UNR med school dean: ‘Shift from volume to value’ most critical healthcare issue
September 25, 2018
RENO, Nev. — Dr. Thomas Schwenk, dean of the University of Nevada, Reno School of Medicine, has been embedded in medicine ever since he enrolled in chemical engineering, and later earned a medical doctorate as well, at the University of Michigan back in 1975.
Forty-three years later, Dr. Schwenk is in his seventh year as the department head of the UNR School of Medicine, which will celebrate 50 years next year.
With that in mind, the Northern Nevada Business View sat down with Dr. Schwenk to talk about how the school and the healthcare industry as a whole has changed since 1969, the country's conflicts over nationally mandated healthcare, and more.
NNBV: With the school of medicine turning 50 next year, what's changed in the past 50 years?
Dr. Schwenk: I think the way to put that anniversary in some perspective is, when we started in 1969, it was very much based in community rural outreach, and free primary care oriented. And was our start for quite some time until we needed to expand, and we needed more teaching capacity, and we needed to serve Las Vegas. So that's when the split occurred. And we started to develop much more of a clinical campus there (in Vegas) in roughly the mid-90s, and kept our basic science campus here. So the basic science campus thrived, clinical campus grew, schools kind of split, and that was sort of another 20 years.
And then we came to this critical point of whether a single school could really serve the entire state and how best to do that? What was most efficient from a financial perspective? How does the particular history and geography and politics of this state affect how public medical education serves the state?
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So when I came and I had the usual introduction to state politics and these North-South conflicts, and I just said, I don't think that's the important question. The important question is how public medical education serves the state. And that's what took us then to this new plan, which is separate schools, separate hospital relationships, separate residency programs, and separate missions in a sense. And so that's a long answer to your question. I think these are natural evolutionary stages for how a school grows, adapts, changes, shifts to serve the state as the state grows and changes.
NNBV: In that same span of 50 years, what are the biggest changes you've seen in the healthcare industry as a whole?
Dr. Schwenk: Oh my goodness. You've got an hour? [laughs]. I'll frame it somewhat in the same way: health care delivery is totally contextual with social change, technological change, and economic change. So 50 years ago it was perfectly fine to have a fairly limited capacity for healthcare — there's lots of things that we couldn't do 50 years ago; that was only 25 years post-World War II. So the technology, medications, devices, tests, treatments, hospital technology, office-based technology … basically, all what we have now, none of that existed at that time. I mean, you had a few antibiotics, a couple high blood pressure medicines, insulin, a couple cardiac medicines. But, none of the cardiac technologies; none of the non-invasive or micro invasive surgical capabilities; none of the robotic capabilities; none of the minimal surgical capabilities; none of the endoscopic procedures like fiber optics; none of that stuff existed.
So what could be done at that time was fine to be sort of fee for service, limited payments; there wasn't that much you could do and therefore there wasn't that much to pay for. And so Medicare comes along; technology explodes; pharmaceutical and scientific breakthroughs explode. And now you've got an entirely different set of things that you can do and therefore an entirely different way that they have to be delivered and therefore an entirely different mechanism by which they're paid for. So they all track. And that leads to the most important issue at the moment, in my opinion, which is this shift from volume to value. The past, as I described, was very much volume based. You couldn't do that much. So you do what you can do and you get paid for what you do. Now you can do so much. There's so much technology. And then you add to that an aging population, a population with increasing prevalence of chronic disease, all the lifestyle diseases, and all that you can do. And suddenly, if you just keep doing all the stuff that a physician can order, then it's unsustainable, it's unaffordable, it just explodes massively. So then society, rightfully, asks, "So what's the value of what you do? Why should I pay for another MRI? What does that get me in terms of value? Should I pay for this new surgical procedure? Should I pay for this new test that's available?" So the phrase quite often goes that the most expensive piece of medical technology in the health care system is the physician's pen. Although that's now not quite right because we do everything on a computer, but it used to be writing, checking boxes of tests to be ordered. So now people are saying what's the value of what you're ordering and what you're doing?"
NNBV: Shifting gears a little bit, How important is it for med school graduates to stay here in Northern Nevada?
Dr. Schwenk: The answer we'd most like is that we want everybody to stay here. And that's what our job is — to serve the state, to improve the quality of care, to lead to a healthy Nevada. So we want everyone to stay. But we don't have total control over the people. You know medical student graduates or residency graduates have huge options and go anywhere they want, all kinds of possibilities because of various shortages that exist. And so there's a certain sort of desirable outcome, which is we want as many people to stay as possible. But that's never going to be 100 percent. Healthcare is not really a statewide issue; it's really a national issue or a global issue.
So here's the dilemma. There are many things that our graduates do that we would say that's really noble, that's a great outcome. We produced a graduate that did this. So what could this be? This could be going off to some other urban area in some other state and doing incredibly important underserved care or doing some missionary work to a developing country or going off to a an outstanding research institute and finding a cure for a disease. "Wow, that's just awesome." But they're not here. So is that a good thing or is that not a good thing? So it's complicated. To define what it means to be successful for the school is difficult because there are probably different answers to that question. The short answer to your question is: yes, we'd love to at least improve dramatically the numbers of physicians per capita in the state and that clearly is a goal. We try to recruit the best students who have the most likelihood of staying. We try to have residency programs so that students will track into those programs and then they'll stay, we try to recruit students from outside (the state) who will come to our residency programs and stay. All that's really good. But I would say that we're also proud when students from time to time go off and do great things elsewhere. I think that's just the reality of medical education. They're not all going to stay, so if they're not going to stay, we hope if they go off and do something they do something great. That's kind of what it comes down to.
NNBV: Mandated national healthcare — how have recent developments changed how healthcare providers business?
Dr. Schwenk: Obamacare is interesting. Obamacare is not really about healthcare delivery it's about healthcare insurance, mostly focused on getting people into the system and that's what most of the efforts were. Which I personally support, and I'll just be very clear about that. I think that you cannot really solve the health care delivery issues until everybody's in the system, whatever system that is. But I'm not alone; if you talk to most physicians, a majority of physicians support single payer healthcare.
I think the fundamental dilemma, politically, right now is people who believe that everybody should be in and everybody should have access to basic care versus people who say, "No, you can have emergency rooms and you can do this, but it's not the obligation of the government to provide a basic level of common health care for everybody." I think that's the dilemma that we're struggling with politically right now. And so what you see politically is all of the opposition to Obamacare until people got it and then they say, "Oh, I like having healthcare and I like the fact that there are no preexisting conditions. And I like the fact that my child can stay on until they're 26 years old." And so now trying to take that away is very complicated politically because you say that that's really good. And I would say as a physician, yes that is good. And so if you if you ask people about their opinions about health care and what do they think about certain conditions like no preexisting condition or access for children up to the age of 26 or other features, people say, "Oh, I want that, I want that." So you must be in support of Obamacare? "No, I hate Obamacare." It doesn't make any sense. People like the aspects of insurance for everybody, but you can be opposed to a particular legislation or a particular bill that was passed. So it gets real complicated as to what does the public want? What does the public think that is right? What's the ethical basis for healthcare? And that's what I think the country is struggling with right now.
This interview has been edited and condensed for clarity.