Students, residents, faculty and physicians are exposed to the managed care environment through the Tufts Health Care Institute.

Peering into the Black Box

Programs Expose Medical Students, Residents and Faculty to Managed Care

by Susan Sanderson, Managed Health Care News, October 2000

In the past decade, the air between managed care and academic medicine has been thick with complaints that newly minted physicians are not being trained in the realities of practicing medicine in a managed care environment. Academia has accused the managed care industry of unnecessarily high levels of control; health plans, in turn, have charged medical education with disseminating an outdated fee-for-service bias. Easing the tension between these two camps are an increasing number of organizations that have developed programs to familiarize medical students, residents and other health care staff with the "black box" of managed care. These programs are focused on helping health care professionals recognize that physicians are increasingly accountable for the cost and quality of both the individual patient and a population of patients in a health system. Under managed care, physicians need a skill set that goes beyond handling paperwork. "This is not just about insurance’" says Rosalie Phillips, MPH, executive director for the Tufts Health Care Institute (Boston). "We are trying to get beyond the notion that this is only about payment mechanisms, and focus on population-based medicine, health improvement, disease management, and patient satisfaction." Taking the Knowledge Directly to the Schools Aetna US Healthcare (Blue Bell, Pa.) launched its Academic Medicine and Managed Care Forum in 1996 to develop a closer working relationship between managed care industry and academic medicine. "Everyone is working together to find better ways to teach students and residents about how the practice of medicine has changed," says Dennis Oakes, the forum’s executive director. Partners include MCO’s, many of the nation’s top academic medical institutions, major employers, pharmaceutical companies, information systems, federal agencies, and others. According to Oakes, today’s physicians should be comfortable practicing population-based medicine, understand reimbursement mechanisms, practice with cultural sensitivity, deal with chronic diseases, and implement evidence-based medicine. To this end, Aetna’s Quality Care Research Fund, administered through the forum, has devoted about $1 million over the past three years to incorporating managed care principles into the medical school curriculum. "Our focus is on getting faculty to understand new principles and support them in conveying those principles to their students and residents," said Oakes. The Quality Care Research Fund started in 1997 with a $15 million commitment from Aetna in support of health services research. The fund continues with financial support from a number of pharmaceutical companies. The curriculum efforts to date include projects from Tulane University School of Medicine and the University of Missouri School of Medicine. In 1998, Tulane received a three-year grant to examine how the institution can fully integrate managed care principles throughout all four years of medical school. In addition, Missouri received another three-year grant in 1999 to develop a core group of health care professionals with the knowledge and skills to provide leadership in academic medical centers in response to the movement toward population-based medicine, integrated managed care systems. "The Values of Both Worlds" The Tufts Health Care Institute (THCI), established in 1995 as a collaborative not-for-profit educational venture between Tufts University School of Medicine and Tufts Health Plan, has developed seminars and educational materials to exposure students, residents, faculty and practicing physicians to the managed care environment. "The Institute reflects the values of both worlds," says Phillips. THCI produces numerous resources, including online products, educational programs and conferences. One major educational effort is the curriculum, "Preparing Residents to Succeed in Managed Care", a four part program supported by Partners for Quality Education, two Tufts-affiliated residency programs, and others. The course features a residency rotation divided between a health plan and a community practice holding significant capitation contracts. Also included are three learning courses, including a CD-ROM that presents a series of scenarios demonstrating how physicians can both accept financial risk and incorporate quality and resource allocation methods in health care. Phillips says that THCI wants students , residents, and physicians to become comfortable with practicing managed care techniques. "In fact, population-based health care can be seen as simply another term for managed care," Phillips notes. Looking at a group of patients as a population that can be studied and learned from can serve as a powerful tool to improve the quality of patient care by "supplementing gut feeling with more concrete knowledge about your patients and your practice patterns," she adds. "Doctors have to put up with a lot of hassles these days, but they are coming to grips with the fact that they practice in a system where cost-effectiveness is highly valued. These educational tools can make a huge difference in bridging that cultural gap." Connecting at the Director’s Level Partnerships for Quality Education (PQE) was launched in 1996, with an $8.3 million grant from The Pew Charitable Trusts. The money initially supported 66 partnerships between residency programs and MCOs and concentrated on incorporating managed care skills into primary care resident education. More recently, The Robert Wood Johnson Foundation has awarded PQE a grant of nearly $9 million to fund more that 150 partnerships between managed care and residency programs for both physicians and nurses. "We especially interested in bringing to the table the importance of getting residents and nurses out of the hospitals and into the community settings where clinicians are managing care within fixed budgets," says Elizabeth March, deputy director of the Partnerships for Quality Education (Boston). "When you strip away all of the politics, the important thing is to teach clinicians how to deliver quality, population-based care." March notes that Partnerships for Quality Education has focused on getting MCOs and practices to collaborate with residency and nursing education directors to develop new curricula and teaching strategies. In addition, residents and nurse practitioner students are participating in nonclinical administrative rotation blocks where they learn about such issues as utilization review, the utilization of formularies and accreditation. "The learners are coming and out of these experiences feeling empowered," says March. "They understand the decision-making process well enough to advocate successfully for their patients’ care". The Challenge of Change Other programs working to educate medical students and residents in the skills required by managed care systems are also in place. "Health plans have a growing interest in doctors to understand and accept the way medicine is now practiced, and these skills might as well be part of the initial training," says Oakes. The hope is that each successive generation of physicians will become more comfortable in capitated environments. "To go from working in a private practice to working in a system is a huge cultural change for many physicians," admits Phillips. "But, even though the managed care industry is still in transition, I can definitely see an increasing interest on the part of academic medicine faculty to better prepare their graduates." Susan Sanderson is a contributing writer based in Arlington, Va.

Web Sites for Information on Teaching Managed Care Aetna’s Academic Medicine and Managed Care Forum: www.academicforum.org Tufts Health Care Institute www.thci.org Partnerships for Quality Education: www.pqe.org Association of American Medical Colleges www.aamc.org

School Days Medical schools are getting more involved in incorporating managed care know-how into their classrooms. "For a long time it was an anathema for those teaching medical students to address the business side of medicine," says M. Brownell Anderson, associate VP for Medical Education at the Washington, D.C.-based Association of American Medical Colleges (AAMC). "But over the last decade, medical schools have taken significant steps to incorporate topics of managed care in the medical school curriculum." According to Anderson, most of the 125 AAMC-member medicla schools now integrate throughout their curricula topics such as health care systems, practice and risk management, and quality improvement. In addition, the Accreditation Council for the Graduate Medical Education has recently included practicing in a system-based health care program as one of the six general competencies residents must demonstrate in order to graduate.