Deadlock Resolved Between Detroit Medical Center and Wayne State University

Laurie Barclay, MD

December 03, 2006

December 3, 2006 — On November 22, Michigan Governor Jennifer M. Granholm announced a resolution to the thorny disputes between Detroit Medical Center (DMC) and Wayne State University (WSU) that threatened the future of the residency programs as well as of healthcare in Detroit. The new multiple-year agreement, also endorsed by WSU President Irvin D. Reid, WSU Medical School Dean Dr. Robert M. Mentzer, Jr, and DMC CEO Michael Duggan, hopes to ensure long-term stability in the partnership.

"The WSU School of Medicine leadership team is confident that the current agreement will bring stability to our undergraduate medical education and graduate medical education programs, and will maintain the safety net for Detroit's most vulnerable populations," Donna Dauphinais, WSU School of Medicine Chief of Staff, told Medscape. "Although no disputes remain, as in any contract, there are likely to be areas that may be interpreted differently by both parties. WSU will remain committed to resolving any such differences, should they occur. We'll continue to keep our eye on the ball — our students, residents, and patients."

The good news concerning resolution of the arduous DMC-WSU negotiations came as a great relief to medical students as well as residents, because failure to reach a mutually acceptable contract had threatened the academic future of both medical and graduate education. If an agreement had not been reached, WSU could have lost accreditation for certain graduate medical programs, potentially resulting in Detroit's loss of about 927 medical residents and up to 700 faculty physicians.

The new 3.5-year teaching, clinical, and administrative contract begins January 1, 2007, which will allow it to synchronize with the academic year for graduate medical education to prevent disruption of academic activities in future years. After the initial 3.5-year term, the contract is automatically extended for an additional year, provided neither party gives 18 months' notice of intent not to renew.

"This, I believe, will give prospective residents a certain level of comfort that their residencies will not be interrupted mid-course," Ms. Dauphinais said.

New Contract Preserves All Current WSU/DMC Residency Training Programs

The new contract preserves all 68 current WSU/DMC residency training programs, a major core of which will remain under joint sponsorship until at least 2009. However, a small number of residencies will become solely sponsored by WSU, with the option remaining for DMC to participate as a training site; and a small number will become solely sponsored by DMC, with WSU designated as DMC's sole academic affiliate. These programs will be sponsored solely by DMC or WSU only if the Accreditation Council for Graduate Medical Education (ACGME) deems that arrangement to be acceptable.

Assuming ACGME approval, WSU will solely sponsor dermatology; ear, nose, and throat; family medicine; and urology. DMC will solely sponsor pediatrics. The "primary core group," consisting of internal medicine, pathology, surgery, obstetrics and gynecology, radiology, and radiation oncology, will continue as jointly sponsored residencies throughout the contract term and for at least 1 year thereafter. After June 30, 2008, either WSU or DMC may apply for sole sponsorship of programs in emergency medicine, neurology, neurosurgery, ophthalmology, physical medicine and rehabilitation, psychiatry, and anesthesiology. The right to exercise this option will rotate each year, with WSU permitted to choose in the first year.

"Continuation of the high-caliber clinical and educational experiences that come from this partnership can only have positive results," Paul Bozyk, MD, president of the WSU/DMC Resident Council, told Medscape. "Even the sole sponsored programs preserve the opportunity for residents to benefit from the best characteristics of both institutions. I believe that this long-term contract will allow all of our training programs to continue to flourish."

A Blue Ribbon Commission on Graduate Medical Education will be appointed by Governor Granholm to evaluate potential options for residency structures and to make recommendations concerning the best ways to train residents in Southeastern Michigan.

"The residents thrive under the current arrangement of training under the dedicated and renowned faculty of WSU while having the opportunity to provide care for the challenging medical needs of our urban community through affiliation with the DMC," Dr. Bozyk added. "Our city's safety net that the state of Michigan has gone through great pains to establish for the medically underserved and uninsured really is structured on the back of residents and fellows being able to provide some sort of primary care under the direction of our attending physicians. That safety net would effectively be crippled by failure to agree on a contract, not only at the primary care level, but of course throughout all levels of subspecialty care."

Loss of Residents and Faculty Physicians

The potential loss of residents and faculty phyicians if an agreement had not been reached could have been especially devastating because WSU faculty physicians and residents under their supervision deliver 80% of the care provided to Medicaid patients and the working poor; DMC provides nearly 25% of all Medicaid care in Michigan; and of Detroit's 690 primary care physicians, more than half are WSU/DMC resident physicians-in-training.

"We were going to lose a lot of residents, and I didn't want to see that happen," Edmund Barbour, MD, president of the Wayne County Medical Society, told Medscape. "I think both sides are pretty pleased about it, and the residents are completely relieved — they know they have a future here in Detroit, and there is a great need for more physicians here. The best thing is that Michigan medicine will have doctors well trained for years to come."

"Across all departments there is great relief that WSU and the DMC have achieved a contract resolution," Dr. Bozyk agreed. "While there certainly was a fair degree of anxiety, at no time was there interruption in patient care or medical education. This speaks volumes about the strengths of our programs and the professionalism of our residencies."

The ACGME conducted a site visit on November 14 to determine the fate of the residency and medical education programs pending contract resolution, and they met again on November 30 to consider their findings and make an official recommendation. Possible repercussions of not having a viable contract could have included having the residency programs placed on probation, which could endanger recruitment of students and faculty, or even having all residencies canceled and residents moved to other programs nationwide. The final ACGME decision is anticipated in about a week.

"We are cautiously optimistic, but we await this decision with an appropriate level of anxiety, given the difficulty of our negotiations," Ms. Dauphinais said.

Dispute Centered on Money, Service Exchange Contract, Exclusivity

According to Dr. Bozyk, with the caveat that he was not present during nor party to contract negotiations, the dispute centered on the total dollar amount to be allocated for teaching, the clinical contract for WSU to provide their services to DMC, and the issue of exclusivity. Some programs felt stymied by the lack of opportunity to train their residents in certain procedures; for example, patient demographics at DMC do not encourage frequent plastic surgery or open heart surgery cases, and the ACGME may have also perceived this as a shortcoming in training.

"If there were no open heart surgery cases available with our principal clinical affiliate, the medical school felt the necessity to look for those cases elsewhere, through collaboration with one of the other local hospitals," Dr. Bozyk explained. "Unfortunately, this was seen as the medical school supporting DMC's competitors, and that opened the door for the large question of exclusivity regarding where WSU physicians could practice. Of course, DMC knows they can't hold any single physicians' group, however, the ability to ensure that the money that DMC is paying WSU is for services rendered at the DMC led to a number of questions."

Bridget G. Hurd, DMC corporate director of public relations, told Medscape that DMC officials declined to comment specifically, beyond what was in the news release. The Detroit Medical News published the text of an email sent to DMC employees on October 9 by CEO Michael Duggan, who declined to comment further when the newspapernotified him that they would publish the email.

"WSU tries to cover with innocent sounding terms like 'diversifying' and 'suburban strategy,' but the cold truth is WSU has already abandoned its historic DMC partnership," Mr. Duggan wrote in the email. "WSU is aggressively building a fleet of lifeboats, establishing numerous suburban hospital contracts so their doctors can one day jump ship and float off into a sea of better payor mix, taking their insured patients with them. Most WSU doctors seem to find this plan distasteful, but it is being pushed with full force by the WSU administration."

According to the new contract, DMC will provide approximately $76 million annually to WSU/University Physicians Group for teaching, clinical, and administrative services, allowing WSU to continue offering essential safety net services to the uninsured, thereby improving the quality of life and healthcare for Detroit residents. The contract also stipulates a potential payment of an additional $8.8 million in performance bonuses and recruitment support.

"Since WSU docs contribute $22 million per year of their own Part B revenue to caring for under- and uninsured patients, we are confident that what we have been able to do [will] maintain Detroit's safety net," Ms. Dauphinais explained. "Of course, WSU and its physician group will continue to advocate for policy that provides healthcare to everyone, regardless of their ability to pay."

New Mutual Performance Criteria Target Improved Patient Care

For the first time in their 26-year partnership, WSU and DMC have agreed on mutual performance criteria targeting improved patient care, with specific goals including reduced rates of surgical infection and shorter hospital stays. Other provisions of the contract include an 18-month phase during which both parties will complete the transition of programs that are changing their primary location. For the remainder of the transition period, both parties have committed to enhance the depth and breadth of their long-term partnership, which includes avoiding any new competitive activities that might harm that partnership.

Dr. Barbour noted that the contract was drawn up with the assistance of an arbitrator, under considerable pressure from the Michigan governor, Detroit's mayor, and the medical community to resolve the dispute. He said he hopes that the 3.5-year period covered by the agreement will be sufficient to work out any remaining conflicts.

"That gives them plenty of time to get things smoothed out so that they don't come up to this problem at the last minute again," Dr. Barbour said. "I'm sure there are still issues that need to be ironed out over the next few years. It was resolved pretty fairly, but I don't think it will be settled or everything cleared up until the future. They'll see the flaws in each side, and they'll work it out — at least they've got time to work together."

Disparate Groups Pulled Together to Solve Crisis

The complex contract negotiations may have had an unexpected benefit in engaging the cooperation of disparate groups involved in Detroit medical care. Residents, students, staff, administration, and local medical societies all pulled together to solve the crisis without compromising ongoing education or patient care.

"The residents showed outstanding leadership skills, tenacity, and public advocacy for the healthcare of the citizens of Detroit," Ms. Dauphinais said. "They were simply phenomenal. This institution always welcomes the leadership of students and residents, and we are very proud for their role in bringing this to successful resolution."

One medical student, who did not respond to requests for comment by Medscape, even had a blog soliciting signatures on a petition in hopes of bringing about a timely agreement.

"One of the best things that we, as a resident body, did throughout the difficult course of negotiations was to enlist the help of our local and state medical organizations," Dr. Bozyk said. "The Wayne County Medical Society of Southeast Michigan and Michigan State Medical Society provided us with a great deal of support and advice along the way. I'm not sure if the resident input to the process could have been successful without their valuable assistance."

"The Wayne County Medical Society is pleased that this end result has been accomplished, and that physicians will be trained to become active practitioners in the Detroit metropolitan area and the state of Michigan," Dr. Barbour concluded.

In a news release, Governor Granholm agreed that the new contract would be instrumental in protecting Michigan's supply of physicians as well as its economic well-being.

"The long-term stability of the partnership between these two institutions is critical for healthcare in Detroit, Southeast Michigan, and the entire state," she said. "Access to healthcare and healthcare education and research are more important than ever to the region and the state, so I congratulate all of the parties for reaching a landmark agreement."

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