportive.

Berkley: Money is always an issue. But making sure we’re putting out the best possible product — my students — and making sure that our faculty is engaged and understands the mission of the school is important. And making sure we are accessing the community, because a very big part of our mission is to make sure that the ladies at Shade Tree and the people at Catholic Charities and the U.S. Vets and Veterans Village are receiving basic healthcare, and they’re receiving it because of my faculty and my students at Touro. I’m proud about that, but I also have to  make sure that my faculty, staff, administrators and students know what they’re doing is very important to this community. And knowing that they’re making a difference, and they need to hear it. Because it’s a tough environment, and a tough job, and they need to know they’re doing a good job.