Save UTMC

by Thomas H. Fine and Dr. Daniel Rapport

Note: this essay was published in the March 7, 2020 edition of the Toledo Blade.

The University of Toledo and its medical center are experiencing troubled times. At its February meeting, the board of trustees’ president made the statement that the current financial performance of the medical center is “not sustainable” and something must be done. Employees of the medical center and the college of medicine have been told by the administration that all options are on the table. This current state of affairs has created a climate of uncertainty that the medical center has never before experienced.

There are two questions facing the University of Toledo and the taxpayers of the state of Ohio. The first is: Does the university need to own and operate a hospital for its medical school? The answer for many universities has been no, though that is not necessarily the correct answer for the University of Toledo. The College of Medicine is quite unique, designed with the hospital as an integral part of the campus. This facilitates the integration of teaching and research with the provision of health care, the core mission of the school. Maintaining ownership ensures that the hospital continues to support this core mission. It may actually be wise for the university to own and operate UTMC, the former Medical College of Ohio Hospital.

The question then becomes: In whose best interest is it for such a hospital to continue to operate? All of the medical students and students in the college of pharmacy, nursing, public health, clinical nurse practitioner, and physician-assistant programs benefit when placed in an academic medicine environment. Doctors in academic medical centers practice differently. They practice at a slower pace than regular doctors in community hospitals, which is important for teaching. Physicians make these choices early on in their careers to practice one way or the other. Attempting to force either to practice differently inevitably is frustrating and disappointing for all. An academic medical center owned and operated by the university benefits the citizens of northwest Ohio and generally the taxpayers of the state who opened this institution with a very specific purpose.

As a result of the affiliation agreement with ProMedica, the vast majority of doctors and resident physicians have transferred from UTMC to the ProMedica Toledo Hospital main campus. This put UTMC in a precarious financial situation. While there was a need for more teaching slots for residents and medical students, this wholesale transfer of physicians, residents, and patients may not have been necessary. There is no advantage in our community or to the taxpayers of Ohio for a single hospital to monopolize the education of our medical students or any of the allied health-care providers. Somehow the idea that both hospitals could serve as training sites has not been able to gain traction.

The financial failure of the UTMC medical center has placed the University of Toledo board of trustees, the president of the university, and the dean of the College of Medicine in a difficult position. On the one hand, they are constrained by the affiliation agreement that requires ProMedica to be the exclusive training site for the residents and medical students.

On the other hand they are responsible for the success or failure of the medical center. Conflicts are inherent in this arrangement, and both the administration and members of the board of trustees have a difficult job making decisions that satisfy all the parties involved, while promoting the mission of the university and the medical center.

It serves the needs of the community, the students, and the employees of the medical center to remain operating. It serves no one’s needs for it to close.

The simple solution is to bring physicians back to the hospital. In fact, a mixture of community and academic providers would create an ideal learning environment. Saving UTMC as an academic medical center, making it financially viable again, is possible, but will require both creative management and financial will.

Who should be making this decision, a conflicted university administration and board of trustees or the General Assembly and governor?

To us the answer is clear. It is time that we as citizens ask our state lawmakers and Gov. Mike DeWine to do the right thing for our community, our students, and for the state of Ohio.

Thomas H. Fine is an associate professor and Dr. Daniel Rapport a professor in the Department of Psychiatry at the University of Toledo College of Medicine. Their views are their own and do not necessarily reflect those of the university.

Note: this editorial was published in the March 6, 2020 edition of the Toledo Blade.

The University of Toledo and the UT medical college, formerly the Medical College of Ohio, have a 50-year co-operation agreement with ProMedica.

The part of the agreement that stipulates movement of faculty and trainees to ProMedica facilities includes a transition period of five years, and we are coming to the end of it. In light of threats by the university to close or sell the University of Toledo Medical Center, critics within the medical college and the community are seeking a reassessment.

Longtime faculty at the medical school say that their doctors and medical students have been stolen away. They say UTMC, the 246-bed hospital that is a companion to the medical college, could be sold or closed. They say this jeopardizes the medical college itself.

ProMedica says the ProMedica affiliation is the best thing that has ever happened to the medical college.

Some say a medical school need not have its own hospital. Many fine medical schools do not. But this hospital was built for the medical college.

The debate has just begun, and more argument and evidence must be presented and weighed.

Ultimately, Gov. Mike DeWine will have to weigh in.

Both sides have good points, but both may be, currently, so caught up in their own interests that they are failing to see the big picture: What is best for the community — for greater Toledo?

But we can say a few things definitively, even now.

1) The medical college must be defended and bolstered above all else. It is essential not only to South Toledo, but to greater Toledo and to the state of Ohio.

2) It is equally important that ProMedica flourish, for the city, the region, and, ultimately, the state.

Toledo’s great industries and industrialists are gone. We have no local bank. The other major health-care system in the city is run from Cincinnati.

ProMedica’s CEO, Randy Oostra has, almost singlehandedly, transformed Toledo’s downtown as well as the leadership culture, and cadre of the city. Civic spirit in greater Toledo is more positive than it has been in 40 years, and the city is attracting talent and reversing the brain drain.

Under Mr. Oostra’s leadership ProMedica saved the long-empty Toledo steam plant, restoring it for a new downtown headquarters and simultaneously kicking off a riverfront revival downtown. Mr. Oostra and ProMedica created the Ebeid Institute to boost urban health in Toledo with better diets while directing national attention to the social determinants of health. ProMedica also donated millions to renovate the Toledo Zoo’s historic museum building.

Mr Oostra is deservedly considered a local hero.

Without Mr. Oostra we are in trouble. Without a locally run ProMedica, no Randy Oostra.

His company needs to be able to compete.

Here is the big picture: We need both institutions. One, the medical college, is the educational gem of the city and the other, ProMedica, is the leading enterprise.

The other thing we know is that, since the merger of the University of Toledo and the medical college, the medical college has declined. It has not been been well-administered. It has been mediocritized. In the last 14 years National Institutes of Health funding has fallen from $16 million to $8 million. That’s not progress. It is regress and decline. Those dollars should have been quadrupled, not cut in half.

Surely one reason for decline is that the UT Board of Trustees has no expertise in running a medical school or in medical and scientific research. And there is no reason to think ProMedica brings such expertise to the table, either.

Research is key to the future of the medical college.

As we move past mutual recrimination and begin to establish facts, the heart of our concern must be this: How do we make the medical school stronger and better while not compromising ProMedica’s ability to compete?

First, the medical college needs investment, and that has to start with repopulating the medical center with doctors — mostly new doctors. A partnership with Toledo Clinic seems an obvious option. Toledo Clinic needs a hospital, and the UT hospital needs docs.

Second, we should consider giving the medical school back its own board — a board of scientists and physicians with expertise and real authority.

Finally, the UT board and administration owe the public and the medical college students and faculty an accounting: Where did the money go? When the merger of the university and the medical college occurred, the medical school, largely through its hospital, was a revenue generator. Now it is allegedly losing millions per month — even with a subsidy from ProMedica, which is supposed to be $50 million a year. Where is that money? There may be honest and valid explanations. If so, the UT board and administration should tell us what they are.

Dear President Gaber,

We have read your February 21 letter to Governor DeWine that was a rebuttal to our letter sent to the Governor with copy to you on February 20.  We note that you chose to write the Governor after we brought the UTMC issue to his attention after you did not respond to our December 14, 2019 letter on the same topic. 

We hope to begin a direct dialogue with you as early as possible, given the precarious nature of UTMC finances reported from the last University of Toledo Board meeting, and the increasing concern among the electorate of south Toledo, Perrysburg, Maumee and other nearby regions that rely on UTMC for health care.  Based on the partial, largely unofficial evidence available to us, it is reasonable to conclude that UTMC financial instability is years in the making and, intended or not, due to a combination of willful neglect and harmful decisions. In this context, we seek additional information specified here.

Decline in Revenue

Effect of UTMC Regulations that Restrict Access of Physicians to UTMC

We appreciate that you are taking actions to revise the regulations that currently restrict non-faculty appointed community physicians from joining the UTMC Medical Staff.  We understand that the UTMC Medical Executive Council approved the necessary bylaw change and that the full UTMC medical staff will vote on the change on Tuesday, March 3.  If the change is approved, we hope that you will urge approval by the UT Board.  Clearly, the removal of this restriction is only one step that should be taken to enable and encourage use of UTMC by non-UTP physicians, whether faculty-appointed or not.

 Question:  Was a proposal to remove the restriction on use of UTMC by non-faculty appointed physicians ever presented to the UToledo Board.  If so:

1. What was the decision and basis for decision?
2. Did any UT Board members ever recuse themselves from voting on such a proposal on the basis of actual and/or potential conflict of interest  by virtue of previous or current positions with ProMedica’s legal counsel (Schumaker, Loop & Kendrick),  ProMedica affiliate Welltower and HCR ManorCare?  If so, please provide a complete list of such instances.

Effect of UT Board Decisions that Restrict Budget for UTMC Marketing and Capital Improvements

The marketing budget of $1 million/year that you reported in your letter is substantially lower than the value that would be typical for a hospital with about $300 million/year revenue.  This market budget amounts to 0.33% of revenue which is 3-10 times lower than the typical 1-3%.  Further, the capital improvements budget was <0.5% of revenue, also far lower than recommended.  These observations lead to the following question and request:

Question: Have any UT Board members ever recused themselves from decisions regarding UTMC marketing and capital expenditures budget decisions on the basis of actual and/or potential conflict of interest  by virtue of previous or current positions with ProMedica’s legal counsel (Schumaker, Loop & Kendrick),  ProMedica affiliate Welltower and HCR ManorCare?  If so, please provide a complete list of such instances?

Request: Please provide a copy of marketing plans over the last five years for UTMC, Dana Cancer Center, and other HSC clinical facilities, and an accounting of the costs and measured impacts, and please report whether the marketing plans met their objectives.

Uninformative/Unclear Financial Statements

You provided UTMC financial data (Figure labeled: “UTMC Historical Financial Loss”) to support the assertion that UTMC was losing money at the time of the affiliation and has not significantly worsened over the time of the affiliation.  Importantly, it is unclear whether UTMC budgetary losses between 2015 and 2019 were based on operating income and losses.  In this context, we note that for many years the annual UTMC overhead costs (e.g. human relations, information technology, legal services, and security) as a fraction of annual revenue have been much higher than observed at other comparable hospitals. We conclude that since the merger between UT and MCO, UTMC solvency has been continuously threatened by extraordinary non-UTMC overhead expenses. 

Questions:

1. Why are the annual costs for HR, IT, legal services, and security costs for UTMC much higher than typical for a hospital with similar annual revenue?
2. Were UTMC operations balanced or even in the black in 2015 (i.e., at the time the   Affiliation Agreement was initiated) and was a significant fraction of the losses for FY 2015-2019 presented in your graph due to transfer of funds from UTMC to cover overhead costs in other UT departments? 
3. If UTMC overhead costs were higher than other comparable hospitals:
   1. was the UT Board made aware of this, and if so, what rationale was provided?
   2. was it recognized that the use of UTMC operating income for non-UTMC overhead was harmful to the future of UTMC?
4. Have any UT Board members ever recused themselves from decisions regarding use of UTMC operating income to cover overhead in other areas of UT on the basis of actual and/or potential conflict of interest  by virtue of previous or current positions with ProMedica’s legal counsel (Schumaker, Loop & Kendrick),  ProMedica affiliate Welltower and HCR ManorCare?  If so, please provide a complete list of such instances?
5. Was there any consideration at the time of the affiliation that governance of UTMC, which was in direct competition with ProMedica hospitals, should be separated from that of COMLS, which was closely affiliated with ProMedica?

Financial Projections

You report that you are thoroughly examining UTMC’s operations and services in the context of economic realities in the current healthcare environment.  We urge you to reassess FY2021 and following year projections after taking the following steps:

1. Remove regulations that restrict community physicians from using UTMC.
2. Prepare projections that model a significant increase in UTMC clinical activity based on physicians newly credentialled over the next year, starting with the fourth quarter of this year (April-June), and increasing through FY 2021.
3. Cease diversion of UTMC operational income to support non-UTMC and non-COMLS overhead.
4. Re-allocate funds previously diverted to non-UTMC department overhead; use them to increase marketing and capital improvement funds in FY 2021 UTMC budget to to levels commensurate with other hospitals (i.e. >1%).
5. Establish a marketing plan with measurable benchmarks.
6. Review governance of UTMC to eliminate conflicts of interest on part of UT Board and/or UTMC administration.

Effect of Affiliation on COMLS

From the standpoint of many Toledo citizens and elected officials that represent them there were many reasons to applaud the vision of the Affiliation, and there is evidence that many of the anticipated benefits are being realized.  Through Affiliation support UT COMLS now provides increased training opportunities for medical students and should enable increased recruitment and retention of medical talent in our region.   However, there are serious concerns that need to be addressed head on.

1. Concerns regarding current and potential for conflict of interest associated with governance of COMLS, UTP, and UTMC by the same person in the context of the Affiliation (as specified above).

• Lack of a clearly articulated strategic plan to improve the ranking of COMLS.  A key goal of the signed Affiliation Agreement is to increase the ranking of the UT COLMS among medical schools.  We have been unable to identify public information regarding an Affiliation strategic plan to achieve this goal.  The generally recognized medical school ranking system was developed by US News &World Report.  Using the USN&WR methodology, medical schools may be ranked according to a “primary care” model or a “research” model.  At the time of affiliation, UT COMLS was in fourth quartile according to both of these ranking systems and that is where it remains today. 

Importantly, if the Affiliated partners share a goal to increase ranking according to the “research” model it is key to focus on NIH funding.  USN&WR states that, “NIH funding is viewed as the most verifiable and credible measure of medical school research”.   This is why we specified the decline in NIH-funding to UT COMLS as a metric for lack of success.  In contrast, College of Medicine & Life Sciences Research dollars displayed in the figure that you provided is an inappropriate ranking metric.

In this context, we are concerned regarding absence of a clearly articulated plan to increase COMLS ranking according to the USN&WR methodology that is enthusiastically supported by, and committed to, by both Promedica and COMLS.  Further, there is concern that the recent Promedica acquisition of >$1 billion in debt and reported >$100 million/year negative operations budget has prevented, and will continue to prevent, Promedica from fulfilling its obligation to this goal.

Questions:

1. In FY 2015-2019, what is total amount of COMLS expenditure of funds provided by Promedica for:
   1. Salaries and start-up support of NIH-funded research faculty currently employed by COMLS?
   2. Research equipment available to COMLS NIH-funded faculty?
   3. Remodeling of research labs currently occupied by NIH-funded investigators in Block Health Sciences and Health Education Buildings?
2. How does the total amount of money reported in answer to question 1 compare to the total amount of money expended by COMLS for same costs in the prior five years (e.g. 2010-2014)?
3. How much money is budgeted by Promedica and COMLS for the costs specified in questions 1a-c for FY2021?

The questions we addressed to you in this letter and our letter from December, 2019 deserve a response with candid and direct answers.  We look forward to such a response within seven business days.  Otherwise, we will continue to seek assistance from the Governor and state legislators. 

Thank you very much for your time and consideration.

Dear Governor DeWine,

We represent citizens of Toledo who are deeply concerned regarding the status of the University of Toledo Medical Center (UTMC) located in South Toledo.  When these concerns were delivered about ten weeks ago to Dr. Christopher Cooper, Dean of the University of Toledo (UT) College of Medicine and Life Sciences (COMLS), he advised that we seek to determine the needs of South Toledo citizens, and then report back to him.

Over the last ten weeks, the “Save UTMC” citizens group has held multiple town hall meetings and solicited input regarding perceived need and value of UTMC and other UT Health Sciences Campus (HSC) facilities to the region.

The response has been emotional and heartfelt.  Over 1500 citizens have signed a petition posted online, and also expressed their concerns.  These citizens expect that our state and local elected leaders will do all they can to ensure that UTMC remain a teaching and research hospital, provide excellent medical care, and attract highly trained professionals to our area.

This initial report summarizes our understanding of how UTMC became financially unstable and provides some solutions that, we believe, will not only put UTMC and other Health Sciences Campus clinical facilities back on a path towards solvency but also restore the vibrant research infrastructure and NIH-funded research activities that have characterized this campus for so many years. We request your support for our efforts and will welcome your recommendations as we finalize our report to UT leaders.

Concerns Regarding Financial Stability of UTMC and the UT HSC

Decline in revenue. As recently as five years ago, because UTMC made money through a combination of clinical activity and Center for Medicaid and Medicare payments for education of residents, it was able to contribute $35 million annually to UT educational and research missions. However, since the affiliation with ProMedica was initiated in 2015, UT faculty-appointed physicians were transferred, along with students and residents, to ProMedica Toledo Hospital. This adverse effect of the affiliation on UTMC is exacerbated by a governance regulation that requires physicians practicing at UTMC to be appointed to the UT COMLS clinical faculty.  The combination of UT faculty-appointed clinician re-location, and regulatory barriers to replacement by community physicians (faculty appointed or not) has led to a decline in revenue from patient admissions, surgical and radiological procedures, and diagnostic tests at UTMC.

Insufficient marketing.  UT leadership has denied UTMC sufficient funds to market their services, including the highly-rated Dana Cancer Center, orthopedics center, and George Isaac Minimally Invasive Surgery Center.

Impending Financial Crisis. At one time income from COMLS student tuition and clinical activities at UTMC and related HSC facilities contributed approximately 60% of revenue to the University of Toledo. Unfortunately, UTMC is now projected to lose at least $25 million this fiscal year.  As UTMC finances have declined over the last four years, it is reasonable to expect that this will decrease the cash on hand for UT. The projected further UTMC budget deficits are likely to put UT in an increasingly precarious financial position. In addition, the UT Physicians Group has been adversely affected by the affiliation.  Many physicians report large numbers of specific instances in which ProMedica is using anti-competitive methods to harm their practices and prevent them from using UT clinical facilities.

Limited benefits from UT/ProMedica Affiliation. Over the past five years the affiliation funds for research have been less than expected. In addition, a UT/ProMedica master research agreement that would facilitate conduct of NIH research at Toledo Hospital and other ProMedica Hospitals has not been completed.  NIH-funding has decreased substantially over this time.

Appeal for support of proposed solutions to restore financial stability and research mission of UTMC

We request to meet with you at your earliest convenience.  In the meeting we will explain in detail why we request that you communicate to the UT Administration/Board of Trustees support for the following actions.

1. Open the UTMC Medical Staff membership to faculty appointed and non-faculty appointed community clinicians.
   1. Change UTMC bylaws to allow non-faculty appointed physicians to practice at UTMC.  This change will be voted on by UTMC Medical Executive Council at February meeting.  If accepted, it will need approval of the UT Board of Trustees to be implemented.
   2. Encourage community physicians to practice at UTMC irrespective of faculty status. Currently, there is a belief among many community physicians that they are not welcome to practice at UTMC as either faculty or non-faculty physicians.  This must change.

2) Encourage UT leadership to approve funds to market UTMC, the Dana Cancer Center, orthopedics center, and George Isaac Minimally Invasive Surgery Center at a level competitive with other regional hospitals.

3) Appoint UT Board members with knowledge and experience regarding all facets of academic medicine central to COMLS and the Health Sciences Campus, including educational, clinical, and research missions.  The goal is to appoint board members who will support and advise appropriately on graduate medical education, increased NIH-funded medical research, and financial stability of UTMC and related clinical facilities.

4) Encourage UT leaders to hire appropriate staff necessary to re-establish outreach to State of Ohio and Federal (e.g. NIH) research funding agencies relevant to faculty in COMLS.

5) Review the UT governance structure with the goal to identify appropriate steps to eliminate possible conflicts of interests as UT leadership makes key decisions relevant to the affiliation agreement between UT COMLS and ProMedica.

Thank you very much for your time and consideration,

Sincerely,

Carty Finkbeiner, Former Mayor of Toledo                            Kevin Dalton, President Toledo Federation of Teachers  

Teresa Fedor, Ohio State Senator                                              Shaun Enright, President, Greater NWO AFL-CIO

Rob Ludeman, Toledo City Councilman                                   James Willey, MD, Professor University of Toledo

Matt Cherry, President, Toledo City Council                          John McSweeny, PhD, Professor University of Toledo

Randy Desposito, President AFSCME Local #2415

Cc: Chancellor Randy Gardner, The Hon. Marcy Kaptur, The Hon. Bob Latta, President Gaber, Dean Cooper