Monday, June 4, 2007

Earlier Thoughts of BigU Administration Concerning
Possibility of St. Thomas/Allina Medical School

An earlier post of Dr. Frank Cerra's email to faculty has been made: "Blanket Email from Senior Vice President for Health Sciences, Kudos and Questions for Proposed Medical School."
Dr. Cerra's message was sent on May 25. Minutes of an earlier discussion have just appeared. It is cited here as background for the dialogue on this matter that is soon to occur.



Faculty Consultative Committee
Thursday, May 17, 2007

5. Discussion with Senior Vice President Cerra

Professor Chomsky welcomed Dr. Cerra to the meeting for his biannual discussion of issues related to the Academic Health Center. Professor Balas started the conversation by asking Dr. Cerra what he thought of the proposal for a medical school at St. Thomas.

Dr. Cerra noted that the proposal is that Allina and St. Thomas will jointly form a new medical school next to Abbot-Northwestern hospital. It is their view that they must address three major areas: prevention, chronic disease management, and end-of-life care (issues that all medical schools are focused on) and that there are not enough primary-care physicians, so they need to start a new medical school. The boards of the two organizations are doing a feasibility study.

They will need a lot of money, Dr. Cerra observed, and must learn what a medical school is and is not. The question of whether Minnesota needs more family-practice/primary-care physicians is a good one, he said. There are parts of Minnesota that are classified federally as facing a shortage of doctors and those areas need family-practice physicians. If, however, one looks at the ratio of doctors to people in the state generally, supposedly Minnesota has a sufficient number of doctors, so the issue is distribution and how far someone should have to drive to see a doctor. Moreover, the University's family-practice programs are not full (a phenomenon true across the country); if there is a shortage of family-practice doctors, why don't Allina and St. Thomas work with the University to fill those programs?

If the two organizations really want to focus on prevention, chronic disease management, and end-of-life care, one can question whether that is best accomplished with physicians. The expertise of nurse-clinicians and clinical pharmacists is more effective in both outcomes and costs. That is the path the schools of the Academic Health Center are looking into.

The operating cost of a medical school is about $1 million per student per year. Instructional costs alone are $200,000 per year per student, fully loaded. If the plan for the new school is to graduate 40 students per year, it would have 160 students, so would cost about $160 million per year. Primary-care/family-practice physicians leave medical school with a debt-to-income ratio of about 2:1: they have about $180,000 to 200,000 in debt and their average starting salary is $80,000 - $100,000. It can take 25-30 years to pay off the debt. That is one reason the slots in the family-practice programs are not full, Dr. Cerra concluded. Others include lifestyle, reimbursement for services, and geographic challenges.

So how will a new medical school be financed? If by endowment, and one assumes a 5% return on the endowment, there will need to be an endowment of $20 million per student. There would need to be lots of money, Dr. Cerra said, and if the donor community put that kind of money in a new medical school, "what is left for the rest of us?" Those are the problems for the community but Minnesota is not that big a place. With about 5 million people it has done amazing things, but it can water down its accomplishments.

Professor Gunnar said she thought there were programs that would support physicians who agree to go to outstate Minnesota. There is not much money in those programs, Dr. Cerra said. If they do open a medical school, will the University offer a plan to provide the training more cheaply? It already does at the Duluth campus, Professor Elliott pointed out, and it is done exceptionally well. A lot of Morris students go to the Duluth medical school, Professor Carpenter said; Dr. Cerra added that they would like to establish pipelines with other campuses as well.

If one considers the physicians in Minnesota, over 70% received their ability to be licensed from the University; in greater Minnesota, over 80% received their training at UMD. That sounds like a better deal for donors, Professor Gunnar said.

How much of this is about the need for family-practice physicians and how much is about St. Thomas wanting another professional school, Professor Martin asked? Dr. Cerra said he did not know, although he has not been successful in his attempts to contact St. Thomas. There is speculation concerning the production of providers in the future so Allina went to St. Thomas; they saw the University is linked to Fairview, and with federal funds for graduate medical education declining, they believe that tuition and health-system payments will fund medical schools. If that is the model, how can they not also do something for nursing, pharmacy, public health, and so on, Dr. Cerra asked? That is an argument for partnering with the University. Dr. Cerra said he did not understand how the nature and values of a full-service health-care system and a faith-based university would mesh. He learned in the University-Fairview discussions that if the values do not match the partnership cannot work.

There is no accreditation prohibition on the establishment of the new medical school, Dr. Cerra said, but he does not understand why the American Association of Medical Schools keeps saying there is a terrible shortage of physicians and medical schools must increase enrollment or the number of medical schools must be increased. That is not true in Minnesota or in most areas of the U.S. and what is driving the call is the increase in osteopathic schools. There are osteopathic and allopathic medical schools; Minnesota's is allopathic, as are the ones at almost all major research-intensive universities. Osteopathic schools are private and are accredited by the same bodies and processes as allopathic schools.

Dr. Cerra said he is not saying he would not support the new medical school but that he does have a lot of questions about it, since the question about the workforce in those areas of treatment has been raised. Why only solve the problems with physicians? If they can be addressed with other providers, it is not clear there is ANY physician shortage except perhaps in a few specialty areas.

Professor Balas thanked Dr. Cerra for the explanation and commented that it seemed to be an odd time to think about a new medical school when the University's budget does not look that good. This is another time when someone is saying the University is not delivering what the state needs, when it is. Dr. Cerra agreed and commented, by way of example, that the University probably doesn't talk enough about the 180 pharmacists who will graduate this year, most of whom will stay in Minnesota. They will also solve the Occupational Therapy/Laboratory Science problem, which no other place has done.

This is undoubtedly a complex problem and there seems to be a difference of opinion about how to solve it. Dr. Cerra is certainly right that starting a new medical school will be expensive, but perhaps not as expensive as he thinks. Coming up with money so that family practice physicians would not be under crushing debt load seems to be a rational thing to do in this situation. But of course the U has not done this to date and thus leave themselves open to questions on the matter. The strategy of running up the tuition rate in an attempt to garner more state support may have backfired. BigU's instate medical school tution is currently the highest for any public university in the country. Certainly the BigU medical school administrataion seems concerned that another med school may drain resources from an already financially precarious situation. This concern is justified.

It should be an interesting summer. Mr. B.

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