22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 3, Smith)

We gratefully acknowledge the sponsorship of the Marian University College of Osteopathic Medicine (Indianapolis, Indiana) for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

 

George Smith, MD; Michigan State University/Sparrow Hospital, Lansikng

George Smith, MD, Michigan State University/Sparrow Hospital, Lansing: I’m substituting today for Doctor Sandral Hullett, who was required to testify in a legal case back in Alabama. In her place, I’ve been asked to be a reactor, observer and commentator on what Hector and Steve have talked about and to relate it back to own  environment.

Compared to what Doctors Flores and Cobb deal with in Los Angeles and Denver, I almost feel like I’m in the backwoods. Lansing is a small market, if you will. The population is about 130,000, with a metropolitan area that’s probably 300,000. It has virtually no managed care whatever.

What  managed care we had in the past crashed in the backlash from the managed care movement that happened a few years back. The institution at which I work is a private, not-for-profit hospital, which is the dominant healthcare system in the city, with about 65% market share. (There’s one other healthcare system that has  a niche in cardiac care that has the rest of the business.)

But beyond commercial insurance, what does the payer situation in the Lansing area look like?

In Michigan, Medicaid is “managed care capititated”, although I use that phrase very loosely. There’s no straight Medicaid in Michigan to any extent. If you get on the Medicaid roles, you are enrolled in some kind of “managed care product”.

There are two other entities – 1) the Physicians’ Health Plan, which is really an IPA that Sparrow Hospital owns, and 2) a physician health organization, Sparrow Physicians Health Network (SPHN), in which Sparrow Hospital is a partner. And that’s the landscape that I work with! We have a lot of the same kind of challenges that Hector and Steve are talking about, although to me it seems much less complicated than everything that they have to deal with.

But what are some of the things that we’re doing related to PPACA and to addressing some of the issues around recruitment money and integrated care? I will highlight three themes:

Residency ties with the clinical years of medical school

From the standpoint of integrated care, we have a very unique medical school. Michigan State University (MSU) is a community-based medical school in that it has no university hospital, per se. Phase two, let’s call it, which would be the clinical years – the third and fourth school of medical school – are done in seven communities around the state of Michigan.

Dr  Linda Garcia-Shelton (who is part of this 22nd National Conference) knows this because she’s a link to the past at MSU. Lansing, where MSU is located, is, of course, one of those communities, but there are several other cities as well. [For a presentation on this subject, see: Proceedings of the 21st National Conference: Consequences of Michigan’s Strategic Initiatives for Medical Student Education.]

Creating an Accountable Care Organization for Lansing

That creates an opportunity – something that we’re looking at right now – for our hospital to create an Accountable Care Organization (ACO) that would be vertically integrated. We would be taking the entire MSU health team group of physicians and bringing them together with the private and employed physicians in the SPHN group  to form one large multidisciplinary integrated group in the Lansing community.

It’s a huge task! I don’t think, however, it’s nearly as contumacious as what Hector and Steve have talked about, because we would be starting with less people that have their fingers in the pie, whether you want to call them cartels or competition or whatever else .

That would be the initial venture. I don’t know when exactly it’s going to happen, but the CEO of our hospital and the MSU Provost and President are very interested in working together and making it happen.

Creating a Teaching Health Center

There is another integrated example of care in the community. This may be very strange for many of you who work with community health centers, FQHCs, FQHC look-alikes. We have been asked by our Sparrow Hospital and are in a position to partner with the health department, MSU and Sparrow, to create an FQHC community health center in a part of Lansing that’s pretty underserved and that has lousy health outcomes. We’ve never done anything like this before.

I have done some research on how to make sure that I don’t step in any cow pies (because I understand from talking to some of my colleagues that have done this, that when you create a residency site that’s an FQHC, if you do not do that correctly, it’s a mess that you will regret. It can be a “lose, lose” for everybody.

There was a really good article in the 2009 Annals of Family Medicine by Carl G. Morris, MD, MPH of the Group Health Cooperative in Seattle and Frederick M. Chen, MD, MPH of the University of Washington, entitled “Training Residents in Community Health Centers: Faciltators and Barriers”.  I was surprised to find that there are only 38 family medicine residency-CHC affiliations in the entire country. Therefore, the barriers to this must be substantial to doing this kind of venture, because the number hasn’t changed much in 20 years.

We’re pursuing the CHC linkages, which we think is an exciting opportunity. We would probably downsize our current residency. We have two family health centers right now; one in Lansing proper, one in a small town south of Lansing. We will take some of the resources from these FHCs to apply to this new site.

We hope that the teaching health center will be a recruitment tool as well. We have lots of resident applicants that come through every year and the first thing many of them ask is “do you have an underserved clinic in a neighborhood where we serve the population that comes to the clinic?” When we answer “No”, we never see or hear from them again. They are often underrepresented minorities from Wayne State University or other schools that would be interested in training in a site like that. That’s something that looks like it’s going to happen. I just need to make sure that it’s done right.

In terms of recruiting people into family medicine, I shuddered a little bit yesterday when I was looking at the ranking list of the different medical schools, because MSU’s up there in family medicine. We may be living off some of our older laurels. I can remember not too long ago when, out of a class of 100, 30 students went into family medicine.

The last two years, even at “good ol’ MSU”, the total in family medicine  of 200 students is about 20. The biggest problem is that out of those 20 students, only three stayed in the State of Michigan. Most of those people came from outside and were returning to their home state. To be honest with you, we have some kind of a connection with California. One of our graduates, who graduated in February, is going to a community health center in Modesto as we speak. I’m going to visit her in a couple of days from now.

We need to do something about our retention problem. We’ve adopted a program, that we call The Integrated Program (TIP). It’s not a new idea. The University of Missouri Columbia Department of Family and Community Medicine started this. The idea is to have a prestigious program for third year students who apply for this opportunity to have a linked fourth year of medical school with the residency, while they’re still in medical school. Even though they are not residents yet, they have a special fourth year. It’s become highly competitive.

We just started this program last year. We have one TIP student in our program beginning in July. We have four people that are interested in the program for next year. In return, they get modest help with their tuition reimbursement and they also have a guaranteed spot in the MATCH the following year if everything works out well for them. We’ve tried that and it seems to be very successful.

The last issue I wanted to mention, with regard to recruiting more students for family medicine, is the impending mismatch between medical school positions and residency slots. I thought of this yesterday when we were talking about the increased numbers of medical students.

It is true that the number of students in medical school classes is exploding. But my Director of Medical Education, Dr. William Gifford, has worked out the math on GME numbers on what happens with all of these students are trying to match up in the number of residency slots that are actually available. There’s a line that will be crossed around 2015, when, even if you take all the IMGs out of the equation across the country, there will be 500 graduates of U. S. schools that will have no home – nowhere to go, because there will be so many students and not enough GME slots. By 2020 that will be 3,000 students without residency positions.

I see PPACA as requiring the need for creating more slots for primary care and family medicine.  This is absolutely crucial, because right now we’ve got this mismatch in which more and more students are coming out of the shoot. If anything residency slots have stayed static or even sagged, because there is no federal support for increasing the number of residency positions. This is a scary problem that we really have to address.

Thank you!

Robert Ross, MD; Oregon Health Sciences University/Cascades East Family Medicine:  Thank you very much for your excellent presentation.