Burnt Orange Report

The Unbearable Lightness of UTMBing

By Jim Dallas

The Houston Press has a cover story this week on the alleged problems with UTMB Galveston's prisoner care program.

UTMB having problems is not exactly news. I used to believe that the Houston media was biased against UTMB, acting as sort of a permanent run-away jury in the World's Largest Frivolous Malpractice Suit. But there's only so long that you can be a part of a community before recognizing that it's problems are, in fact, problems. And UTMB has problems.

I'm about as close as one can get to an institution with UTMB as one can get without being an insider. My brother and sister were born there (as were countless friends), my parents have worked there for decades (as have countless friends-parents), I did several school projects with the support and in UTMB labs.

So I'm going to try to be generous in dissecting UTMB's problems, and proposing what I think may be the only solution to put health care in south-east Texas back on track.

To Boldly Go...

The University of Texas Medical Branch at Galveston is not "a hospital." This is a mis-conception that needs to be clarified out front.

Rather, UTMB is a sprawling, 85-acre, 13,000-employee, $1.3 billion-a-year campus (link) which includes six hospitals and a slew of other clinics, centers, and institutes, a product of perpetual growth.

It all started over a hundred years ago with one building: Big Red. Since then, many tens of buildings have been built, rebuilt, torn down, replaced, and so on; there are now 53 building in the UTMB campus.

While this is about half the number of buildings at the Texas Medical Center in Houston, the TMC is a conglomeration of a dozen (or so) different education systems, ten major hospitals, and dozens of other institutions each with its own independent administration and institutional focus.

Aside from the Shriners Burn Hospital and a few smaller entities, which are independent, UTMB shares a common administration and mission. It lacks, however, a clear institutional niche.

It is probably fair to say that UTMB dabbles in a little bit of everything - prison care, research, indigent care, specialty care, teaching (and not just medical students), etc. To fully grasp the enormity of the insitution, you have to look at the multiple org charts which are necessary to explain it (one alone would not suffice).

UTMB's practice is extensive for several reasons. The first is history; until 1949, UTMB was the only medical school in Texas, and for years afterward was the primary center for treating indigent. As such, UTMB had to adjust to treating patients of every age and condition.

In more recent times, however, UTMB has actively sought out new lines of work (such as caring for Harris County's prisoners). In the last ten years, the number of outpatient visits has doubled and is on track to hit 900,000 per year. Additionally, UTMB now does nearly 50,000 telemedicine consultations a year (up from none less than ten years ago).

This growth comes, in large part, because it has been an economic imperative.

I'm A Doctor, Not A Miracle Worker: UTMB and the economics of the Health Care Industry

Like many institutions of higher education, UTMB has been getting less money from the state and has been expected to "earn" more of its money, like a business.

While there was a slight-drop off in 2004, earned revenue (from patient care, etc.) now makes up about 70 percent of UTMB's income, with state funding at a mere 18 percent (it was 40 percent in 1995). In terms of actual dollars spent, state funding for UTMB has not changed significantly in the last ten years.

These numbers, however, only scratch the surface of what has happened.

In the last ten years, competition has become intense among health care institutions over prized HMO/PPO contracts. UTMB has succeeding in winning quite a few of these contracts - according to the 2000 strategic plan (which appears to be the most recent source), 56 contracts covering 165,000 people. The move away from HMOs and towards PPOs, however, has given many insured area residents more choice in picking a provider. And all too often, those who can afford not to are not chosing to go to UTMB. Often, patients who use to go to UTMB for care go to more-specialized, highly ranked hospitals such as Texas Childrens (ranked number 4 in US News and World Reports "Best Hospital" list for pediatrics) or M.D. Anderson (Ranked number 1 for cancer). UTMB wasn't even listed in the 2004 US News and World Report rankings, much less ranked.

The result of this is that UTMB is having to squeeze every last dollar out of those patients who do choose to seek care in Galveston - as well as those, such as prisoners - who really don't have a choice at all.

While UTMB trumpets the large amount (nearly $500 million worth) of free care it provides to the indigent and others, it has gotten into the practice of rationing health care for the uninsured. Moreover, UTMB's staff is seeing a lot more patients than they used to:

To be sure, the overwhelming majority of visits are outpatient. This can still lead to considerable headaches for staffers, however.

The result is that UTMB's patient demographic is shrinking into two sectors - the poor (and working class families with insurance who are still more-or-less forced to go to UTMB because of HMO/PPO rules) and those who are seeking treatment for ailments which are, essentially, not profitable to treat. This trend is basically at odds with UTMB's profit directive, and is leading to further and further belt-tightening at the further expense of overall happiness.

At the same time, of course, UTMB is still burdened with the responsibilities of bringing up the next crop of medical students, doing world-class research, and so on and so forth. There are limits to how far UTMB can go with its business-like mentality before it cuts into these very un-business-like priorities.

He's Dead, Jim: A Prescription for Reform

At the risk of being a pessimist, I am going to go ahead and concur with those I know who know best (disclaimer, I would include my dad among them) that UTMB is, frankly, caught in a death spiral. It is too large, too generalist, under-funded, over-extended, and terminally-incapable of reviving its reputation.

What UTMB needs is shock therapy. First, it needs a major increase in state funding to set its books in order. Second, it needs to do what any troubled business would do: downsize and spin-off its constituent parts. Specifically, UTMB needs to probably split itself into several institutions with clear niches and institutional goals.

Some might complain that breaking up UTMB would impede its ability to provide "holistic" care to the Galveston community, which is sort of a nice way of saying that UTMB won't be the Super Wal-Mart of health care any more, with a little something for everybody and the possibility of cradle-to-grave service. However, the fact is that one institution simply cannot provide for an individual any more, at least in an age of three-year jobs and under our employer-pays health care insurance regime.