Rackleff, Linda Z.; O'Connell, Mark T. MD; Warren, Dwight W. PhD; Friedland, Michael L. MD
In this article, we describe how the University of Miami Miller School of Medicine (UM) and Florida Atlantic University (FAU) were able to make a successful case to state policymakers for a regional medical campus as a cost-effective approach to expanding undergraduate and graduate medical education opportunities in southeastern Florida.
Until the mid-1990s, the general consensus among most Florida policymakers was that the state's overall supply of physicians was adequate and that a surplus existed in some medical specialties. Around 1995, concerns began to be expressed about a potentially imminent Florida physician shortage by representatives of four Florida universities interested in creating new medical schools on their campuses: Florida State University (FSU) in Tallahassee, Florida International University (FIU) in Miami, the University of Central Florida in Orlando (UCF), and FAU in Palm Beach County. These universities noted that Florida had distinguishing characteristics that could have negative implications for the adequacy of the state's physician workforce in the near future. Florida has one of the oldest and most quickly growing populations of the elderly, who consume medical services at a significantly higher rate than do younger individuals. The percentage of Floridians over the age of 65 is projected to grow more rapidly than that of any other age group, with a 3.5 million (124%) increase in the number of elderly persons projected to occur between 2000 and 2030.1 Similarly, the members of Florida's physician workforce are significantly older than are physicians nationally; 26% of Florida's physicians are over the age of 65, compared with 16% nationally.2 Florida has relatively limited access to medical education and training, consistently ranking in the lowest decile nationally in both the number of positions for medical school students and for residents per 100,000 persons in the population.3
Policymakers' search for cost-effective strategies
In the late 1990s, the Florida Board of Regents, the governing entity for the Florida state university system, began to evaluate various approaches that could be undertaken to expand access to undergraduate and graduate medical education within the state. From the beginning of this evaluation, the board placed strong emphasis on each approach's cost to state taxpayers and each approach's expediency (i.e., how quickly it could result in an increase in the state's physician workforce). Among the mechanisms that the board evaluated were (a) creating one or more new public medical schools, (b) expanding the capacity on the main campuses of the state's two public allopathic medical schools, the University of Florida (UF) and the University of South Florida (USF), and one private allopathic medical school, the UM, (c) establishing one or more regional medical campuses of the existing medical schools, and/or (d) expanding residency training opportunities. (See Figure 1 for the locations of Florida's medical schools, including the new regional campus at FAU.)
The state cost to build new medical schools.
When FSU proposed a new medical school in 1998, the supporting budget indicated that the cost to the state would be approximately $38 million in annual operating funds and $65 million in facilities construction funds. The state's share of the cost per medical student for a new FSU medical school was estimated to be $80,000 in annual operating costs when the school reached full enrollment of 480 students. FSU did not propose to create a faculty practice plan, which could supplement state funding for the undergraduate medical education program. As a result, state costs per medical student at the new FSU program were projected to remain relatively high compared with the amount of state funding available per medical student at USF ($22,200) and UF ($16,100). At both UF and USF, state funding per medical student had been steadily declining during the past decade, as clinical revenue increased as a source of funding for undergraduate medical education to constitute approximately 45% and 50%, respectively, of the medical schools' budgets. The proposed implementation schedule for the new FSU medical school provided for graduation of the charter class six years after legislative authorization of the new school.
The state cost to expand enrollment on the main campuses of the existing medical schools.
Data submitted by the state's three allopathic medical schools (UF, USF, and UM) indicated that they could collectively expand their enrollment by a total of 162 students at a cost to the state of approximately $4.86 million, or $30,000 per student, in annual recurring operating funds. UF, USF, and UM were able to add enrollment to their existing classes at a cost to the state of approximately $50,000 per student less than per-student state costs for a new medical school because the academic and administrative infrastructure already in place at the medical schools was adequate to support the expanded enrollment without the need to employ significant numbers of additional faculty and staff. However, none of the three medical schools could increase their enrollments without expenditures for new or remodeled facilities that totaled $69.6 million in nonrecurring state costs. UM indicted that it could expand medical school enrollment by only 22 students on its main campus in Miami. Even this modest expansion, at a cost to the state of $2.64 million in annual operating costs, was dependent on the construction of a new building, estimated to cost $12.43 million, to accommodate basic science instruction for first- and second-year medical students. The proposed expansion plan submitted by UM, UF, and USF provided for a five-year phased-in increase in the number of medical school graduates, beginning two years after receipt of necessary state funding.
Establishing the Regional Medical Campus
In July 1997, the chancellor of the Florida state university system convened a meeting of representatives of UM, FAU, and FIU to discuss the development of a potential partnership between UM and FAU and/or FIU to expand access to medical education in southeast Florida, the most densely populated area of the state, which had no public medical school. The state already had a long-standing and highly successful relationship with the UM medical school, which began in the late 1960s when the Florida legislature agreed to support UM to provide medical education to Florida residents if UM achieved accreditation by the Liaison Committee on Medical Education (LCME) before UF's newly established medical school was accredited. The UM “first accredited medical school” appropriation, equal to approximately $30,000 per student to support up to 500 Florida residents matriculating at UM's medical school, has continued annually thereafter. In 1998, providing UM with the opportunity to establish a two-year regional medical program on the FAU and/or FIU campuses was considered to be a logical expansion of the state's relationship with the UM Miami campus and a potentially more cost-effective means to expand access to medical education in southeast Florida than was construction of a new public medical school at either FAU or FIU.
This initial meeting led to an agreement by UM and FAU to proceed to explore how a program could be structured that would enable students to complete the first two years of medical school on the main campus of FAU in Boca Raton before transferring to UM medical school's main campus in Miami for years three and four. FIU declined in favor of continuing its efforts to gain approval to establish its own medical school on its Miami campus.
Securing state resources
The proposed budget that UM and FAU developed for a two-year regional campus at FAU that would ultimately have a total enrollment of 64 students was $4.4 million in recurring state operating costs, or approximately $69,000 per student. Although the state cost per medical student for the proposed regional campus was more than the $30,000 state cost per student to expand enrollment on UM's main campus in Miami, the regional campus could accommodate a total of 64 students, almost three times the number of additional students UM could add on its main campus. UM and FAU proposed that the majority of the instruction on the regional campus would be in the form of lectures delivered by UM faculty; the lectures would be simulcast via teleconferencing to the regional campus. Consequently, although a modest number of faculty and staff would be required on the regional campus, personnel costs on the regional campus would be significantly below the faculty costs required to deliver the first two years of the medical school curriculum using the more traditional live instructor approach contemplated by FSU's budget of $80,000 per medical student. The FAU regional medical campus was also less expensive than constructing a new medical school because centralized administrative and academic support functions (student services, financial aid, faculty affairs, etc.) were already in place on the UM main campus in Miami and would not have to be completely replicated on the regional campus. Finally, the FAU regional campus would require no additional construction funding because the regional campus medical students could be housed in a new $30 million biomedical sciences building being planned on the FAU main campus, for which private funds had been secured and state matching funds committed.
In FY98–99, the Florida legislature determined that authorizing and funding a two-year regional campus of UM at FAU was a cost-effective mechanism to expand access to medical education in southeast Florida. The new campus was named the University of Miami Miller School of Medicine at Florida Atlantic University. A total of $1.55 million was appropriated to FAU to plan for the regional medical campus between 1998 and 2000. No additional appropriations were made in FY01–02 or FY02–03, largely because of the significant appropriations that were directed to begin the FSU medical school, which was authorized by the Florida Legislature in 2000. The absence of two consecutive years of state funding required that admission of the charter regional campus class of 16 students, originally planned for 2002, be delayed until FY04–05, when $2.3 million was appropriated.
Expansion to a four-year regional campus
By 2004, when the charter class of students was admitted to the two-year UM regional medical campus program at FAU, it began to seem increasingly likely that either FIU and/or UCF would ultimately be successful in their campaigns to secure authorization for two more new medical schools. A one-time window of opportunity was occurring for UM and FAU to receive authorization to expand the regional campus to a four-year program.
These two schools were again able to demonstrate that investing in expansion of the regional medical campus to a four-year program was cost-effective for the state. The budget for the four-year regional campus program was $14.4 million in annual state operating costs for 256 students, or $56,000 per medical student. Operating costs for the four-year regional campus program that were significantly below the cost to the state of building a new medical school could be achieved on the regional campus because UM would share the costs of the clinical faculty required for the four-year program with FAU. UM and FAU also noted that expansion of the program to four years would produce medical school graduates more quickly than would new four-year medical schools. UM and FAU also proposed to create a new, innovative four-year curriculum on the regional campus that would constitute a separate track within UM. Finally, UM and FAU proposed that the four-year regional medical program would serve as a catalyst for the development of residency programs with a total of as many as 250 to 300 new residency positions, to be located in a consortium of southeast Florida community hospitals. In 2005, the Florida Board of Governors endorsed and the Florida legislature authorized expansion of the UM regional medical campus to a four-year program.
Perceived benefits to UM of a partnership with FAU
Although the partnership between UM and FAU to provide undergraduate medical education in Palm Beach County proposed by the Board of Regents in the late 1990s was not a concept initiated by UM, that medical school found the concept appealing because it enabled UM to achieve two important objectives: expanding its clinical practice enterprise and its fundraising activities beyond Miami-Dade County. A significant number of patients living in North Broward and Palm Beach Counties who had been commuting to Miami to see UM medical faculty specialists had been urging UM to establish clinical practice sites closer to their homes. UM had begun to respond to this demand by establishing branches of its Miami-based Bascom Palmer Eye Institute and Sylvester Cancer Center in Palm Beach County and North Broward County. Creation of a two-year regional medical campus at FAU that would subsequently be expanded to a four-year program provided UM with the opportunity to begin to assemble a cadre of clinical faculty for undergraduate and graduate medical education teaching purposes who would also be available to provide clinical services to patients living in the area. With a population ranking among the most affluent in the state, Palm Beach County provided a promising opportunity for the generation of clinical income. UM was also interested in expanding fundraising activities in Palm Beach County, whose affluent residents were considered to be an untapped source for philanthropy.
Perceived benefits to FAU of a partnership with UM
FAU had begun as early as the mid-1990s to explore the feasibility of creating a four-year medical school on its campus. However, alignment of political influence in the state legislature suggested that if any new medical school was to be approved in the near future, it was most likely to be at FSU. This prediction proved to be true when the legislature approved the creation of the FSU medical school in 2000. FAU continued, however, to be open to exploring other mechanisms in which it could participate to provide access to medical education on its campus. The proposed partnership with UM for a two-year regional campus program at FAU was attractive to FAU because the presence of UM medical students and faculty on the FAU campus would enhance FAU's ability to compete successfully for major biomedical research funding and would generally enhance the reputation and stature of the university in the region and state. It was also anticipated that the presence of a regional medical program at FAU would benefit Palm Beach County by improving the quality of health care available to its citizens and enabling the county to attract business and industry involved in the biomedical sciences. This expectation has already proven to be accurate. In 2006, the Scripps Research Institute finalized plans to locate a major research complex on the FAU regional campus in Jupiter, Florida, in northern Palm Beach County.
Opportunities and Challenges Implementing the Regional Campus
UM and FAU have faced a variety of challenges as they have collaborated to plan and implement the regional medical campus. Only one of these challenges, the necessity to charge private medical school tuition on a public university campus, is a direct result of one university being a private and the other a public entity. Other challenges are those that predictably arise whenever two institutions, with their own unique histories, cultures, and ways of doing business, join forces to achieve a mutual objective.
State support for the regional medical campus has been somewhat unpredictable since the two-year regional campus was first authorized in 1998. As of FY05–06, the state had appropriated $6.4 million in recurring annual operating funds of the $14.4. million in annual recurring funding required to fully fund the four-year regional campus. In FY06–07, the legislature appropriated $5.0 million in nonrecurring funding to the regional medical campus and also authorized the creation of two new state medical schools at FIU in Miami and at UCF in Orlando. A total of $4.7 million in recurring funding is being requested for the FAU regional campus for FY07–08 in order to stay on schedule for full implementation by 2011.
The lack of predictability in state funding for the regional medical campus seems to be more a function of the absence of a comprehensive strategic state plan for expansion of the state's medical school capacity than a reflection of any specific reservations about the UM-FAU regional medical campus. Securing necessary recurring state funding to fully implement the four-year regional campus program will continue to be a major challenge for UM and FAU in the coming years as the existing public medical schools at UF, USF, and FSU and the two newly authorized public medical schools at FIU and UCF compete for state resources.
As noted earlier, LCME accreditation standards for geographically separate campuses require that the tuition charged on the regional campus be equivalent to tuition on the main campus. Therefore, students on the FAU regional medical campus pay UM tuition, which, for in-state students for the current academic year, is $29,298, or approximately $11,000 more than the average in-state tuition at the state's three public medical schools. UM has committed to maintaining its tuition at current levels. However, Florida public medical school tuition, which has been below national averages, has risen approximately 34% and 31%, respectively, for in-state and nonresident students during the past five years. If public medical school tuition continues to rise in the next several years, parity between UM and Florida public medical school tuition is expected to be reached in the near future.
Challenges of Delivering Instruction on Two Campuses
From the earliest discussions between UM and FAU about the curriculum to be offered at the regional campus, there was agreement that separate LCME accreditation of the FAU regional medical campus would not be sought. Instead, the program on the FAU campus would be developed as a geographically separate program track of UM. The LCME has specific accreditation standards for regional (geographically separate) campuses. On regional campuses, separate educational tracks may be offered that have objectives that are different from, or in addition to, the curricular objectives of the parent institution. To meet the unique objectives of the separate track, regional campuses may also have distinct course structures, instructional methods, and grading and evaluation methods that are specifically designed for that purpose. However, LCME accreditation standards require the main and regional campuses to share a common set of core institutional educational objectives that all students are expected to achieve. Students on main and regional campuses must also be held accountable to a common set of comparable standards for academic progress.4
UM and FAU have signed two memoranda of understanding, summarized in the Appendix, that address the protocols that govern the current two-year undergraduate medical education program. The last class of students was admitted to the two-year regional campus program in 2006 and will transfer to the UM main campus for the last two years of medical school in 2008. UM and FAU are in the process of reviewing these operating procedures to identify modifications to that will be necessary for implementation and administration of the four-year undergraduate medical education program that will begin in August 2007.
Maintaining comparability of the educational experience between the UM main campus and regional campus has been relatively straightforward for the two-year regional campus program because first- and second-year course content and course objectives are equivalent and courses are taught in parallel at both campuses, using a combination of distance learning and FAU biomedical science faculty for on-site instruction. As the number of FAU-based students has increased from the 16 students admitted to the 2004 charter class to the 32 students admitted in 2005 and 2006, more live lectures are being given at FAU. In 2004, approximately 60% to 65% of instruction was delivered live by FAU faculty or clinical community physician faculty on the regional campus, and 40% was delivered by distance learning. The percentage of instruction delivered by distance learning from Miami has fallen steadily; for the class admitted in 2006, approximately 75% of all instruction is occurring live on the regional campus.
As the percentage of instruction delivered on the regional campus by distance learning transmitted from Miami has fallen and the percentage of instruction delivered live on the regional campus has increased, the perception has arisen intermittently among FAU regional campus faculty and students that faculty lectures originating from the UM Miami campus do not necessarily cover the published objectives for the course or lecture in question and may include different and/or additional objectives that are not being covered by FAU faculty. This potential disconnect between the two campus curricula has been exacerbated by concerns that course examinations are developed primarily by UM faculty, with insufficient involvement of, or consultation with, FAU faculty, who may not have an opportunity to review an examination until immediately before it is administered on the regional campus. Because of regional campus students' perception that UM faculty have greater control over curricular content and examination development than do FAU regional campus faculty, many regional campus students have chosen to skip live FAU faculty lectures in favor of watching either simulcast lectures from the Miami campus or archived videos of UM faculty lectures that have been available to students on both campuses by the end of the day on which they were given. As a result, attendance at some regional campus lectures has been poor, particularly for sessions given by community physician guest lecturers. Although student attendance and full participation in all aspects of the medical school experience at both the UM and FAU campuses is strongly encouraged, there is no school policy requiring attendance at lectures. The decision whether to require attendance at lectures resides with individual course coordinators. Attendance at lectures is not required for the majority of courses.
The administrations at both campuses are revising policies and making a concerted effort to facilitate open communication and collaboration among faculty at both campuses to support their efforts to jointly develop and share exam questions. All exam questions are being submitted to the curriculum office for dissemination to relevant faculty for review and feedback. Frequent videoconferencing between faculty at the two campuses to discuss examination-related issues is being strongly encouraged. To promote attendance at FAU lectures, live Webcasts of all lectures at the Miami and FAU campuses were discontinued in April 2005.
Some concern has also been raised about the lack of continuity created within courses that include multiple part-time community clinical faculty, each of whom may only provide a single lecture. The need for better, more formalized faculty development, particularly for part-time clinical faculty, has also been recognized. New criteria have been introduced requiring a minimum commitment of time from clinical faculty from the community who teach in the program to improve continuity and integration of the material. The objective is to employ a smaller number of community clinical faculty, each of whom teach a minimum number of hours. A Director of Medical Education and Faculty Development has been employed on the regional campus to institute a faculty development program for clinical faculty.
Despite the challenges that UM and FAU have encountered delivering instruction on two campuses, students on the regional medical campus have performed as well as, if not better than, students on the main UM campus on outcome measures of student performance, including examination scores, course grades, and promotion rates from year one to year two.
The New Four-Year Educational Program
The authorization of the new four-year regional medical campus at FAU in 2005 has provided a unique window of opportunity to create, from the ground up, a truly innovative and creative undergraduate medical educational program without the dilution of energy and resources that consensus building would require to change the existing curriculum on the UM main campus. It is anticipated that successful educational innovations from the regional campus can ultimately be transferred back to the Miami campus curriculum with greater likelihood of buy-in and successful implementation.
During 2006, FAU and UM faculty finalized a document that describes the guiding principles for the new four-year medical education program, and they are now in the process of developing the curricular content for the new regional campus curriculum. The regional campus program will be distinguished from the program offered on the Miami campus by an emphasis on (a) case-based and patient-centered education through collaborative, small-group student learning communities, (b) an integrated curriculum that breaks down traditional barriers between the basic, clinical, and social sciences and between the academic health center and the community, (c) core competencies and critical curricular content in areas including comprehensive chronic disease management, geriatrics, population-based medicine, interprofessional training and care delivery, and the physicianship skill set of leadership, professionalism, quality assessment and improvement, evidence-based practice and decision making, and medical informatics and information management, and (d) interprofessional educational experiences involving medical students and students from other programs of health professions education (i.e., nurses, dentists, public health students, social workers, etc.). The use of lectures originating from the Miami campus will be largely discontinued, except in cases of lecturers or topics that cannot be provided on the FAU campus. The goal is to decouple the curriculum used on the FAU campus from that used on the Miami campus to allow the regional campus to explore alternative ways of organizing and delivering the curriculum while still holding students and faculty to core course content and core student competencies that faculty on both campuses will be required to cover and that students on both campuses will be required to master. Course examinations and competency assessments on both campuses will be keyed to these core course content areas and core competencies. The new curriculum will be in place for the class of students who will begin the four-year regional medical campus program in August 2007.
Creating new residency programs in southeast Florida
It is imperative that additional residency program capacity be created in southeast Florida at the same time that additional medical school capacity is created to ensure that regional medical campus graduates have an opportunity to remain in the area to complete residency training. Because of the strong link between where physicians complete residency training and where they subsequently establish practice, it is highly likely that a majority of the individuals who complete residency programs in southeast Florida will remain in that area to practice. It is also critically important that as many residency programs as possible in the core specialties of internal medicine, general surgery, pediatrics, and obstetrics-gynecology are in place in Palm Beach County by 2009, when the charter four-year regional campus class admitted in 2007 begins clinical clerkships.
There is a particular deficit in graduate medical education opportunities in the heavily populated multicounty region in southeast Florida that includes Palm Beach and Broward Counties. There are no allopathic residency programs between Miami-Dade County, where Jackson Memorial Hospital, the major teaching hospital for the UM medical school, is located, and Alachua County, the location of Shands Hospital, the major teaching hospital for the UF medical school.
Despite the pronounced need for more Florida residency training programs, few new programs have been created in Florida or nationally because of a cap placed on Medicare funding for residency training in the federal Balanced Budget Act of 1997. The Medicare program is the largest explicit source of funding for residency and fellowship training. The 1997 cap effectively freezes the number of residents who are eligible for Medicare direct and indirect graduate medical education funding to the numbers in residency programs as of December 31, 1996. However, the Medicare funding caps do not apply to hospitals that have never had a residency program. Therefore, because none of the community hospitals in Palm Beach County have ever had residency programs, they are eligible for Medicare funding for any new Accreditation Council for Graduate Medical Education (ACGME) residency programs created. Creating residency programs in community hospitals that have never been academic institutions has its own challenges. Such hospitals may have few, if any, physicians on staff who have served as administrators or faculty in graduate medical education programs. Few of the physicians on community hospital medical staffs have ever engaged in research and scholarship, which is required by the ACGME for individuals serving as residency program directors, associate directors, and key clinical faculty. Although every attempt is being made by UM to identify community physicians who can qualify as residency program directors and faculty, it may also be necessary to recruit physicians with academic experience from either UM or other medical schools or teaching hospitals to serve in these capacities. This recruitment must be done carefully and strategically to minimize community physicians' concerns about competition from physicians recruited to the area to serve as faculty in the new residency programs.
UM and FAU are in the planning phase to develop residency programs in multiple specialties through a two-pronged approach: (a) affiliation with Boca Raton Community Hospital, which plans to build a major new teaching hospital on the FAU campus, and which will ultimately sponsor several residency programs with a total of approximately 125 residents, beginning as early as 2012, and (b) creation of a multihospital consortium, beginning as early as 2008, that will offer between 150 and 175 additional residency slots sponsored by UM in multiple specialties, including specialties such as pediatrics that cannot be supported at Boca Raton Community Hospital. UM has submitted an application to the ACGME for its first Palm Beach County residency program, which will be an internal medicine residency program.
Establishing a UM faculty group practice in Palm Beach County
UM is in the process of developing plans for the configuration and location of a faculty group practice in Palm Beach County that is anticipated to open within the next six months. The faculty practice is being developed through close collaboration between the individuals responsible for managing the UM faculty practice in Miami and the faculty at UM and FAU who have responsibility for planning and implementing the new four-year regional campus curriculum and new residency programs in Palm Beach County. This collaboration is critical to ensure that, to the maximum extent feasible, clinical faculty recruited to meet the academic needs of the undergraduate and graduate medical education programs are also able to meet the strategic clinical objectives of the faculty group practice. Efforts are also being made to identify as many Palm Beach County community physicians as possible who are qualified to serve as clinical faculty and are willing to practice exclusively in the UM faculty practice plan. It is hoped that this strategy will help to lessen community physicians' concerns about competition from UM faculty physicians imported into the county.
A Successful Mechanism
The partnership between UM and FAU has proven to be a successful and effective mechanism to achieve the individual and mutual objectives of the two universities, as well as those of the state of Florida to meet physician workforce needs. The regional medical campus has enabled the state to expand access to undergraduate medical education in one of the most highly populated regions of the state at a cost to state taxpayers that is below that of constructing a new public medical school. Equally important, the presence of the new four-year regional campus is serving as the catalyst for the creation of new residency programs in a region of the state where there have been no graduate medical education training opportunities. UM has used the four-year regional campus as an opportunity to implement a new and innovative undergraduate medical education curriculum that is significantly different in organization, emphasis, and mode of instructional delivery from the curriculum on the main campus. UM medical students will, therefore, have a choice between two educational tracks that would not have been available otherwise. Developing and adopting formal, written memoranda of understanding and affiliation agreements at various junctures as the partnership between the two universities has evolved has been critical. These documents have defined each institution's respective duties and responsibilities and have made it possible for the two institutions to maintain a shared vision for the evolving regional medical campus. Building the partnership has been a completely new experience for both UM and FAU. The challenges that have arisen have been primarily the results of the need to coordinate each institution's differing administrative procedures and have been relatively easily managed. As the two universities move into the even more challenging phase of transforming the FAU program into a four-year regional medical campus, each institution has committed to maintaining the frequent and open lines of communication that have enabled their partnership to be so successful. UM and FAU have encountered virtually no serious impediments that are results of the public-private nature of the partnership. The UM-FAU experience suggests that comparable partnerships between medical schools, be they public or private, are highly viable approaches to expanding medical school enrollment and meeting physician workforce needs.