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Nevada Residencies
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 for your convenience or inconvenience. (3) Examples of onerous 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 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 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 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 and other healthcare providers when complying with the ACGME requirements and state laws to limit the hours residents work to 80 hrs/wk. (18)
The NHA (Nevada Hospital Association) report to the Governor stated that residencies cost the hospitals $16.5 million and they were reimbursed on $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 disturbing 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 caused nationally via 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,
research, and
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)
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