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Discussion
As Nevada's population grows, there is much debate about how best to meet the health care needs of the state. Common statistics bandied about include that we are 46th in the number of physicians per 100K population (175/100K versus national average 275) (40), (106) have poor statistics on a wide variety of common and uncommon diseases (41), and rank 46th out of 50 in the percentage of uninsured (42). The Governor's commission on medical education, research, and training stated: Indeed, Nevada has a healthcare crisis. This crisis will only grow worse if we accept and tolerate the current situation and idly watch while our population doubles to 4.3 million in 2030. (41)
But is Nevada really in a healthcare crisis? And are these cited statistics particularly useful in determining if the healthcare needs of the state are being met? It is hard to believe folks flooded and continue to flock to the fastest growing state in the country for the past 20 years, overtaken just this year by Arizona, if there existed a healthcare crisis of such epic proportion. (42), (43) Although still composing the critical core, especially in complex diagnostic and procedural situations, healthcare nowadays is not nearly as monopolized by physicians as was the case in the past. (45) A diverse number of non-physician healthcare providers are gaining increasing licensing power to treat a wide variety of medical conditions. In fact, some have questioned whether physicians remain the most efficient and costs effective healthcare supplier for many of the services they currently provide, and if patients should have the option of seeking lower cost alternatives. Just as life expectancy is not an adequate barometer of the quality of healthcare, neither are the various rankings of disease manifestations and outcomes in Nevada, as lifestyle and cultural variables play a far greater role. The ranks of the uninsured included the young, the wealthy and the transient, and all combinations thereof, groups plentiful in Nevada and therefore not necessarily prime indicators of a 'health care crisis'. (74), (75)
Even assuming we suffer from some degree of a healthcare crisis and more physicians are the solution, how do we increase the number of physicians in Nevada? By increasing the number of medical students or residents? Studies have shown residents are more likely to stay in state than medical students, but on average only 47.6% of residents practice where they train (46), (47). And of the ones that stay, how many spend significant portions of their careers in the state where they trained? Interestingly, some states are apparently more attractive than others:
Pennsylvania, with its high medical liability insurance premiums, is another state looking to improve resident retention. In 2004, 7.8% of Pennsylvania doctors-in-training stayed after completing residency, down from 50.5% in 1994, according to the Pennsylvania Medical Society. (46)
So, these figures, along with economic common sense, dictate that practice conditions in the state are much more relevant to the number of physicians than the number of medical students or residents. Although the Governor's commission on medical education, research, and training touches on this issue, a much greater emphasis is placed on expanding existing institutions and increasing medical education and graduate medical education. In fact, nearly uniformly around the country, public medical schools clamor for increased funding and expanded classes and hospitals argue for increases in funding for residency programs. In aforementioned Pennsylvania:
Spanier also asked state officials for a special $10 million appropriation for the Penn State College of Medicine at the Medical Center in Hershey in each of the coming three years. The $4.8 million currently provided to Penn State's medical college "is the smallest appropriation of any public medical school in the country and is less than 10 percent of the national average," he said. (49)
Nonetheless, despite the apparent noncorrelation, some states acquiesce and join the Feds in spending large amounts of taxpayer $$$ on public medical schools and residencies:
New York's Medicaid program has spent more than $8 billion over the last five years on graduate medical education - $77,000 per graduate resident in 2005 compared to similar states like California that spent just $21,000 per resident. (97)
In effect, the taxpayers of these states are subsidizing the medical education of doctors who will be practicing in other states. For an extreme example, in Haiti it was documented that at one point out of 264 medical doctors who graduated from a Haitian medical school all but three left the country, mostly for the United States. (98), (99)
Officials in Nevada follow the same line, UNSOM, the board of Reagent, the Governor's Commission and other government officials have advocated for general increases in state spending. Among other proposals, some specific requests include:
Increasing the UNSOM medical budget from $27 million to $53 million and expanding the class size from 52 to 96.
Increase faculty additions by a one time $20 million influx over 2 years
Increase supporting costs of this new faculty, $6.1 million over 2 years
$2.9 million for the Department of Medical Genetics and Development and Department of Molecular Medicine
A $300-$350 million for a Health Sciences Center, an academic medical center with a focus on research, training, and clinical practice (50), (51)
Mirroring the proposals for medical students and residents, the same entities are proposing large multimillion dollar state funding increases and expansions for most other branches of healthcare workers. (50), (51)
Even if medical students or residents were the answer to Nevada's 'healthcare woes', who is currently supplying them? Touro University is churning out nearly three times the number of doctors (4x if the PAs are included) that UNSOM is, without costing Nevada taxpayers $27 million / year and $519,230 per doctor. This pattern is likely occurring in all areas of education and health education, provided private industry can compete with the subsidized tuition and training offered by the state. Touro U filled a need that was not being filled by the state, the paucity of medical students and ripeness of the Las Vegas community begged for investment. By filling this need Touro U inadvertently demonstrated the efficiency of private enterprise of performing a function that is often monopolized by the state.
As mentioned, the differences between the two systems, public vs private, MD vs DO, clinical revenue vs tuition based, become most glaring during the 3rd and 4th year rotations. UNSOM seems to stand strongly behind their philosophy, stating:
UNSOM plans to add approximately 300 faculty over the next decade as a core of full-time faculty are essential to a quality medical school. (italics added) (41)
And:
The relatively small number of students in each class permits a degree of personal and individual attention that is essential to attaining excellence in medical education. The approximately 235 full-time faculty and more than 1,000 community physicians involved in the school’s mission are highly qualified to conduct programs in clinical medicine, research and education. (italics added) (34), (52)
The effect of class size in education research is a matter of debate and can be summed up as:
Research suggests there may be some advantages to smaller classes--though if so, the benefits are modest and come at a very high price tag. And whether this research is actually correct is a matter of debate. (53), (54), (55), (56), (57)
Whether this research can be applied to medical school and 3rd and 4th year rotations is a matter of opinion. Certainly DO students across the country trained in Touro U's community and tuition based model have gone onto excel in many of the most competitive residencies in the nation. Insurance companies, hospitals, the general public, and government providers, if we consider the latter opinion worthy of appreciation, make no distinction between the two groups of licensed physicians or their training models.
It could be argued that residents, far more pertinent than medical students in impacting healthcare in the state, are nearly all under the banner of UNSOM, 238 to 16, or in the next two years 238+ to (roughly) 100. Yet, the affiliation of residencies with medical schools is mostly a matter of semantics. Hospitals are the entities involved in establishing a residency not medical schools, although in most cases they use a local medical school's name because of requirement or convenience. State money, at least through UNSOM's budget, is not involved or impacted by its residency programs, even though it often plays the role of third party middle man payer because of onerous regulations. If UNSOM and Touro U did not exist hospitals could still establish said residencies. So, the degree with which local medical schools impact residencies remains unclear, although certainly positive correlations and opportunities exist to some degree.
Lastly, the differences between private and political control over institutions are worthy of elaboration. Beyond inherent slow adaptation, inflexibility, and resistance to change, state control invariably involves susceptibility to cronyism and the vaulting of political considerations above the public interest. Why else, might we ask, was UNSOM headquartered in Reno, when the burgeoning state medical community was in Las Vegas? Even in 1969, the year of UNSOM's founding, Las Vegas had nearly three times (304,744 vs 121,068) the population of Reno and was growing much more rapidly. (79), (80) It is likely UNSOM became embroiled in the infamous 'north-south' Nevada political battles and we can assume future decisions, such as the locations of other facilities and personnel decisions are weighed heavily by their political impacts.
Lessened accountability and political vulnerabilities place state funded institutions at risk for budget cuts and errors:
A funding mishap in the 2001 legislative session caused CCSN (Community Colleges of Southern Nevada) to receive $7.6 million less than it should have, reducing expenses for the quality of student services and the number of classes available for students. Determining when the problem became known is a matter of debate between university system officials. (84)
And even outright fraud:
Clark
County Manager Virginia Valentine fired Thomas (UMC hospital CEO)
on Tuesday after outside auditors revealed that the hospital lost $34.3 million in its last fiscal
year, $15.5 million more than Thomas reported to county leaders in November. (96)
State institutions can themselves become powerful political players, and even use taxpayer money to hire lobbyists:
As per the report, CCSN used more lobbyists and spent more money than any of the other institutions. (81)
Speaking of lobbying, UNLV officials have landed themselves a new lobbyist for the 2007 Legislature.<.> He will make $127,000 a year. (82)
The former Democratic congressional candidate (Tessa Hafen) said she landed her new job, as a lobbyist for University of Nevada Health Sciences System, after she made a chance phone call to a former associate. <.> Short on time, Rogers decided to waive the search process and hired Hafen on a six-month contract at a pro rated salary of $100,000 a year. (83)
Carson City conservative activist Chuck Muth, through a citizen's outreach group, had a rather succinct opinion:
"There ought to be a law banning the use of taxpayer dollars to pay lobbyists for government entities," he wrote on his blog. "Let the department heads, who are already on the public dole, do their own lobbying for more of our money." (83)
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