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Medical Education in Nevada:
A Tale of Two Medical Schools
By Travis Snyder, DO09, TUCOM NV
Appendix: Introduction, Nevada Medical School Profiles, Nevada Residencies, Discussion, Recommendations, Conclusion, References.
What is the proper roll for government in society? Policy makers constantly wrestle with this question as they attempt to address issues of concern to their communities. In many areas the private sector is acknowledged as more efficient and innovative than the public sector. History has shown governmental regulation and control over industries and sectors of the economy often yield dismal results. However, the debate is far from settled and large swathes of the US economy still fall under sway of the state and/or federal government. Two notable such areas are Education and Healthcare, and, most especially, the education of healthcare workers. The state of Nevada presents a unique opportunity to compare and contrast two differing styles of Medical education. This alternating dance of competition and cooperation between the two schools, pardon the pun, of thought serve as a microcosm to similar movements playing out across the country and will be the focus of this paper.
Nevada Medical School Profiles
The University of Nevada School of Medicine (UNSOM) was established in Reno by the Nevada State Legislature in 1969. Although it was built as an addition to the University of Nevada Reno, it retains separate funding. Currently each entering class consists of 52 MD medical students, 45 of whom are state residents. Priority for the remaining slots are given to states without public medical schools. (31) Next year the school will expand it's class size to 62 and ultimately to 96 in the next decade. (35) Tuition is $9,596 a year for NV residents, $14,164 for nonresidents of the aforementioned states and $27,877 for nonresidents. (33) UNSOM receives $27 million in state funding per year and employs 235 full time faculty. (34), (35)
Touro University opened its doors in Henderson, a suburb of Las Vegas, in the summer of 2004, growing rapidly with a current entering class size of 135 DO medical students (tuition $34,318), with a maximum capacity of 167, a current PA (Physician Assistant) class of 48 (tuition $25,065), with a maximum capacity of 150, a current OT (Occupational Therapy) class of 27 (tuition $21,840) with a maximum capacity of 60, and a current Nursing class of 56 (tuition $21,840), which can be broken down in MSN, BC-RN, and MSN-RN degrees, with a maximum capacity of 90. Touro is privately funded, investing $6 million in startup costs, and recently purchased the land it sits on plus an additional 500,000 square feet of future expansion space for $34 million. The school receives no state funding, but does possess tax exempt status. The School of Medicine employs 32 full time faculty, and the rest of the school 19. Notwithstanding outside contractors, Touro U has 107 total people on their payroll. (28), (25), (26)
Regarding their medical programs, the first two years at both schools are quite similar; students learn the basic skills and theories of doctoring, and prepare for national board examinations. In addition, students from both schools engage in research, community service, and shadowing in their respective communities. In the third and fourth year rotations the requirements are nearly identical, students must complete 6 core rotations of internal medicine, family practice, surgery, psychiatry, emergency medicine, plus electives (37). In the first two years Osteopathic students learn OMM (Osteopathic Manipulative Medicine) a hands-on manipulative treatment and must return monthly during their 3rd and 4th year rotations to Touro U for the required course, Osteopathic Principles and Practices. (78)
However, despite these similarities, important differences arise between the two schools in the 3rd and 4th year. UNSOM employs 149 full time faculty to teach students during their 3rd and 4th year rotations, while Touro U relies on unpaid community (and faculty) volunteers. (23), (91) In addition to teaching, full time UNSOM faculty engage in clinical practice and research, accounting for a majority of the funds in UNSOM's $70 million dollar/year operation (23), (32), (92), (93), (94), (102). The faculty of both schools receive CME, Continued Medical Education, credit (a continued requirement for licensure) for teaching medical students. (108) Undoubtedly, there are positives and negatives inherent in both systems. UNSOM students may get the benefit of more one on one attention, or maybe even two on one, as there are 1.5 times the faculty as there are 3rd and 4th year students. Touro U students are, perhaps, exposed to more realistic clinical settings and 'natural' physician practice at a much cheaper cost. (92), (93), (94), (95)
Thus far, here in NV and across the country, it appears these systems have generally functioned well side by side; yet tensions do occur. First, community doctors may resent the subsidized competition from the state university employed physicians, and paying the taxes to support them. One out of every 30 practicing physicians in NV (There are 4333 MDs and 408 DOs practicing in NV (5), (6)) is a full time UNSOM employee, and UNSOM recoups only 70 cents on every dollar invested in their clinical practice employees (41). Secondly, full time UNSOM employees are prohibited from teaching rotating Touro U students. To some extent this is understandable, as UNSOM resources, taxpayer derived though they may be, are intended for UNSOM students. However, problems arise when certain prime teaching locations (UNSOM employees tend to be concentrated in the large area hospitals) are apparently either monopolized or underutilized, notably in the areas of OB/GYN and psychiatry. Fortunately, these 'conflicts', if it is even fair to call them that, are the exception rather than the rule, a testament to the large, diverse, and underutilized medical community of Las Vegas.
Chart 1 (26), (41)
Cost to Nevada Taxpayers
$27 million / year
$519,000 per student
NV Res $9,596.00
Non Res avg $14,164.00
Nonresidents $ 27,877.00
Touro University 2006-07 class
MS – 38
BC, MS - 15
RN, MS - 3
($40+ million in direct out of state investment)
(? out of state investment)
*Although not included because they are not medically related, Touro U has 33 students enrolled part time in a masters of education department (including specialized degrees in special education and autism) available for $328 /credit.
It is, perhaps, contextually misleading to discuss the residencies and fellowships in Nevada through the prism of said medical schools, as residencies are funded by the Federal Government and occasionally in part by the relevant hospital. While residencies need to be (osteopathic) and are generally (allopathic) associated with Medical Schools, residencies accept applicants from any school across the country. Osteopathic residencies only take DO students, while Allopathic residencies are generally open to MD and DO students. There exists a smattering of dually accredited DO, MD residencies across the country (7), but the number remains small as the red tape and regulatory steps necessary to get even one accreditation are prohibitive enough as is.
To start a residency, at least on the osteopathic side, one needs to form an 'OPTI' (Osteopathic Postdoctoral Training Institute), which consists of a hospital and a college of osteopathic medicine both accredited by various divisions of the AOA (American Osteopathic Association). (1), (2) The process involves constant onsite inspections, approvals, and paperwork by a wide variety of private and government agencies including the subspecialty representative group; for example the ACOFP (American College of Osteopathic Family Practitioners) is required to inspect, report, and sign off on any new family practice residency (4), (37), (91). The AOA has a 154 page acronym filled booklet on the process, available online for perusal. (3) Examples of regulations contained therein include lists of mandated written policies the residency must have, such as a 'sexual harassment policy' and, at an age where all medical journals are available online, 'a professionally staffed library containing a wide selection of modern textbooks and current periodicals'. (3) Indeed, included amongst Valley Hospital's newest constructions is a library (37). The residency must fulfill obligations regarding 'the match' with the NRPM (National Resident Matching Program [AMA]) and the AOA equivalent. (111) The residency must also comply with numerous federal laws and mandates, not to mention the convoluted accounting system of the federal department, Centers for Medicaid & Medicare Services.
The Medicare formula used to reimburse and fund the residency programs expenses is so complex that no one seems to fully understand it, including those intricately involved in the process and, perhaps, even including the original authors and current administrators. (13), (37), (91) It involves indirect (IME) and direct (DME) payments to hospitals based on the number of residents, the ratio of residents to beds, and the ratio of Medicare inpatient patients at the hospital. (8), (9), (10), (12), (14)
From appearances, in order to start a residency program one must simultaneously wear the hat of secretary, lawyer, accountant, and physician. The time and investment necessary to establish a residency surely removes the 'little guy', from the process, ensuring only large hospitals with extensive resources are able to take on such a Herculean task. Gone are the days of the 'guild', following a mentor in his/her private practice and learning the tricks of the trade. (11) Could a private group of, say, seven radiologist acquire a resident or two if they so desired? In the present system it would be nearly impossible.
Given the above, we might wonder why residencies exist at all. Even if large hospitals have 'cornered the market', if you will, for residencies, why do they bother? While surely altruism, prestige, and desire to pass down knowledge play significant roles, we must also consider that a given hospital is reimbursed, on average, over $70,000 per resident by the Federal Government (14), (10). Given that residents routinely work 80 hours a week or more and earn between 35-50K, some not even making minimum wage, for much of the same work attendings (fully employed doctors) are paid hundreds of thousands annually to perform, it it not surprising that some hospitals find residents intensely profitable (15), (16). In fact, when scaling back residencies, some administrators calculated they would need to hire 2.5 PAs to replace each resident. (17) Other hospitals reported financial difficulties in hiring PAs (at $60-80K each) and other healthcare providers when complying with the ACGME requirements and state laws to limit the hours residents work to 80 hrs/wk. (18), (114)
The NHA (Nevada Hospital Association) report to the Governor stated that residencies cost the hospitals $16.5 million and they were reimbursed only $2.5 million:
Medicare reimbursed hospitals 15.42% of the dollars directly spent to support resident programs, per the most recently filed cost reports. In summary, hospitals paid $14 million (net amount) of any amounts reimbursed to support the physician residency programs in Nevada. (27)
These statements may be misleading because the NHA, curiously, appears to be leaving out the indirect Medicare payments and neglecting to add in the value of the resident's labor, leaving an uneducated observer with the impression that NV hospitals are hemorrhaging $14 million through their residency programs. More information is needed on this.
Like other acts of government, the incentives, disincentives, and complexities of reimbursement policy have created unintended perverse outcomes. For example, "Before 2000, freestanding children’s teaching hospitals received yearly an average $374 per resident in GME funds from Medicare, whereas nonchildren’s teaching hospitals received an average $87,034 per resident. This disparity in the level of federal funding for freestanding pediatric versus nonpediatric teaching hospitals is attributable to few Medicare patients being cared for in children’s hospitals." (italics added) (19)
Reminiscent of government attempts to regulate and subsidize agriculture and pay farmers not to grow crops: "In an unorthodox bid to ease a growing glut of physicians, the federal government has agreed to pay hospitals around the country hundreds of millions of dollars not to train doctors. The initiative, embedded in the new federal budget agreement, extends to all 1,025 U.S. teaching hospitals an offer similar to a experiment approved for New York early this year. That experiment, which will pay New York hospitals $400 million over the next several years..." "Since it began, Medicare has underwritten residency training programs heavily and has, in effect, made residents a prized, inexpensive kind of labor for their hospitals. Taxpayers spend $7 billion a year on such training." (italics added) (20), (100)
One of the most disruptive and far reaching stipulations of residency subsidies is the requirement that hospitals have only three years to grow their residency programs before payments are capped. In other words, federal subsidies will only cover the number of residents present in the residency at the end of three years: forever. As one can imagine, this creates a precarious dash to rapidly expand a teaching hospital, with little correlation to the existing healthcare market in the area. Some Hospitals expand 'capped' residencies, receiving funding from other sources, or finding value enough in the labor of residents in addition to future recruiting opportunities, to cover the costs.
This ad hoc system causes a patchwork of shortages and gluts locally, mirroring the devastation seen nationally from the recurrent attempts to 'tweak' the clumsy framework, leading to supposed phenomena like the oversupply of physicians and residents as the federal system was flooded with cash during the 90s, and the purported undersupply currently taking place during cutbacks. (103), (104), (105) Despite discomfort in the presumption anyone can know or predict the number of docs and residents 'needed', it is a safe bet future attempts at top down management will again result in a form of overcompensatory failure. (105)
All of this directly effects residencies in NV, especially as the allopathic residencies are effectively capped out. First, some background. There are currently 4 teaching hospitals in the Las Vegas area (22): UMC, St. Rose, Sunrise, Valley, and one in the Reno area, Washoe Medical Center (21). All the hospitals are privately owned and operated except for UMC, which is owned by Clark County. UNSOM has: "a total of 238 residents in 3 accredited programs in Reno (Family Medicine, Psychiatry and Internal Medicine) and two fellowship programs (Geriatric Medicine and Child Psychiatry); and 10 accredited programs in Las Vegas (Pediatrics, Ob/GYN, Emergency Medicine, Surgery, Plastic Surgery, Family Medicine, Internal Medicine, Psychiatry, Dental Medicine and Pediatric Dental Medicine) as well as three fellowship programs (Sports Medicine, OB for Family Physicians, and Trauma/Critical Care Surgery). The internal medicine programs also offer preliminary programs for those individuals needing them to progress to other specialties. At this time, we are unsure how many additional positions will be added over the next several years." (23), (24), (25)
Some options for possible
allopathic residency expansion were put forth by the Governor's commission on medical education,
training. One was federal legislation:
In order to expand Nevada’s GME “slots” federal
legislation will need to be introduced. The Nevada Hospital Association (NHA) has already asked our
congressional delegation to introduce legislation that would provide hospitals with existing
residency and fellowship programs with the ability to increase and develop new GME slots for
hospitals, especially in states experiencing rapid population growth. A strong letter of support
from the Governor to Federal Legislators is important. (41)
Another was a proposal by the hospitals themselves (NHA) to pony up some $45 million to expand the number of residencies by 250. (27) The state has also looked at funding residencies, in Jan 2005 Gov Guinn proposed state funding for 40 residencies. (36) Perhaps unsurprisingly, the governor's commission was unable to find information on this. (41)
The Osteopathic residencies are confined to Valley Hospital, which began their residency program this year (2006) with 26 residents, 14 in internal medicine, 1 in family practice, 10 in internship (four switched over to internal medicine), and 1 in dermatology. This February, in the 'match' (where physicians apply to residency programs), Valley will be adding 32 new residents. By the end of their three year expansion they hope to have around 100 total residents. In addition to the stated residencies, Valley has oral confirmation of an ophthalmology program and is looking at a number of other specialties and fellowships. (37), (38), (39) While this is an exciting time for Valley and the Osteopathic community, they are surely hindered by the need to expand so rapidly in limited time.
Key to the future of Nevada Graduate Medical Education will be decisions emerging from the deliberations of the Nevada Consortium of Graduate Medical Education. The Consortium consists of the CEOs of the area teaching hospitals and Dr. John McDonald, Dean of UNSOM and Dr. Mitchell Forman, Dean of Touro U. The consortium is looking at ways to expand and enhance GME in Nevada, including examining the feasibility of 'dual certification' of MD DO residencies and 'side by side' MD DO residencies in the same hospital(s). (29), (37)
Chart 2 (41)
Chart 3 (109)
|NV||162630||TUCOM/VALLEY HOSPITAL MED CTR||LAS VEGAS||T||16||6||10|
|NV||162630||TUCOM/VALLEY HOSPITAL MED CTR||LAS VEGAS||C-FP||2||0||2|
|NV||162630||TUCOM/VALLEY HOSPITAL MED CTR||LAS VEGAS||C-IM||14||12||2|
By comparing the two charts you can see many of the vacancies were subsequently filled in the 'scramble' (post match - match for those not matching at first). (109) The same data is not available for the allopathic matches. (110), (111)
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), (113) 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 more routine 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 this 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 medical community begged for investment. By filling this need Touro U inadvertently demonstrated the efficiency of private enterprise in 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)
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. Upon occasion Touro students on rotation find themselves working one on one with former residency directors from prestigious universities who have gone into private practice. 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)
The following 10 recommendations have been construed with the goals of increasing access to healthcare, lowering the costs of healthcare, and improving the quality of healthcare in the state of Nevada. Let it be stressed, these are personal recommendations, arrived at through the above statistics, analysis, study, and, of course, predisposing ideology. These recommendations should not be associated with the many people interviewed for this paper as none of them expressed any of the following views nor is it likely they would subscribe to many or even any of them. I should emphasize that the administrations of Touro and Valley were entirely apolitical in their responses to requests for factual information. A common theme heard was the desire to cooperate with UNSOM for the mutual benefit of the students and to advance the interests of the state of Nevada.
Recommendation 1: Continue to reform medical malpractice in the State of Nevada. The Democratic controlled State and House refused to pass meaningful malpractice reform in regular and special session and thus the voters of Nevada approved mal practice reform in 2004 via ballot initiative, which among other changes solidified and capped noneconomic or pain and suffering damages at $350,000. The voter approved law will be challenged in court, as trial attorneys await a 'perfect storm' case, and thus state legislative action remains imperative. (64), (65), (66), (68), (87), (107) Ultimate reform will likely involve removal of 'special' legal rules for medical malpractice, which predispose for abuse (similar solutions have been proposed for workers comp). (71), (72), (73)
Recommendation 2: Allow Nevada Residents to purchase out of state insurance on a national market. (75)
Recommendation 3: Abolish all instate health insurance requirements and regulations, including the 47+ mandates (NV ranks in the top 10 in the country for most health insurance mandates). (58), (59), (66), 67), (77) In fact, health 'insurance' in the United States is a misnomer, as the term has been corrupted, semantically diverted to placate the social planning appetites of politicians. (69), (70), (71) For background, mandates are treatments and conditions that must be covered by anyone offering health insurance. Various medical interest groups lobby to have their treatments covered and collectively these drive up the price of health insurance. For example, in Nevada it is illegal for health insurance not to cover 40 inpatient and 40 outpatient days in mental health benefits. (67)
Recommendation 4: Expand the recently passed measure, sponsored by State Sen Joe Heck, to allow importation of pharmaceuticals from Canada to include other countries and eliminate the 'FDA approved' requirement. (59), (60), (61), (62), (63)
Recommendation 5: Liberalize Nevada medical licensing laws. (87), (90) Allow patients the option to see other medical specialists instead of physicians and vice versa. (45), (88) Strengthen the power of state professional group associations to self regulate and police their own members and encourage said state and their respective national organizations to attain greater uniformity in interstate licensure. (89) In lieu of the aforementioned, ratify and pursue such models as the nursing compact:
The Nursing Licensure Compact is a mutual recognition model of
nursing licensure that allows a nurse to have one
In addition, eliminate political control and influence over state licensing boards by removing the governor's power of appointment to these boards. (76), (86)
Recommendation 6: Privatize all state funded medical education institutions. As this paper purports to illustrate, private industry can supply the training of healthcare workers more efficiently and cost effectively than the state. Removing state subsidies will allow private industry to grow unimpeded and without competing with area physicians and other healthcare workers. In addition to relieving Nevada taxpayers by cutting state spending, the millions of dollars of generated out of state investment provide significant economic benefit. At minimum, halt future increases in funding. (35)
Recommendation 7: In the same vein as recommendation 6, shelve all plans for a 'Health Science Center', and/or a 'Nevada Academic Medical Center', and ax any current state funding of residencies or research facilities. (35), (50), (51), (85)
Recommendation 8: On a federal level, eliminate all federal spending and subsidies (over $7 billion per year) on residents and fellowships (20). While this influx of $$$ has led to some encouragement of residency programs, the stipulations and requirements have created, if the figures are even to be believed, reoccurring cycles of gluts and shortages, disproportionate congregation and standardizations of facilities (by exclusion), and a resulting diminishing of the educational experience coexistent with horrendous financial inefficiency (103). Private donors, hospitals, future medical employers, and the students themselves are surely more than capable of shouldering any increased financial burden. This could also apply to the tuition of medical students, through state and federal loan subsidies. In other unregulated industries, expensive tuition reflects salaries in a much gentler supply and demand driven cycle.
Recommendation 9: Encourage professional organizations and their subspecialty affiliates to facilitate residency approval and eliminate costly and timely compliance. The best form of encouragement may involve liberalizing licensing laws, removing the current legal monopolies and raising the threat of competition, concomitant with loss of federal GME subsidies. (45)
Recommendation 10: More of a general recommendation than specific: get government off the backs of those in the healthcare business and industry. Liberalize regulations for small businesses (many doctors run their practices as small businesses). Lower taxes on doctors, insurance companies, hospitals, and all other healthcare providers. Allow hospitals to expand and franchise without undo paperwork or zoning tripups. In short, make Nevada a great place to live by returning to the roots of what made it prosper in the first place: freedom. (113)
In conclusion, the goal of improving healthcare in Nevada is a goal all policy makers share. It is important to approach this goal thoroughly, armed with the latest statistics, and with an open mind to all proposals. I recognize many of the recommendations laid out in this paper are not politically feasible at this time, but the hope is that lawmakers can come together to make tough decisions on behalf of the citizens of the state of Nevada.
However, somewhat surprisingly, not all the woes of healthcare in NV lie, at least directly, at the foot of lawmakers. The difficulty of creating new residencies and the stringentness of state licensing requirements can be significantly attributed to private professional groups, AOA, AMA etc... Of course, with government granted monopolies on services one can argue there is little incentive or pressure for improvement or streamlining.
Returning to answer our original question: What is the proper roll for government in society? The answer, at least in regarding the education of healthcare providers, suggests there is little or no role in which government is helpful or effective. While it would be warm and tolerant, and partly accurate to say 'the two competing and cooperating systems together create the best conditions for healthcare training in NV', it would also be remiss. If the state funded system can survive as a private entity, keeping its head above water in the marketplace of ideas and in the face of true competition, then this conclusion will be happily retracted. It would behoove those in the private healthcare medical training industries, private DO and MD schools in particular, to recognize the state impact on their future bottom line and advocate accordingly.
Speaking of a 'marketplace', it is often said healthcare does not function as a 'free market' and therefore must be regulated and subsidized. In fact, the importance of the healthcare necessitates alleviation from political interference, and the resulting shortages, stagnations, and inefficiencies typically resultant from top down state command. If a free market approach works best for the education of healthcare workers, critics would be wise to reconsider this approach for the rest of the healthcare as well.
This piece is still under construction and development. Comments, private or public are appreciate.
Medical school expansion wrong approach / Sticking it to taxpayers won't cure sickly business climate for doctors
4/26/06 Review Journal Dr. Harrison H. Sheld
Touro U in the News
UNSOM in the News
History of Nevada malpractice.
7/29/07 Update (Chicago AOA/SOMA Convention)
"There were also some good discussions regarding residencies and the rapid growth of the Osteopathic profession. It is projected that the percentage of physicians who are osteopathic physicians (DOs) will rise from the current 6% to over 20%. It is interesting to note there is not a shortage of residencies in the lower paying specialties; in fact, in some areas there is a glut. One speaker even, wisely in my opinion, asked whether certain struggling DO residencies should be opened to MDs (the reverse is true). It is probably the case that scare residencies are competitive in large part because they are 'high paying'. But why are they high paying? Is it because the 'public interest and safety' necessitate the attraction of impeccably 'qualified' applicants, or because the policies/regulations intrinsic to those subspecialty societies make the residencies scarce, thus raising the salaries of those in the field? In my mind, the latter possibility is most likely and certainly worthy of investigation, as the negative repercussions reverberate through the entire profession and indirectly harm patient care by increasing the cost of healthcare, thereby decreasing access. Doctors and residents in those subspecialties have little incentive, if we consider the unconscious permeating feedback loops, to change the present system; in fact, it is medical students who gain the most from advocating a fix; therefore it seems this issue is one meriting student led discussion and investigation."
References and Sources:
23) Personal correspondence Dr. Miriam Bar-on, Associate Dean of Graduate Medical Education, UNSOM
25) Personal correspondence Sara Cooper, Bursar, Touro U
28) Personal correspondence Lisa Ross, Administration, Touro U
29) Personal correspondence Dr. Mitchell Forman, Dean, Touro U
30) Personal correspondence Dr. Michael Harter, Vice President of Administration, Touro U
37) Personal correspondence Deborah O'Conner, Administrative Director of Graduate Medical Education, Valley Hospital
39) Personal correspondence Dr. David Park, Director Primary Care, Touro U, Clinical Director Family Practice Residency Program, Valley
59) Personal Correspondence State Senator Joesph Heck (R) District 5
68) Personal Correspondence Denise Davis, Executive Director Nevada Osteopathic Medical Association
75) http://www.musicforamerica.org/node/49608 (in comments: wsj.com Health and Poverty August 27, 2004)
76) Personal Correspondence Dr. Weldon Havins, Director of Medical Jurisprudence, Touro U, President Clark County Medical Society
91) Personal Correspondence Dr. Andrew Eisen, Associate Dean for Clinical Education, Touro U
98) Infections and Inequalities, by Dr. Paul Farmer
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