The University of Virginia Eastern Virginia Medical School

by James C. Sherlock

With additional information and thoughts generated by responses to my original posts on this matter, I offer this post as a final proposal before the November 15 release of the Sentara-funded “study” of what I call the Sentara Plan for Eastern Virginia Medical school.

The nation is short of doctors and shorter yet of good doctors. The nation has to produce more of both or the situation projects to worsen.

There is an opportunity here in Virginia to deal with both objectives.

But the Sentara Plan is not it.

Background

The Eastern Virginia Medical School (EVMS) already has facilities and dedicated professors but seeks to upgrade both the quantity and quality of its medical training and research. It needs a strategic partner to do it.

EVMS courted William and Mary in 2011 – 2012 to try to break through to a higher level of education. The reasons the merger didn’t work from William and Mary’s perspective included:

  • William and Mary was concerned EVMS is not a well ranked medical school
  • William and Mary was concerned EVMS would drain money from its own programs
  • Sentara, as the incumbent affiliate hospital, would not commit more funding to the medical school.

From a new Virginian-Pilot story on EVMS and Sentara:

“EVMS seeks a new model as a means to get more capital and improve its academic reputation.”

“Sentara wants to better “align” EVMS’ medical group with its own.” … The (EVMS Medical) group composed of 150 physician-teachers and 40 other health professionals, supports the medical school and treats over 1,600 patients a day”.

(Bacon’s Rebellion author note: Sentara wants those 1,600 patients referred to Sentara specialists and most importantly, treated in Sentara facilities.)

More from the Virginian-Pilot story:

“Eastern Virginia lags behind the state and nation in infant mortality, cancer, heart disease and diabetes. Most of these poor rankings reflect disparities with minority and low-income populations.”

“For instance, the infant death rate in Virginia and the United States was 5.8 out of 1,000 live births in 2017. But in Norfolk, the rate of Black baby deaths was 18.2.”

“Regarding prostate cancer, the national death rate was 19.5 out of 100,000 lives in 2015. But in Portsmouth, Black men died at a rate of 66.5 out of 100,000 — nearly four times that of white men in the city.

Sentara, as a payback for its state-awarded healthcare monopoly in Hampton Roads, was supposed to take its profits and improve the health of the poor over the past decades, but it had what it considered more important things to do with its money.

So, the state has at least two jobs in considering at this point what to do about medicine in Hampton Roads — improve EVMS and improve the quality of the health of its minority residents.

Plan A – The Sentara Plan

Sentara, which has effectively controlled EVMS since its beginning, has put together a plan and a study that seeks to tie EVMS to Old Dominion University and perhaps Norfolk State University as well as Sentara. From the Virginian-Pilot:

“Private parties began exploring potential integrations of Eastern Virginia Medical School with Old Dominion University and Sentara Healthcare about 10 months before telling top leaders of the medical school.

Dr. Richard V. Homan, president and provost of EVMS, said [ReInvent chairman John “Dubby”] Wynne called him July 17 to tell him about the Manatt [Health Strategies] engagement and process. It was then he learned of the idea, he said in an email to Manatt representatives in August.

“Neither the Board nor I had any knowledge of the Manatt engagement and nor of the previous meetings with Manatt and other parties which occurred over the past 10 months,” he said.

Governor Ralph Northam, an EVMS grad, was apparently in on the secret deal at some point and appears preliminarily in favor.

Northam, who announced the project Aug. 5, said the results may lead to significant changes for Hampton Roads’ “health care ecosystem,” which serves more than 1 million people.

“This is an important effort to benefit Hampton Roads, and the Commonwealth as a whole,” Northam, a pediatric neurologist, said then.

Undiscussed at least in public is how that combination being assessed by a study paid for by the institutions hoping to merge with EVMS will somehow

  • make EVMS a better medical school or
  • improve the awful health of the region’s minorities.

Again from the Virginian-Pilot:

The consultant, Manatt Health Strategies, is expected to deliver a report Nov. 15, ahead of the General Assembly session in January. Its advice could lead to new legislation or budget amendments for lawmakers to consider that seek to make the medical school more financially stable.

In other words, this plan represents a hostile takeover of EVMS with a short deadline to get it through the General Assembly.

All of the participants — Sentara, ODU and the private think tank ReInvent — say that this plan is secret. Sentara is paying for most of the study, so we don’t have to bite our nails waiting to see how it turns out.

If the plan is adopted, EVMS will be anchored forever to Old Dominion University, a school ranked by U.S. News and World-Report #258 among national universities and perhaps Norfolk State, which on a regular basis over the years has skirted decertification.

If ODU takes EVMS as its medical school, it would be the 4th lowest ranked university in the continental United States with a medical school that itself is ranked among the top 92 medical schools for primary care.

If EVMS is tied to ODU and Norfolk State, I predict that in 10 years it will be fighting for its accreditation.

Plan B – A Plan that Can Work for Hampton Roads and Virginia

So what is a better alternative? Skeptics would say almost anything, but I have one that will make Hampton Roads a medical hub rather than a medical afterthought and move it towards solving its horrible minority health problems.

The University of Virginia School of Medicine next year will open an Inova campus in Northern Virginia. That facility was sanctioned by the State Council of Higher Education for Virginia (SCHEV), the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC) and the Liaison Committee on Medical Education (LCME), a U.S. Department of Education-recognized accrediting body for programs leading to the MD degree in the United States.

It will be centered on Fairfax hospital. The partners are funding a great deal of construction to support the effort.

The Fairfax campus will host students who after their first two years in Charlottesville choose to complete their third and fourth years of training in Fairfax.

Eastern Virginia Medical School presents a completely different opportunity. It is already located on the same campus as Sentara Norfolk General and its Level One trauma center and Children’s Hospital of the Kings Daughters. EVMS already has gleaming new facilities. What they don’t have is the ability to attract top-notch students or research grants.

Adding Hampton University to the collaboration would make that grouping even more powerful. It is superbly led, and Hampton University can provide a nursing school to the collaboration and contribute its unique Hampton University Proton Therapy Institute capabilities. It hosts the largest free-standing facility of its kind in the world. Proton therapy is most popularly used in the treatment of head and neck, brain, and prostate cancer, but growing results from its application for other cancer types, including breast, lung, GI and more, have continued to prove positive.

Urban Bon Secours Hospitals in Norfolk and Portsmouth are nearby, as is the Navy’s immense Portsmouth Naval Hospital. Virginia Beach, Virginia’s largest city, is next door.

Hampton Roads is home to over 1.5 million Virginians, as well as the world’s largest naval base, the Port of Virginia, major Air Force, Army and Coast Guard installations and a huge tourism industry. What it does not have is a first rate medical school.

This plan would certainly fit the mission of the University of Virginia Medical School and would provide significant boost to medical education in the state. Additionally, the UVa Center for Health Humanities and Ethics can find no more compelling location for carrying out its mission than reversing the awful minority health numbers in Hampton Roads.

The College of William and Mary, its 2013 objections resolved, could be brought into the coalition if desired.

How to Pay for Plan B

The way to pay for this plan and for improving the healthcare of the poor in Hampton Roads would be to eliminate Sentara’s tax exemptions in Virginia.

No fair assessment of Sentara’s Forms 990 over the past 20 years would conclude that they have earned those exemptions. Sentara would still qualify for its federal exemptions since, alas, the IRS simply does not examine whether a 501(c)3 health system earns its exemptions – never has.

For-profit HCA’s five largest hospitals in Virginia paid almost $145 million in taxes in 2018, the last year public records are available from the state. Sentara’s 12 hospitals paid effectively nothing.

You might think that Sentara, a not-for-profit, would offer a lot more charity care than for-profit HCA. You would be wrong. HCA’s hospitals’ charity care in 2018, the last year before Medicaid expansion, was 17% of net patient revenue. Sentara’s was 18%.

That move would not only generate a great deal of revenue for the state, but importantly would generate considerable revenue through property taxes for the communities that are home to both Sentara’s fabulously profitable hospitals in Hampton Roads and the minority populations that have suffered with substandard healthcare.

Precautions

I have sent this essay in letter format to the State Council of Higher Education for Virginia (SCHEV), the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC), the Liaison Committee on Medical Education (LCME) and Centers for Medicare/Medicaid Services (CMS) for their perusal in advance of any report.

I included an appendix with the recent national ranking and graduation numbers for the various players so they won’t have to bother themselves.
I think they will be able to see the current Sentara-led effort for what it is and be properly prepared to receive it.

The Governor likely can influence the SCHEV, but he may not have much luck with SACSCOC, LCME or CMS.

Recommendation

The Governor might wish to study Plan B before rushing legislation to the General Assembly based on the Sentara plan “study” in 2021, a non-budget year.

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15 responses to “The University of Virginia Eastern Virginia Medical School

  1. James Wyatt Whitehead V

    Would the elimination of Sentara’s tax exemptions provide enough cash to cover the expenses of Plan B?

    Plan B does sound like it would serve patients better and advance health care to those that have been left behind.

    • Yes.

      HCA’s 5 largest hospitals in Virginia paid almost $145 million in taxes in 2018, the last year public records are available from the state. Sentara’s 12 hospitals paid effectively nothing.

      You might think that Sentara, a not-for-profit, would offer a lot more charity care than for-profit HCA. You would be wrong. HCA’s hospitals charity care in 2018, the last year before Medicaid expansion, was 17% of net patient revenue. Sentara’s was 18%.

  2. “Governor Ralph Northam, an EVMS grad, was apparently in on the secret deal at some point and appears preliminarily in favor.”

    Given that our governor will be an unemployed doctor (with long employment ties to the Hampton Roads medical community) does it seem appropriate that he is involved in a “secret deal” involving the medical community in Hampton Roads?

    Sounds like a classic example of a Virginia politician feathering his post-political bed.

  3. UVA Medical School is closely affiliated with UVA Health. I think UVA Health has been reducing competition over time in its operating areas, although there is Sentara Martha Jefferson in Charlottesville. (I argued a couple of years ago that the multi-billion UVA Strategic Investment was capitalized largely based on operating “profits” from the non-profit UVA Hospital. Will this proposal have any impact on competition in the region?

    What in the proposal would make it more likely there are more and more capable doctors who stayed in the region? I had a couple of college friends go to EVMS and they did not end up staying in the region. The doctor shortage in the U.S. (compared to OECD countries) appears to be related to the controls on the number of spots in medical schools.

    I think some regional leaders have long wanted to merge ODU and EVMS more to bolster ODU than EVMS. When the W&M merger fell through, it was only a matter of time before this came up again. What you gave was the financial summary (W&M didn’t think it made financial sense), but the underlying takeaways I recall was 1) the Sentara entanglement diminished financial incentives and 2) it would be difficult to achieve economies in the basic science part of the education curriculum due to the physical separation of EVMS and W&M). It looks like you want to address point 1, but would there be basic science education coming from UVA (or other partners) to achieve economies?

  4. I totally share Jim’s suspicions of Sentara’s intentions. The “nonprofit” enterprise is, in fact, extremely profitable, but it has steered most of its profits into financing acquisitions and expansions with the effect of creating a vertically integrated monopoly. Plan A would strengthen Sentara’s hold over the physician community and make its monopoly stronger and more unassailable than ever.

    However, I have a practical question about his Plan B. The hard fact is that EVMS is physically and programatically integrated with Sentara. If EVMS aligns with UVa, UVa Health care, and Bon Secours, how does he disentangle all those connections? Would anyone even be interested in taking on such a challenge?

    • James Wyatt Whitehead V

      Now that you mentioned vertical integration Plan A comes into focus for me. Sentara is following the way of Carnegie, Rockefeller, and Gustavus Swift. There has to be a holding company waiting to swallow Plan A once it is built.

      • The whole enterprise will be non-profit whichever plan is chosen. Sentara itself is a holding company with 63 separate companies, but it will not control any university in the mix.

    • First, they are not entangled by anything but EVMS’ current dependence upon Sentara for funding. That dependence, but not the funding, would disappear under the new arrangements.

      No need to cut Sentara hospitals out of the new arrangement. But the new, better and more powerful UVa/EVMS would be able to draw better and more students and grants and cut better deals with the affiliated hospitals.

      Sentara would no longer be in financial control of EVMS, and would not be in a position to demand that EVMS turn over its medical group.

      Sentara and Bon Secours hospitals would be available, as they are now, to train med students, and CHKD could be added to the mix for pediatric med students.

    • This entire plan depends upon UVa stepping up to take EVMS as its own. It certainly stepped up to build a medical school from scratch in the mean streets of Fairfax County.

      This is a perfect fit for the social justice mission at UVa because of the horrible minority health statistics here.

      Whether it will step up or not is to be seen. As far as I know, my suggestion is the first time they will have heard the idea.

  5. On a completely different issue, many, many years ago, there was an idea to turn all of the cities of Hampton Roads into boroughs as in NYC

    • Made some sense then but a couple didn’t want to be tied to Portsmouth with its myriad issues.

      Result could have been unified police, fire, ems, code enforcement, etc. but nobody also wanted to give up their little fiefdoms where they could play amateur politician … especially Norfolk and the Beach.

  6. As a U V A graduate who trained at EVMS and works in the Hampton Roads area, I will tell you that the synergy between Old Dominion University, Sentara and Eastern Virginia medical school is strong. I work as a physician in that setting every day and I see the benefits of the arrangement first hand. Like any other complex relationship, there have been peaks and valleys, but to suggest that UVA would be a better medical and financial partner is not grounded in fact. Your characterization that William and Mary walked away from a possible merger with EVMS because it was not a well ranked medical school is a gross simplification of some thing that was far more complex. Your concern that EVMS would lose accreditation if it’s affiliated with Old Dominion University is baseless. Old Dominion is rapidly developing a regional and state reputation with a commitment to excellence, certainly on par with VCU, in terms of its academic credentials. Our medical group hires doctors who have trained at UVA and EVMS, as well as other medical schools in our country. We hire those with undergraduate degrees from Old Dominion and University of Virginia, and others. We have found none of these things are reliable predictors of clinical and academic success. What constitutes the make up of a successful physician is a commitment to a philosophy of lifelong learning and dedication to patients. No medical school or university has a monopoly on that skill set. I believe that time will show that there are three major universities associated with medical schools in the state, and they include UVA, VCU and Old Dominion University. You can probably add Virginia Tech and its school of osteopathic medicine to that list. I hope that these decisions, whether they are made behind closed doors or in the open, are made with the best interest of the patients of Hampton Roads at heart, and that these decision-makers do not let academic snobbery or pride get in the way.

    • Doctor, thank you for your service.

      My goal is to secure the future, raise the quality of EVMS and expand its production of physicians for Virginia and the rest of America and to improve the medical quality of the whole of Hampton Roads.

      Is there really any choice in Virginia if those are your goals other than to seek the help of the University of Virginia Medical School to make those upgrades happen?

      Is there any real choice other than to call Sentara out for the horrible minority health statistics that have festered under their watch?

      There is no consideration of either improving the quality of EVMS or expanding its output in the Sentara Plan.

      I had to make a choice about how far to go when deciding whether to blow the whistle on Sentara’s latest power grab.

      If you think the Sentara Plan has anything to do with EVMS, ODU or Norfolk State, disabuse yourself of that thought. As the Virginian-Pilot article pointed out, it is about Sentara Medical Group wanting to take control of the EVMS Medical Group and their 1600 patients per day. The rest is window dressing.

      To fully expose that plan for what it is, it was necessary for me to expose the poor academic rankings and graduation statistics of ODU and Norfolk State. It was Sentara that made that necessary. That was also not my choice.

      You wrote that “Your characterization that William and Mary walked away from a possible merger with EVMS because it was not a well ranked medical school is a gross simplification of some thing that was far more complex.” Call the Virginian-Pilot and complain, that was their characterization, not mine.

      ODU is a striver and I wish them well, but is nonetheless ranked #284 among national universities. As I said in my essay, that would make ODU the fourth lowest ranked national university in the United States with a medical school ranked among the top 92 medical schools. At least before the merger.

      That is not the future that either you or I want for Hampton Roads medicine.

      As for Norfolk State, that would be unthinkable if the Sentara Plan did not include it. Sentara throwing Norfolk State into their plan as a last minute possibility was exactly what it looks like, a plea for votes in the General Assembly Black Caucus, and it is insulting.

      Am I wrong to recommend that Hampton University, a superbly led and nationally recognized and ranked Black Ivy in Hampton Roads with its unique Hampton University Proton Therapy Institute capabilities, replace Norfolk State in the Sentara Plan? If Sentara cared about EVMS, this would have been their recommendation.

      If that is “academic snobbery or pride” on my part, it is a fight I did not pick but one that is necessary to derail the fast track, secretly concocted and demonstrably flawed plan that Sentara has devised.

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