Mad River Family Practice - How is Our Investment Doing - Tara Wagner


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Mad River Family Practice - How is Our Investment Doing - Tara Wagner - as presented at The Strengthening Ohio’s Safety Net Roundtable April 29, 2011. For more info, visit

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  • Good morning, and thank you for inviting me to speak at today’s Round Table. It is my understanding that Logan County is not a service are for the Health Path Foundation of Ohio, so it is an honor to be here. Let me tell you a little bit about myself. I am the Program Manager of the OSU Rural FM program. I started working with Dr. Longenecker and the program six months after its start in July 1998. My work experience at that point was in the legal field; serving as a deputy clerk for our county criminal court and as a court stenographer for several years. In this position, I have had the opportunity to support the 15 family medicine physician graduates of our programs in their careers. My presentation today is about the story of Mad River Family Practice: The OSU Rural Family Medicine Program. This presentation was created by my Program Director, Dr. Randall Longenecker, and together we have presented it on a couple of occasions. Specifically, to the Mary Rutan Hospital BOD in 2009 and the RTT Conclave that we hosted just this past February 2011. I would like to offer a disclaimer. As the program manager of the residency program since it’s infancy, I will do my best to present to you the facts as I understand them. However, please know,it is Dr. Longenecker who is the expert in this area regarding RTTs. We are both extremely passionate about our work and are doing our best to make others aware of rural graduate medical education.
  • As I indicated, The OSU Rural Program at Mad River Family Practice began in July of 1998. We are one of 26 RTT programs in the U.S. Dr. Longenecker began working on the program back in 1996, the CEO of our local community hospital, Mary Rutan, impressed upon him the importance to the institution in investing in people and in education. With the right connections, That became possible. Ask if everyone is familiar with 1-2 Rural TT? If not, Explain. The OSU Rural Program is an integrated “2-2-2” residency program in Family Medicine. We were the first one in the nation. “ Integrated” because under ACGME accreditation, OSU is our sponsoring insitituion (having only 2 residents per year, we are required to be associated with a larger residency program and are considered a “rural traiing track” of that program. Housed at Mary Rutan Hospital and Oakhill Medical Center Educational experiences embedded in an on going family practice, preparing physicians to work in rural small-town settings, preferably in Ohio
  • Map to show were Logan County is.
  • Back in 2009, our Mary Rutan Hospital’s current CEO asked Dr. Longenecker and I to present to the BOD answering the question of “How is our investing doing?” Well, we believe we have done well. But the group that we are particulary proud of are the three physicians who have stayed in Logan County, OH: Dr. Baker is currently a physician in our emergency room at Mary Rutan Hospital. She and her husband own and organic farm just outside of Logan County, near LaRue, OH Drs. Leesa McCauley and Laura Sorg are currently practicing at Mad River Family Practice. Dr. McCauley and her husband have integrated in our community, living in a very quaint part of Logan County, West Liberty, OH, with their two children. Dr. Sorg and her husband live in Marysville with their son. All were raised in rural America and believed in coming back to rural areas to offer their services as a physician.
  • In the eyes of our BOD, we may have started as a way to train doctors for Logan County, but outcomes have become much more, many of them unexpected. We have become (read slide). I will go into each one as we move through the presentation.
  • We have a healthy clinical practice: Productivity – patient visits, birth, hospital admissions; faculty physicians have met their MGMA benchmarks for clinical productivity in each of the past 10 years. Charitable care (e.g. We are the practice who sees unassigned OB patients) Downstream revenues - $2 million/FTE primary care physician (2 to 2.5, caring for an active primary care population for approximately 4,500 individuals.) Quality of medical care and patient safety – We like to think of ourselves as a “learning practice,” continually working at practice improvement, and for example; with the lowest cessarean rates and as good or better perinatal outcomes than any other practice in our own community and those around us.
  • Other Community Benefits: We provide monthly group prenatal visits to our Amish Population In our community medicine curriculum, our residents do rotations at each of the community service organizations to gain better understanding of the services they provide to our community and their patients. Additionally, the residents are required to do a community invention project, which is actually how the Amish Group prenatal visits came to be. Residents have also gone into the schools to discuss with elementary students the effects of smoking, performing personal hygiene and most recently, one of our residents is working with local law enforcement to educate students on prescription drug abuse. Community Leadership – Patient Advisory Board – Income into our Community - Our community isn’t just where we live, it is our state and our nation. Locally, I have represented our program and practice by serving on local Boards, with the most recent being the Chamber Board of Directors, working my way up to Chairperson last year. Dr. Longenecker has represented MRH in Columbus and Washington DC on issues relating to Rural medical education. In fact, MRH has had a voice at tables to which they would never have been invited to, if it were not for the Rural Program). Dr. L has had the opportunity to be a part of developing legislation around physician training and other workforce needs as part of the health reform package, to which was thrown out  . I will share with you
  • Other health professions education (Elaborate on slide) Med students for clerkship rotations Nurse practitioner students Pharmacy students
  • Visibility – medical students from all over Ohio with an interest in rural practice now know about Mary Rutan Hospital through our Rural Health Scholars Program. This program was created by Dr. L and I and we have done it annually for about 10 years. It is open to all of the medical schools in OH. We invite students to apply to the program, review their application and choose around 15 students to participate in a weekend retreat centering around rural health issues. Some of the topics we have formed the retreat around have been: Defining “rural” Advocacy in rural medicine Women’s Health Behavioral Health
  • This slide is a little date in that these are revenue figures for 2007-2008, but suffice it to say that Mary Rutan Hospital has NOT subsidized the clinical practice for those first 10 years.
  • To date, we have graduated 15 family physicians, all of whom have gone to practice in rural areas of OH,Texas, NC, WI, & Canada.
  • What have been our ongoing challenges with the program: Student and faculty recruitment, retention and regeneration (we are competing for the 15-20 students in the WORLD who truly want and rural training track education, and would come here even if offered a position in a larger urban program: While I said MRH has not subsidized the clinical practice, it has subsidized the educational portion of the program solely for the past 9 years. The educational program was started by a grant and OSU contributed to the program for the first 4 years, since then MRH has been funding our educational mission to the tune of $115,000 per resident per year, compared to benchmarks ranging from $125K to $260k. Program adaptation – We have had varying number of residents over the years. Choosing not to fill our slots with the wrong resident physican because of our size – one bad egg in a program our size is a challenge; Demands of patient care continue and with limited faculty and residents, the challeges continue to grow, economic realities – it costs more to do business. Change in faculty – Esch getting married, Wenger leaving, Johnson coming and going, resident going to come on as faculty and 4 weeks before her residency graduation, she informed us she would not be coming – significant blow to our practice.
  • Adversity forces innovation and only persistence leads to long-term success. The challenge Dr. Longenecker and I presented to our BOD back in 2009 was to invest for the long-term, continue to invest in people and education, which we believed, and continue to believe, are the lifeblood of any health institution. Back in 2009, our hospital BOD were very much in favor of our program, offering continued support. However, in January of 2011, Dr. Longenecker and I were on our way back from the Rural Health Policy institute and received a call from our CEO that our program would only be funded for another year.
  • So what happened in 2011? Well, our clinical practice has become more heavily Medicaid. We are the only family medicine practice owned by Mary Rutan Hospital and see approximately 30% Medicaid in our practice. In fact, we are the only practice that sees new Medicaid. Our physicians and residents used to deliver from 100-125 births a year and we have decreased down to almost half. The faculty turnover as I mentioned before Recession – Mary Rutan hospital has operated in the black for 30 years and are now facing red ink due to a combination of declining investment income, inpatient revenues and an OB tragedy… Ohio hospital tax has increased A transition to a sole community hospital which changed the hospitals reimbursement rate. And the big one – A CONSULTANT CAME
  • Here is a slide to share with you the income trends of MRFP. You can see the decline based on all of the factors that I have indicated.
  • Other factors that have contributed to our challenges was the adjacent medical practice who has decided to no longer care for patients in the hospital and no longer want to share call with MRFP faculty. WE do not have enough physicians to go around. Recruiting a family medicine hospitalist to help with call and duty hour supervision of interns was not seen as financially possible. Recruiting a family physician with OB skills in Ohio is virtually impossible. We have been trying to do that for the past 13 years. Additionally, we have been trying to recruit a program director. And the introduction of EHR
  • So where are we going from here. We Dr. L and I are individuals who persevere against all odds. We are passionate about what we do and are looking to keep Mad River Family Practice alive through exploring other practice models, RHC, CHC with the ultimate goal to become a Teaching Health Center. Our most recent venture is the RTT Technical Assistance Program. Part of the President’s Improving Rural Health Care Initiative, the RTT Technical Assistance Program is a demonstration program with the goal of improving fill rates of RTT programs, increasing the sustainability of existing RTT programs, and helping new RTT programs get started. By engaging the expertise of RTT program directors, faculty, and staff around the nation, this program provides an opportunity to share information about the factors that have helped existing RTT programs to thrive, better understand their threats, and provide technical assistance to help support success and expansion of all RTTs. This national program, with Dr. L serving as the program manager, is a consortium devoted to sustaining medical education in rural places. Partners in this endeavor are the National Rural Health Association, National Organization for State Offices of Rural Health, Rural Assistance Center and WWAMI (Washington-Wyoming – Alaska-Montana and Idaho) Rural Health Research Center.
  • So is the sun rising or setting here? It is rising, and that is what we do at Mad River Family Practice. We rise to the most adverse of situations and learn from our challenges. I left this slide blank for a reason. I want you to write this down: What would we want you to know, The Health Path Foundation of Ohio: Just because The OSU Rural Program is suspending itself, does not prohibit another rural community in Ohio from doing the same thing. Dr. Longenecker wanted me to let you know that he offers his assistance should anyone be interested. It’s the community investment that matters in the long-term, outside “partners” come and go! The residency program and MRFP would not have survived this long with out a hospital such as Mary Rutan. However, obtaining that support from the citizens of the community, making them aware of the residency and buying into the program, would also provide a arm of support that would be significant. Finally, when you invest in programs such as RTTs, make sure you are investing in the program from the bottom up, not from the top down. In other words, do not give resources to an institution expecting it to get down to the program you are intending to sponsor. Rural Training Track residency programs are vital, but fragile. You must give directly to the program! Thank you very much for your time today and allowing me to share our story. Are there any questions?
  • Mad River Family Practice - How is Our Investment Doing - Tara Wagner

    1. 1. Mad River Family Practice Randall Longenecker MD, Rural Program Director Tara Wagner, Program Manager Presented to the Mary Rutan Hospital Board, April 2009; Updated for the RTT Conclave February 2011; The Health Path Foundation of Ohio April 2011
    2. 2. 26 - 1-2 Rural Training Tracks in the US
    3. 3. Logan County (Bellefontaine), Ohio
    4. 4. How is our investment doing?
    5. 5. More than a residency… <ul><li>Clinical practice </li></ul><ul><li>Other community benefits </li></ul><ul><li>Other health professions education </li></ul><ul><li>Faculty personal and professional development (physician retention) </li></ul><ul><li>Visibility among potential physician recruits </li></ul><ul><li>Advocacy </li></ul>
    6. 6. A Healthy Clinical Practice <ul><li>Productivity – patient visits, births, hospital admissions; faculty physicians have met their MGMA benchmarks for clinical productivity in each of the past 10 years </li></ul><ul><li>Charitable care (e.g. unassigned OB – provides justification for DSH funding) </li></ul><ul><li>Downstream revenue - $2 million/FTE primary care physician (2 to 2.5 FTE, caring for an active primary care population of approximately 4,500 individuals) </li></ul><ul><li>Quality of medical care and patient safety </li></ul>
    7. 7. Other Community Benefits <ul><li>Amish group prenatal visits </li></ul><ul><li>Community Medicine curriculum and Community Intervention </li></ul><ul><li>Community Leadership </li></ul>
    8. 8. Health Professions Education <ul><li>Medical, nursing, and pharmacy students </li></ul><ul><li>Bioethics education for OSU residents, hospital staff and community </li></ul><ul><li>Collaborative practice education at the College of Nursing </li></ul><ul><li>Interprofessional education at The Ohio State University </li></ul>
    9. 9. Visibility
    10. 12. Ongoing Challenges <ul><li>Student recruitment (competing for 2 of the 15-20 students in the world who desire a RTT education in the US) </li></ul><ul><li>Faculty recruitment, retention, and regeneration </li></ul><ul><li>Funding the educational mission - ~$110,000 per resident per year (compared to benchmarks of $125,000 to $250,000 in direct expenses) </li></ul><ul><li>Program adaptation - number of residents, demands of patient care, economic realities, change in faculty </li></ul>
    11. 13. Our challenge to the Board… Invest for the long-term in people and education…, the lifeblood of a healthy institution.
    12. 14. So what happened in 2011…? <ul><li>Clinical practice has become more heavily Medicaid </li></ul><ul><li>OB volume has decreased </li></ul><ul><li>Faculty turnover </li></ul><ul><li>Recession - a hospital that has been in the black for 30 years is facing red ink (combination of declining investment income, inpatient revenues, OB tragedy…) </li></ul><ul><li>Ohio hospital tax </li></ul><ul><li>Transition to Sole Community Hospital reimbursement </li></ul><ul><li>Consultant came </li></ul>
    13. 16. Other factors… <ul><li>Adjacent medical practice, with who we share call, has decided to no longer care for patients in the hospital, no longer share call with MRFP faculty </li></ul><ul><li>Recruiting a Family Medicine hospitalist, to help with call and Duty Hour supervision of interns was not seen as financially possible </li></ul><ul><li>Recruiting a family physician with OB skills in Ohio is virtually impossible </li></ul><ul><li>Introduction of EHR </li></ul>
    14. 17. New Directions… <ul><li>Morph MRFP into a Rural Health Professions “Campus” </li></ul><ul><ul><li>Rural Health Center </li></ul></ul><ul><ul><li>Community Health Center </li></ul></ul><ul><ul><li>Teaching Health Center </li></ul></ul><ul><li>Rural Training Track Technical Assistance Program </li></ul><ul><ul><li>Sustain and increase RTT residency programs </li></ul></ul><ul><ul><li>Establish a national network </li></ul></ul><ul><ul><li>Identify and inform regarding key policy issues related </li></ul></ul><ul><ul><li>to RTT programs and Rural GME </li></ul></ul>