Consolidating Pediatric Specialty Services:

Transcription

1 Consolidating Pediatric Specialty Services: Rationale and Lessons Learned Michael Artman, MD Senior Vice President, Pediatrician-in-Chief Chair, Department of Pediatrics University of Missouri-Kansas City and Kansas University Medical Center Arnold W. Strauss, MD Professor of Pediatrics Cincinnati Children s Hospital Medical Center The Children s Mercy Hospital, 2017

2 Rationale for Consolidation Pediatric subspecialists care for rare diseases There are 7,000 different such rare diseases There are a limited number of pediatric subspecialists Complex pediatric patients often require multi-disciplinary care Current research discoveries are transforming care for rare diseases and require large collaborative networks Pediatric research is underfunded with insufficient cadre of scientists Development of new approaches and evaluation of the outcomes of these novel therapies require collaboration across institutions to ensure sufficient volume of patients

3 Workforce of Pediatricians US Population 316,128,839 Children <18 years 76,658,019 Annual births 3,952,841 Pediatricians 55,509 Or 88,992 (AMA data) # US children for each pediatrician Data from US Census Bureau and Department of Labor Statistics, American Association of Medical Colleges-2010, American Medical Association-2013

4 Recognized Pediatric Subspecialties Adolescent Medicine 614 Allergy and Immunology* Cardiology 2672 Child Abuse 324 Child Psychiatry* Child Neurology* Critical Care 2,120 Dermatology* Developmental/Behavioral 720 Emergency Medicine 2,046 Endocrinology 1,635 Gastroenterology, Hepatology, Nutrition 1,469 Genetics* Hematology-Oncology 2,780 Infectious Diseases 1,432 Neonatology 5,552 Nephrology 843 Pulmonary Medicine 1,091 Rheumatology 364 Sports Medicine* Total 23,662 Total number of subspecialty board-certified specialists in US since 1960, so some have retired * Not certified by the American Board of Pediatrics

5 Fragmentation of Subspecialty Services The Chicago Loop and Lake Michigan

6 Pediatrics in Chicago in 2018 MSA population 9.5 million; ~100,000 births/year but declining 6 allopathic medical schools teaching pediatrics NIH Funding (2017) rankings among American pediatric institutions: 35th, 41st, 54th, 55th, or no funding. Total funding of $24.4 million annually Pediatric subspecialty academic faculty (full-time, employed only) Northwestern-352 University of Chicago-130 Rush-70 Loyola-~40 UIC-~40 Chicago Med-??

7 Pediatrics in Chicago pediatric hospitals provide subspecialty services/staffed beds One free-standing and separate governance 288 Three as separate physical plants within adult systems 106, 117, 161 Three as children s hospitals within an adult hospital 86, 120 Two specialty hospitals (rehabilitation, orthopedic only) 49, 60 Total staffed beds 987 Market share: pediatric and NICU inpatient days 39% US News 2017 Rankings: #7, #66, #75, and others not ranked at all 33 other Chicago MSA hospitals admit pediatric patients There are 23 level III neonatal intensive care units Children s Hospital Associated Web Site Illinois IDPH data from 2016

8 Other MSAs with Fragmented Services # Children s Hospitals MSA Population US News Hospital Rankings New York , 26, 37, 41, 57, 67, NR Dallas , 63, NR Miami , 53, NR Minn-St Paul , 71, NR St. Louis , 72, NR Cleveland , 35, 60 Richmond none ranked No Top 10 Children s Hospital in these MSAs

9 Consolidation of Pediatric Services Ohio River, Cincinnati

10 Consolidation of Pediatric Services: Cincinnati MSA population of 2.1M people; 25,000 births/year (declining) One medical school $125 Million in NIH research funding, 3rd most in the US Pediatric Academic Faculty; 775 academic pediatricians One Children s Hospital since consolidation in 1970s Ranked #3 in US News 540 staffed beds One other Level III NICU staffed by same neonatologists No other hospitals admit pediatric patients

11 Other consolidated Pediatric Services # Children s Hospitals MSA Population USNews Rankings Philadelphia , NR Atlanta Seattle San Diego Pittsburgh Columbus

12 Benefits of Consolidation Clinical Care Increased efficiency; Reduced variability; Improved outcomes Expanded rare disease expertise; Expedited multidisciplinary care Improved margin and reinvestment Research Greater research funding and better ability to evaluate outcomes Education: Enhanced opportunities; uniform experiences for learners Advocacy: Louder single voice for children and families Philanthropy: Increased support

13 Case Study: Consolidating Pediatric Clinical Care, Research and Education Development of a single Department of Pediatrics at a freestanding independent Children s Hospital serving two medical schools and academic medical centers Children s Mercy Kansas City University of Missouri-Kansas City School of Medicine (UMKC) Kansas University Medical Center (KUMC) The Children s Mercy Hospital, 2017

14 Diary of the Journey Where and When it Began Children s Mercy Hospital is an independent free-standing children s hospital system, based in Kansas City, MO (MSA population ~2.1M) Affiliated with the University of Missouri-Kansas City (School of Medicine located across the street) October, 2010: I became Chair of the Department of Pediatrics at Children s Mercy and UMKC School of Medicine

15 Diary of the Journey Here s Where it Gets Interesting Kansas University Medical Center is a competing AMC 3.7 miles away in Kansas City, KS I also became Chair of the Department of Pediatrics at KUMC in January, 2014 Trivia Question: Who is the only Chair of 2 different departments, in 2 different medical schools, in 2 different states?

16 Why Did We Embark?

17 Why Did We Embark?

18 Capitalize on the Benefits of Consolidation Clinical Care Increased efficiency; Reduced variability; Improved outcomes Expanded rare disease expertise; Expedited multidisciplinary care Improved margin and reinvestment Research Greater research funding and better ability to evaluate outcomes Education: Enhanced opportunities; uniform experiences for learners Advocacy: Louder single voice for children and families Philanthropy: Increased support

19 How Did We Prepare? Learn from history to understand challenges

20 History and Background May 30, 1854: Kansas-Nebraska Act Repealed the Missouri Compromise Initiated a chain of events that culminated in the Civil War KS and MO have been competitors since

21 History and Background Children s Mercy and KU have taken 2-3 serious runs at this in the past 30 years Most recently about 10 years ago What has changed? New leadership at both institutions More intense economic pressures What has not changed? Kansas Missouri rivalry Misperceptions and cultural differences

22 How Did We Prepare? Recognize that perceptions reality Confront cultural differences by aligning perceptions with reality

23 Initial Self-Perceptions KU Pediatrics self-perceptions: We have strong academics We are great educators We are outstanding clinicians Children s Mercy self-perceptions: We have strong academics We are great educators We are outstanding clinicians

24 Initial Perceptions Reality KU perceptions of Children s: arrogant, no research, not interested in teaching, only subspecialty care programs Children s perceptions of KU: arrogant, no research, only interested in teaching, only general and developmental & behavioral pediatrics

25 How Did We Prepare? Assess current status of both departments

26 How Did We Prepare? Confidentiality Agreement, MOU Organized steering committee and work groups Developed and shared a common fact base Engaged an outside neutral third-party ECG Management Consultants

27 How Are We Going to Get There? Initial conversations in September, 2012 September-December, 2012 quietly laying the foundation and finalizing MOU Public announcement of intentions Dec : Steering Committee and Work Group meetings with targeted focus Ongoing communication with all stakeholders

28 Steering Committee Co-Chairs: Michael Artman (Children s), Steven Stites (KU) Balanced representation CEO s, CNO s, CFO s, CMO s Research, education, faculty affairs Charged with defining the vision, evaluating options, guiding the overall direction and processes

29 Work Groups Balanced Representation and Shared Leadership Clinical Practice Education Compensation & Benefits Govt. Relations/Advocacy Legal Affairs Transitional Care Research Faculty Affairs Communications Surgical Collaborations Finance

30 How Did We Prepare? Developed and shared a common fact base Engaged an outside neutral third-party ECG Management Consultants

31 Fact Base: KC Geography

32 Fact Base: KC Geography

33 Fact Base: KC Geography

34 Fact Base: KC Geography

35 Fact Base: KC Geography

36 Fact Base Information and data were submitted to the outside consulting group Clinical: capacity, volumes and activities Education: UME, GME, other Research: funding, publications, honors Data were scrubbed, checked, and presented to the various stakeholders

37 How Are We Going to Get There? If we don't change our direction we're likely to end up where we're headed Chinese Proverb

38 How Are We Going to Get There? Transparency is essential Relentless communication Reassure UMKC we are not abandoning Reassure KU that Children s is not taking over Reassure Children s of the mutual benefits Reassure staff, residents, fellows, students Repeat regularly and frequently Then do it again and again and again

39 How Far Have We Come? Clinical Programs ID, Neurology, Cardiology, Neonatology, General Surgery, General Pediatrics Underway in GI, Endocrinology, Nephrology, Pulmonary, Rheumatology, Hospital Medicine, Palliative Care, Hem-Onc, Transition to adults One Division Director Combined single division of general pediatrics Combined single division of neonatology

40 How Far Have We Come? Research Children s became a consortium member of the KU NCI Cancer Center Expanded joint research grants/projects Appointed a new Director of the joint childhood obesity/nutrition center Children s faculty active in KU CTSA Shared lab space across campuses

41 How Far Have We Come? Education KU medical students: core clerkship rotations at Children s Mercy Joint didactic sessions for residents Residents having joint retreats Agreed to a single merged pediatric residency program (2020) Joint educational programs (Grand Rounds, lecutureships, etc.)

42 Keys to success What Have We Learned? Strong leadership + grassroots engagement Transparency, honesty, integrity, mutual respect Effective process and organization; follow-up Focus on the destination; modify path as needed Relentless communication (x infinity) Fact-based and data-driven decisions guided by what is best for the children and families

43 What Have We Learned? Speed Bumps That Slow Us Down We have yet to resolve the complexities imposed by working across state lines Malpractice and licensure Reimbursement, especially Medicaid Government relations and advocacy Faculty affairs and appointments

44 What Have We Learned? Speed Bumps That Slow Us Down Children s Mercy and KU Hospital are still technically competing entities Anti-trust and confidentiality are paramount Credentialing; PSA s; different EMR s Co-branding is potentially contentious Financial relations are complicated Developing master affiliation agreements takes longer than anticipated

45 What Have We Learned? Summary of Our Experiences Turning competitors into partners is indeed possible, given the right conditions Communication and leadership are keys Transparency and a logical, purpose-driven mission are essential for group engagement

46

47

48 Primary Care Providers for Children Pediatricians 55,509 Dual-trained internal medicine and pediatrics 3,844 Family medicine physicians 106,549 See about 15% children in their practice Advanced practice pediatric nurses ~13,000

49 China-US Pediatric Workforce Comparison United States Population 316,128,839 <18 years 76,658,019 Annual births 3,952,841 Pediatricians 55,509 children/pediatrician 1,381 China 1,390,510,630 ~295,200,000 16,400,000 ~94,000 ~3,140