When Lisa Alberts, M.D., finished medical school three years ago, she knew she wanted to do her internal medicine residency somewhere she could get experience treating patients in managed-care settings. After graduating from the Medical College of Pennsylvania, Alberts landed at Legacy Health System in Portland, Ore., and ended up with more managed-care experience than she could have dreamed of.
Last year, Alberts and five other third-year Legacy residents became the first graduates of a new primary-care training program that took them out of the hospital and into community-based private practices.
"I wanted to be trained in an area where (managed care) was part of the system so I could get used to it and learn how to deal with it and take care of patients, rather than being trained in a traditional environment and then going out into the real world and trying to learn how to take care of patients," Alberts says.
Through the Partnerships for Quality Education, a three-year, $8.3 million grant program from the Pew Charitable Trusts, Legacy and seven other academic health centers across the country are joining forces with local managed-care organizations to train primary-care residents in managed-care settings.
Legacy is partnering with two group practices, HealthFirst Medical Group and MedPartners Mullikin Medical Centers, and with Regence Blue Cross and Blue Shield of Oregon. Last year, Alberts spent a half day each week at HealthFirst, a primary-care-based multispecialty practice with 142 providers and 13 locations in the Portland area. Alberts and the other residents provided care to a panel of patients, sat in on contracting and utilization review meetings, and attended regular seminars on such topics as quality improvement, prevention and disease management.
As many as 130 million Americans now receive their healthcare under some form of managed-care contract. According to the American Medical Association, about 85% of practitioners have at least one managed-care contract and an increasing number of group practices are accepting capitation. Academic health centers also are feeling managed care's impact: Private payers have increasingly steered clear of teaching hospitals (and their inflated prices) in recent years, and clinical revenues are plummeting.
While managed care has profoundly affected the way physicians practice medicine, its impact on residency training is nearly imperceptible. Training for most of the nation's 104,000 residents focuses on inpatient care and hospital-based outpatient clinics. At the undergraduate level, only one allopathic medical school has a required managed-care course and 27 offer an elective, according to the Association of American Medical Colleges.
This lack of exposure has left physicians ill-prepared to deal with managed care's clinical and business basics and has resulted in physicians scrambling to learn contracting, utilization review and quality improvement.
"We've got a healthcare system that is changing rapidly, but an education system that really hasn't changed significantly for decades," says Gordon Moore, M.D., director of PQE and director of teaching programs at Harvard Pilgrim Health Care in Boston.
Bridging the gap
Pew is now attempting to bridge the often-acrimonious gap between managed-care companies and teaching hospitals by facilitating training programs in community settings. The other PQE recipients are Cornell University Medical College, New York Hospital, and Empire Blue Cross and Blue Shield; Georgetown University Medical Center and Kaiser Permanente; Harvard Medical School and Harvard Pilgrim Health Care; Henry Ford Health System and Case Western Reserve University School of Medicine; Tufts Managed Care Institute; University of Pennsylvania Health System and Independence Blue Cross; and Lovelace Health System and University of New Mexico School of Medicine.
The three-year grants range from Legacy's $450,000 to Harvard's $1.29 million.
Additionally, 55 associate partners will receive $10,000 grants to support the development of managed-care training programs.
Other training programs, such as the University of California Los Angeles' Center for Managed Care Education, place residents in private practice settings and have done so for years. But the Pew program is the first nationwide effort to revamp medical training: The PQE partners' charge is to create models that can be replicated by training programs across the country. Moore says the grants will focus on teaching the principles and tenets of managed care in which he says all physicians should be trained: population-based healthcare, the use of clinical guidelines and disease prevention.
"Once you start demystifying managed care, (residents) begin to see that managed care has some elements that are potentially very positive for the healthcare system in this country," he says.
In Oregon, a new batch of third-year residents recently began their yearlong rotations at HealthFirst and MedPartners Mullikin. They also will complete block rotations (a one-month immersion experience) at independent practice associations in Salem, Ore., and spend time at Regence Blues working on administrative projects. "Our existing model for teaching residents is right when it comes to emergency and acute diseases," says HealthFirst Medical Director John Santa, M.D. "But here we're encouraging them to focus on the whole population of patients that they and their colleagues are responsible for."
Steve Jones, M.D., director of Legacy's residency program, says the health system has wanted to broaden residents' experience for a while.
"We have our own teaching clinics, but with most teaching hospital clinics, they tend to be an unusual assortment of patients and their care is often very difficult," Jones says. "We had felt for some time that for selected residents, an experience in a more traditional office practice would give them the kind of different look at medicine that would be positive."
Alberts, who is now chief resident, says the patient population she saw at HealthFirst is a more accurate reflection of patients she'll encounter once her training is done. "It's definitely a different patient population," she says.
"In the (hospital-based) clinics, because we took a lot of people who couldn't pay, we were getting a lot of people who were drug addicts, people with mental health problems. It can be challenging and frustrating. It's been nice to get some basic primary-care medicine."
Alberts also says dealing with HealthFirst's multiple payers was one of the program's most valuable lessons. In traditional resident clinics, she says, "you don't have to deal with insurance companies. You just try to find the least expensive way of doing things so (patients) are not financially burdened. At HealthFirst, we have to learn 50 insurance companies and systems."
The rotation at HealthFirst is so realistic that residents even receive a cash incentive if quality and financial targets are met. While performance incentives have been controversial within the medical community, Santa says the residents actually embraced the idea of an incentive. "The residents were curious to see how influential the incentives are," he says. The $400 to $500 incentive must be used for educational purposes, but "it's enough to get their attention and give them a little bit of a feel for what it's like in a practice setting."
On the opposite coast, the Tufts Managed Care Institute is guiding family practice and internal medicine residents from Newton-Wellesley and Beverly hospitals outside Boston through rotations in capitated community practices. The Tufts Managed Care Institute was created in 1995 by the Tufts Health Plan (an IPA-model HMO) and the Tufts University School of Medicine. Its mission is to help physicians practice in a high-quality managed healthcare system.
Some of the institute's $1.28 million grant is being used to develop an interactive CD-ROM that depicts life at fictional Midvale Medical Associates.
Residents learn about Midvale's difficulties with contracting, risk sharing, resource allocation and quality improvement through case presentations.
Executive Director Rosalie Phillips says the institute hopes to eventually sell the CD-ROM to residency programs across the country. The London-based pharmaceutical company Zeneca Group has agreed to purchase and distribute this first CD-ROM to residency programs.
And in Pittsburgh, five internal medicine residents from Western Pennsylvania Hospital recently began their once-a-week, two-year rotation through local private practices. In addition, all second-year medical residents do a block rotation in a managed-care office setting and spend some time working within Highmark Blue Cross and Blue Shield.
Premier Medical Group, a multispecialty group practice with 19 locations and 60 physicians, is one of the sites where residents will be for the next two years.
Sandra Balcik, Premier's managed-care operations specialist, organizes managed-care lectures and curriculum for the residents and recently guided them through the basics of managed care. "What we're trying to focus on with them is that managed care is here," she says. "Clinically, they've been trained and are very sound. But in this arena, they know they have to be clinically sound, and they also have to be financially marketable."
Unlike the disjointed care often found in hospital-based clinics, where there is little continuity in records or medical staff, community clinics offer residents exposure to more coordinated healthcare, says James Costlow, M.D., Premier's residency director.
"Unlike a lot of academic clinics, this is integrated care," Costlow says. "There's one chart for each patient. If that patient sees me and has a lymphoma and has to go over to an oncologist for chemo, it's the same chart that follows through. It's the same access to the lab, same access to X-ray. And on any given day, most of these physicians are in the building. It doesn't tend to work that way in an academic situation."
Perks for HMOs
The benefits for managed-care companies are numerous, says Allen Johnson, M.D., medical director of Regence Blues in Oregon. "It certainly makes sense that in a highly penetrated managed-care market such as this, we should be doing something to educate residents about what it means for them once they're out in practice, rather than waiting until after they're out," he says.
Philip Boulter, M.D., senior vice president and chief medical officer of the Tufts Health Plan, agrees. "From the health plan standpoint, if I have a knowledgeable physician who knows the terminology, understands the processes that are part of managed care and understands how to communicate those issues to the consumer, then I think I have a more educated physician in dealing with what can sometimes be a contentious, patient-physician-health plan interaction," Boulter says.
As long as PQE continues to fund such collaborative projects, they're easy for managed-care organizations and teaching hospitals to embrace. When the money runs out, however, the relationship may not be so rosy. Not surprisingly, managed-care companies are reluctant to foot the bill.
"I think there are certain competencies that we would like to see physicians who would work in managed care develop," says Johnson of Regence Blues. "I think we should be willing to pay for it, but we also should have some control of the product if we're going to pay for it. Will a program pay for any sort of standardized testing to show that the people they're putting through the programs are qualified?"
Santa asserts that such partnerships are self-funding, because the residents generate business and revenues once they're in the community clinics.
"Financially, it appears to be very feasible. The major barrier in the future will be the creation of partnerships between hospital teaching programs and community practices in which the partners will be able to find some equity in how to finance this," he says. "But it's pretty clear there are sufficient funds available to fund this without needing grants, etc."
Another issue the partners will have to tackle is the drain on hospital-based clinics, cautions Legacy's Jones.
"By and large the medical groups have wanted the cream of the crop," Jones says. "We have 17 residents; they would like the top six. To a certain extent they've gotten them. That's taken the brain power out of our own clinics, and the faculty say, 'Hey, what's going on? You're taking our best help.' "
Other physicians believe residency simply isn't the appropriate place for managed-care training. "Residents have enough to do with just the medical training. Postgraduate training is where we should think of putting this in," says Uwe Goehlert, M.D., medical director for Towson (Md.) Health Express, an urgent-care clinic. Goehlert is one of the more than 200 physicians nationwide who recently took the first American Board of Managed Care Medicine examination offered by the American College of Managed Care Medicine. The college says physicians who pass can use the Certification in Managed Care Medicine initials as part of their professional signature and as a way to market themselves to managed-care companies and patients.
"A lot of it is just learning the parlance and jargon because there are so many different arrangements," Goehlert says. "The biggest part I personally got out of it is breaking into the managed-care market and being able to understand it, because vocabulary is 50% of the problem."
While practitioners like Goehlert are eager to embrace managed care, many other physicians resent managed care's influence on medicine and fear managed care will teach physicians to put bottom lines ahead of patients and reward them for seeing more patients in less time.
Patrick Dunn, M.D., an internist who works with residents in a traditional setting at both Legacy and HealthFirst, defends the program, arguing that no matter where physicians practice, reimbursement and productivity will always be considerations. Managed care simply teaches residents to be more cost conscious, not less caring, he says.
"Regardless of the reimbursement method, there are always ethical issues," Dunn says. "There's always going to be an incentive if physicians are paid for their services. In fee-for-service, physicians are paid for doing more for patients. Patients may tend to like it. They feel like things are being done more for them, but it's not always the most cost-effective."
Health systems that wish to teach residents how to deal with any managed-care issues should begin by making sure their faculty members are adequately prepared, says David Shulkin, M.D., chief medical officer and chief quality officer of the University of Pennsylvania Health System.
"You can teach students and residents all of the correct information, then you put them in a situation where the faculty member who is their supervisor completely disregards that information," Shulkin says. "Years of work and education will go down the tubes in a matter of a day. Our design is not to target the residents and students initially until we're confident we've gotten the faculty to teach and support in a managed-care environment. Once you've done that, your job becomes easier."
In response to criticism that business has no place in medical training, PQE's Moore says physicians remain caregivers, but they also must be realistic about today's healthcare environment.
"I think it's important for physicians to know about how medical care is organized and how it's paid for and what it costs," he says. "On the other hand, I have little hesitation about making doctors businessmen. I don't think they need to learn how to be accountants; they need to learn to think about the cost-effectiveness of what they do. There are lots of things that cost a lot of money that don't provide a lot of value. We need to think about incorporating cost-effectiveness into our practices."