So far, medical and educational leaders in Missoula do not appear to have embraced the idea of opening a for-profit osteopathic school here.
The hospitals have stayed mostly mum. Last week, Providence St. Patrick Hospital and Community Medical Center both issued brief noncommittal statements about the school in response to interview requests.
Community noted the proposal is under discussion, and St. Pat's said it's still gathering information.
The University of Montana sponsors a medical residency program, but UM president Royce Engstrom said he is still evaluating the pros and cons of the venture proposed by Manipal Education Americas.
"I think that it isn't clear, one way or another, in my opinion, at this time," Engstrom said.
In the interview, he said UM must consider not only its role in Missoula, but also what's best for the Montana University System as a whole.
The announcement that Manipal wants to open its first U.S. school in Missoula took place earlier this month at a meeting of the Missoula Economic Partnership. There, the head of the partnership touted the potential boon to the local economy, estimated to be an annual $45 million contribution.
At the meeting, Mayor John Engen requested time on the agenda to voice his strong support for Manipal. Last week, he said he still hopes to convince the hospitals and UM to sign onto the idea.
"It seems to me that the Montana university with the mandate to do health sciences programming ought to be the city where a medical school is," Engen said.
A different company is looking to open a medical college in Bozeman.
The school in Missoula would be Manipal's first in the U.S., so it does not have a domestic track record of success or failure.
In short, it's raising questions.
Should a for-profit medical school operate in Missoula? Will it put undue pressure on residencies? Will it hurt the hospitals?
In the U.S., for-profit schools are a relatively new concept in medicine, and their viability for the long term is untested. A couple institutions have seen early successes, but professionals involved note support from local institutions is key.
So far, many Missoula leaders look to be holding back, and at least one medical professional in the state believes the discussion should slow down.
The University of Washington School of Medicine operates as WWAMI in Wyoming, Alaska, Montana and Idaho. In Montana, Jay Erickson encouraged caution as the conversation continues.
"I'm not sure why there's such a hurry over the placement of these schools," said Erickson, assistant dean for regional affairs in Montana and WWAMI clinical coordinator.
"It seems like Montanans have always had a reasoned approach to solving Montana problems, and it seems like that's a better approach than having out-of-state investors sort of driving these medical education efforts."
Both companies that want to open medical colleges in Montana would run schools of osteopathic medicine. According to the American Osteopathic Association, doctors of osteopathic medicine, or DOs, are "fully licensed physicians who practice in every medical specialty."
DOs take a holistic approach to medicine, and they look at the way lifestyle and environmental factors affect wellness. They account for 11 percent of physicians in the U.S., but osteopathic medicine is "one of the fastest-growing segments of health care."
At Partnership Health Center in Missoula, director Kim Mansch said an estimated 40 percent of the physicians on staff are DOs. According to another doctor, DOs are culturally inclined to public health and under-served populations.
"When we've recruited, a DO is fine with us. It's the same as an MD," Mansch said.
To date, though, Manipal has only operated overseas, in India, Malaysia, Nepal and Antigua, and its school in Missoula would be a first for the company under U.S. accreditation standards.
According to a 2013 article in a health care journal called Health Services Insights, ventures in the Caribbean generally have had less oversight, and its students haven't fared as well academically as ones from the U.S. and Canada.
In the first of three U.S. licensing exams, for instance, first-time test takers from the U.S. and Canada scored a 96 percent pass rate in 2012, according to the peer-reviewed publication. Their counterparts from non-U.S. schools, including the Caribbean, passed at a 76 percent rate.
Manipal, though, bests even students from the U.S. and Canada: Last week, it noted a comparable pass rate of 97 percent by its students in Antigua, who take the U.S. exam.
Elsewhere, and within the medical community, the for-profit medical school has been controversial.
The first in the U.S. in recent history, Rocky Vista University College of Osteopathic Medicine in Colorado, admitted its inaugural class in 2008.
One year earlier, George Mychaskiw, then a DO and chief of anesthesia at a children's hospital in Mississippi, called out the for-profit model for its potential to erode credibility of the osteopathic profession, according to an article in American Medical News.
"This is a very unsavory situation," Mychaskiw said at the time.
Now, Mychaskiw is the founding dean and chief academic officer at another for-profit medical college, one in Las Cruces, New Mexico. There, the Burrell Group runs the Burrell College of Osteopathic Medicine, the same outfit looking to open a medical college in Bozeman.
"My thinking changed on it a lot. It's sort of pragmatic," Mychaskiw said last week.
Initially, he worried about credibility, and he was concerned Rocky Vista would place profit over medicine: "Will it become sort of a throwaway degree that is just there to print money?"
The leadership hasn't allowed that to happen, though, and neither has the accrediting agency, he said. In fact, as far as Mychaskiw is concerned, the school meets high standards, and the body overseeing them has grown robust.
"Over the last decade, COCA (the Commission on Osteopathic College Accreditation) has come into its own as a rigorous accreditor," he said.
A few years ago, Mychaskiw became interested in opening a school where the need for physicians was great, and the borderlands had some of the "worst shortages in the country."
Raising the $80 million to $100 million for a nonprofit in a place that many consider the "edge of the world" would have taken more than a decade, maybe 15 years, he said. Given the success at Rocky Vista, supporters of a college in Las Cruces turned to private investors.
"Over 60 years, the investors get a fair return. Not a usurious return, but a fair return," he said.
Now, he considers himself Paul on the road to Damascus when it comes to for-profit medical education.
"It's not that I'm a convert to the model, but at this time in history, in this location, in this economy, this is the best way to fulfill the mission," Mychaskiw said.
Joseph Giaimo, former chair of the U.S. Department of Education for the American Osteopathic Association, agreed COCA has become rigorous.
The agency meets on a regular basis with its schools, some 30 osteopathic medical schools in the country, including two for-profit ones, and its members "vigorously interrogate" the schools.
The accreditation standards are the same regardless of the financial model, so for-profit schools receive the same scrutiny, he said. New schools such as Burrell set money aside to guarantee the first classes will matriculate.
"They have strict requirements as far as their fiduciary responsibility to the students," Giaimo said.
COCA accredits osteopathic schools, which turn out DOs. The Liaison Committee on Medical Education, or LCME, accredits allopathic schools, which turn out MDs.
Dan Hunt, co-secretary for the LCME, said the U.S. currently has 145 medical schools including two that are for-profit organizations. One of the for-profit schools, in California, received preliminary accreditation in June.
"It's a pretty new phenomenon," Hunt said.
In Missoula, Manipal has argued the school will help alleviate Montana's shortage of physicians, but Hunt doesn't buy the often-cited rationale. That's because physicians can't practice or be licensed until they've completed a residency, and he said the U.S. has little capacity.
More residencies are expensive to create, he said. Plus, he said, a new generation of graduates from newly opened schools, some 20 MD schools in the past eight years, will create more pressure on existing slots.
"It's getting very tight, and students are having to look for residencies that they otherwise never would have expected. It is getting (to be), and it will become, a serious problem in the relatively near future," Hunt said, noting legislation could offer solutions.
In Missoula, Mansch said Partnership has 10 residency slots a year, a large number. Manipal proposes to enroll 150 students a year, each needing to do a residency.
Medical professionals note most doctors end up working near the place they did their residency, so additional spaces in Montana look to be one key to alleviating the need for doctors.
Practically speaking, though, opening more slots would be challenging for Partnership, given the scheduling and rotations, Mansch said. Partnership otherwise takes a neutral stance on the proposed medical college.
Erickson, with WWAMI, agreed residencies would be a challenge, and he said the additional medical students would "certainly affect clinical training in the state." The enrollment in Manipal would be five times more than the enrollment in the WWAMI program.
"It's a long hard process to open up graduate medical education residency training programs," he said.
Montana WWAMI has first- and second-year students completing their classroom work at Montana State University in Bozeman. It estimates more than 40 percent of its graduates who study in Montana return to practice here.
Hospitals must be willing to play a role, he said, but a small state without large population centers is limited in the number of residencies it can create.
Representatives of the Family Medicine Residency of Western Montana program initially declined interviews and directed calls to the UM president's office, at the university's request. Subsequently, with permission from UM, associate program director Nerissa Koehn offered the following written statement:
"We admit 10 resident doctors to the intensive three-year program every year. Our program depends on the local and regional medical community to train these physicians, and those resources are limited.
"As a result, there should be significant research into our communities' capacity to provide additional high-quality clinical teaching resources."
In New Mexico, though, Mychaskiw said Burrell created more than 100 residency positions: "There are new residencies where people thought none could be done."
And demonstrating sufficient residency capacity is an accreditation standard, officials said.
As one of the only local leaders to come out in support of Manipal, Mayor Engen said he continues to advocate for the school, and the school continues to do its own due diligence.
"Really, I love the concept of a quality medical school in Missoula," Engen said.
He has requested more information from Manipal, but his conversations with its leaders have led him to believe the school doesn't have its eye on profit alone. He said its officers are keen on the moral imperative as well.
"It really is about turning out quality physicians to provide care for a population that needs docs," Engen said.
He trusts the accreditation body will do the more thorough and specific review, once Manipal applies; it had not submitted documentation as of last week.
In the meantime, Engen said his goal is to bring skeptics of the college and Manipal's officers into a room so the company can directly address concerns.
"I want to get those objections out on the table and see if they're real or imagined in this case, and if they're real, what we can do to overcome them," Engen said.