When they hear the popular refrain that “the best way to get good health care in Las Vegas is by going to McCarran International Airport,” community leaders realize they have a problem.
That’s behind a drive to create a four-year medical school at the University of Nevada, Las Vegas to address the region’s shortage of doctors, which some say is only going to worsen with implementation of the Affordable Care Act.
Nevada ranks 45th in the nation in the number of physicians per 100,000 population and 46th when it comes to primary care doctors, which will be in greater demand with the Jan. 1 expansion of health care coverage through insurance and Medicaid.
Supporters say a Southern Nevada medical school will not only put a dent in the doctor shortage and improve health care, but also cultivate research, attract federal research funds and private philanthropy, and spur medical innovations that would drive the statewide economy.
But support for the school isn’t universal.
Although out-and-out opposition isn’t apparent, some stakeholders contend the focus should first be on creating more residency programs at hospitals and clinics where doctors are trained after they graduate from any four-year medical school.
In November, officials from UNLV, the University of Nevada, Reno, the University of Nevada School of Medicine in Reno (UNSOM) and the Nevada System of Higher Education signed a memorandum of understanding agreeing to create a four-year medical school in Las Vegas. The agreement also calls for comparable improvements to facilities and programs in Reno, home of the state’s only public medical school, essentially making it a four-year school instead of hosting only the first two years of instruction.
The stage has been set for 2015, when the Nevada Legislature is expected to consider funding for a Southern Nevada school that could open as soon as 2016; that is a challenging sell given recent state cuts in higher education. A statewide commission is developing a plan.
“I can’t envision anything having a greater impact on the university and region,” said Donald Snyder, UNLV’s acting president. “It’s truly a game-changer for the university. It connects the university with the community and has the social benefit of improving health care.”
According to a report by consultant Tripp Umbach commissioned by UNLV’s Lincy Institute, the state’s population is expected to grow by almost 1 million, to 3.7 million, by 2034. That growth will further stress the health care system.
The consultant’s report describes a state with an aging population, further stressed by health care reform and unable to meet the current health care needs of residents, let alone handle that future growth, without another source of trained doctors.
“It’s not that I want a medical school, but that we need a medical school,” said Mark Doubrava, a member of the Nevada System of Higher Education Board of Regents who kick-started the issue by calling for a discussion at last June’s regents meeting. “We’re the largest metropolitan area in the United States without a public medical school.”
Doubrava, a Las Vegas eye doctor and Reno alumnus, said a medical school will not only produce the quantity and quality of doctors that Southern Nevada needs, but also serve as a magnet for out-of-state doctors who want to relocate to a city with an academic medical institution.
“UNSOM isn’t strong enough, and I can say that as an alum and regent,” Doubrava said. “It doesn’t have the power to attract what we need in Southern Nevada when we talk about the lack of specialists and a lack of primary care physicians.”
Lincy Institute Executive Director Robert Lang said Southern Nevadans make it clear in interviews and with their actions that they lack confidence in Las Vegas medicine. It’s not unusual for residents of any city to travel across the country for treatment in complicated cases, but Las Vegans go to Los Angeles even for routine exams, he said.
“People are consuming fairly routine service from Los Angeles because … they aren’t confident in the delivery of that service,” Lang said. “There hasn’t been a pipeline to Southern Nevada to provide that service. A med school solves the reputation and pipeline issue, and it would add tremendously to the economic output of the region.”
In 2030, a decade after graduating its first class, a UNLV medical school would generate $1.1 billion in local economic activity and create 8,000 jobs, Lang said. In addition, expansion of UNSOM would double the economic impact to $600 million in Northern Nevada and add 4,000 jobs, Lang said.
A Brookings Mountain West report said Southern Nevada is missing nearly one-third of its medical economy, and describes Las Vegas as having the smallest share of its economy tied to health services among the nation’s top 100 cities. Health care should account for 18 percent of the Las Vegas economy, up from the current 12 percent, Lang said.
“If you want to diversify your economy, you don’t have to invent something or trade with China,” Lang said. “Just provide medical service instead of importing medicine. Everyone else does their own health care.’’
Tripp Umbach recommends the new medical school start classes in 2016 with an initial class of 60. Enrollment would grow incrementally, to an incoming class of 120 in 2030. To keep graduates from the new UNLV school and from UNSOM in Nevada, the consultant said, the state needs a minimum of 240 new residency positions statewide.
Nationally, students who complete both their undergraduate medical training and residency in the same state have a 70 percent chance of remaining in that state, Tripp Umbach reports. Students who complete only their residency in the state have a 50 percent chance of remaining, it said.
UNSOM has 335 graduates in residency programs, with 234 of those post-graduate training slots in Las Vegas. The bulk of the positions are at University Medical Center, but Sunrise Hospital and Veterans Administration Hospital also have some.
Each resident spot costs $100,000 to $150,000 per year, of which Medicare might pay 40 percent, the hospital 55 percent and the state less than 5 percent, experts say. In 1997, the federal government capped the number of trainees at each hospital by limiting federal funding, said Miriam Bar-on, associate dean of graduate medical education at UNSOM.
The cap applies to existing teaching hospitals, but allows new hospitals without training programs to develop them over five years. Clark County, meanwhile, provides millions of dollars in residency funding through UMC while the state provides a minimal amount.
That has prompted some calls for the state to spend more on residency programs instead of digging deep to start an entirely new school. They note that UNSOM gets $30 million of its $160 million annual budget from the state.
Keith Brill, president of the Clark County Medical Society, said his organization favors “anything that improves health care for Southern Nevada,” and if a medical school accomplishes that, the society would support it. But he added that residency programs are the best way right now to get more quality doctors in Southern Nevada.
Brill said UNSOM and Touro University’s campus in Henderson graduate 200 doctors a year; if most leave the state for residency training, they’re unlikely to return to practice in Nevada.
“The whole medical school issue that came out brought to light the shortage of residency programs,” Brill said. “A medical school without consideration of residency programs is a little short-sighted. We’re not against a medical school, but just want it done in the right way.”
Brill said that means creating an academic medical center like those in other states that have a hospital associated with a university. That is something Doubrava said the Board of Regents wouldn’t favor, because the state doesn’t want to be in the hospital business.
Touro Dean Mitchell Forman said UNLV should get its own medical school, but that there is no rush and that the focus instead should be on adding more residency programs at hospitals and private practices where doctors receive three to seven years of training after graduating from a four-year medical school.
“Having another medical school at a time we can’t accommodate graduates of our current medical school doesn’t seem to make sense to me,” Forman said. “You and I are paying for other states to get the graduates of that program. Is it important to have a medical school? Absolutely. There’s going to be a time where we can accommodate another medical school. We already have another medical school opening shop at Roseman.”
The Nevada State Medical Association has thrown its support for expanding graduate medical education.
“Expansion of graduate medical education opportunities must occur in order for Nevada to retain the physicians trained at our two existing medical schools,” said Stacy Woodbury, executive director of the state medical association. “The key is to have more residency slots within our state. Medicare funds have long been a traditional source of funding but there isn’t likely to be an increase in federal funds available to Nevada for this purpose.”
Nevada needs to grow its cohort of primary care physicians from more than 1,400 to more than 2,600 in the next 15 years, Woodbury said. While saying the association has yet to take a position on a UNLV medical school, Woodbury noted that the limited number of three-year residencies mean that maybe 50 to 100 of Nevada’s 200 graduates each year have an in-state opportunity.
“Four hundred sounds like a lot of slots; but if you’re outputting 200 doctors and only 100 of these slots come up, then half of those people are going to go out of state,” Woodbury said. “If we build another medical school and graduate another 100 doctors a year, we aren’t going to have any more residencies left.”
Doubrava counters that spending the roughly $15 million to $20 million per year in state money UNLV would need annually for a medical school operation on residencies instead wouldn’t provide the same economic impact. He envisions a UNLV school taking over UMC’s current 170 residencies under UNSOM because Clark County officials will want to support the local medical school. UNSOM will need to search out more residencies in Reno and elsewhere in the state, he said.
Doubrava said the UNR school hasn’t been able to tap Southern Nevada donors who would favor a Las Vegas-based medical school. A school with associated residencies in Southern Nevada will attract even more support to make those programs even better, he said.
Lang said the prospect of landing big donations argues in favor of a UNLV-run, freestanding school, rather than creating a UNSOM southern campus. Philanthropy will help cover much of the $70 million to $80 million cost for new buildings.
“No one is going to put any philanthropy in unless it’s a UNLV med school,” Lang said. “They have screamed that. Unless it’s administered by UNLV and reports to the president of UNLV, there doesn’t seem to be lots of big players in philanthropy in Southern Nevada willing to put too much in it.”
Despite the momentum for the proposal, there have been dissenting voices and calls for a go-slow approach to launching a UNLV medical school.
John Packham, the director of health policy research at UNSOM, in a 2013 newspaper column called the idea of lawmakers underwriting a new medical school a laughable and “preposterous proposal.”
Doubrava said Packham has softened his position since, but it shows that elected officials will need data and must be convinced that launching a medical school in Las Vegas benefits the state and region.
“I think two or three years ago the geopolitical climate was that there’s only one medical school and that is at UNR,” Doubrava said. “We will have to show the Reno school will stay intact and progress at its own rate, and that will make a lot of people feel comfortable. I think the more people that hear about and get their questions answered and see the benefits will make this a reality.”
Lang said a medical school would get built because it will more than pay for itself with the jobs and tax revenues it creates, at least $40 million a year by 2030. Starting a medical school is equivalent to the economic benefits of the construction industry, yet unlike construction, he said.
“We don’t have a recession in medicine,” Lang said. “And when you do medicine well, you attract businesses who want to relocate. I think there’s a reason to be optimistic I think we’re going to get this done.”