Are new doctors learning to love managed care?

Patient panels, clinical guidelines, formularies, utilization review, test denials--could this really be residency?

By Deborah Grandinetti, Senior Associate Editor

Undergraduate Medical Education for the 21st Century gathers its project leaders and teaches students (above) how to practice cost-effectively.

When internist Stacy Tribble interviewed for her first job out of residency training this year, she met with 10 practices and sparked strong interest among them all. Part of her appeal: her managed care training. "I can see 10 patients in a half-day," she told prospective employers--an impressive number for a new doctor. "I can dictate, chart, and code appropriately. I know how to use formularies, and to make referrals consistent with the guidelines of insurance companies."

Like most of her peers, Tribble began her residency training in an academic health center with its own outpatient clinic. But she spent the last year in a private multispecialty practice, HealthFirst Medical Group of Portland, OR. There Tribble was responsible for a panel of patients and was measured on productivity, revenues generated, and patient satisfaction. The program was designed to immerse her in the realities of a managed care practice.

It was a year of constantly being asked by her preceptors, "What is the evidence? Does it work? Is it worth it?" Tribble emerged not only with practical skills, but with a fundamentally different orientation from that of residents in more traditional programs. In short, she's cost-conscious. She doesn't question the notion that health care dollars need to be apportioned carefully over a patient population, or that it's her job to do so. And she's comfortable communicating that to patients.

"When someone wants an MRI for a bad back and the symptoms don't warrant it, I've gotten very good at explaining the situation so the patient doesn't feel he's not getting something he needs," says Tribble. Her ability to initiate those conversations--without resentment or awkwardness--represents a sea change in the training of young physicians.

In fact, the whole movement of schooling new doctors in managed care tenets promises to change the very foundation of medical practice. If residents are taught to think in terms of "patient populations" and "global resources," what happens to the physician's sworn duty to serve the individual patient's needs above all else? And when that ideal loses primacy--and defenders--what will that mean for the profession?

"I accept that the Hippocratic oath makes it difficult for doctors to think about how we allocate resources," says infectious disease specialist Gordon T. Moore, director of the grant program that provided funding for Tribble's residency. "But I think, inevitably, we'll have to. Physicians can't remain outside the process."

Rosalie R. Phillips, executive director of Tufts Managed Care Institute in Boston and an assistant clinical professor at Tufts University School of Medicine, envisions a time when a population-based focus will be implicit in medical education. "Medical schools don't say they teach fee-for-service medicine, but a fee-for-service approach has been embedded in specific courses," she argues. Within a decade or so, Phillips predicts, the medical school curriculum will stress the importance of conserving re-sources and balancing the needs of the individual against those of the whole.

The transmission of these values to medical students and residents in groundbreaking programs like the one Stacy Tribble went through marks the beginning of that shift.

Big plans, big names, big money

The residency at HealthFirst was part of a new model being advanced by Partnerships for Quality Education (PQE), a grant program launched in 1996 with $8.3 million from the Pew Charitable Trusts, a Philadelphia-based philanthropic foundation. PQE's mission: to revamp medical education so young primary care doctors are better equipped for today's health care environment.

"When you've got 17,000 new medical students every year, the overwhelming majority of whom are hostile to and poorly in-formed about current health care delivery and financing systems, you've got a real problem," says Moore, PQE program director and a professor at Harvard Medical School.

To date, PQE has awarded 66 grants, with plans for another 150 over the next three years. The second wave of funding, $8.9 million, has come from the Robert Wood Johnson Foundation. All the grants have gone to partnerships between academic health centers and managed care organizations. Each partnership is developing a new and, ideally, reproducible approach to primary care residency. In Portland, for instance, an academic medical center, Legacy Health System, has joined with Regence BlueCross BlueShield of Oregon and two community practice sites, HealthFirst and MedPartners. They hope to demonstrate the benefits capitated community practices gain by participating in residency training, such as first crack at the new talent.

Among the other alliances are Georgetown University and Kaiser Permanente; Weill Medical College of Cornell University, New York Hospital, and Empire Blue Cross and Blue Shield; Harvard Medical School and Harvard Pilgrim Health Care; Case Western Reserve University School of Medicine and Henry Ford Health System; University of Pennsylvania Health System and Independence Blue Cross; University of New Mexico Health Sciences Center School of Medicine and Lovelace Health Systems; University of California at Irvine College of Medicine and PacifiCare Health Systems; and Tufts Managed Care Institute, a joint venture of Tufts Health Plan and Tufts University School of Medicine.

While PQE is the only national effort of its kind, Moore says that about 100 similar initiatives are in place regionally. While such programs reach only about 10 to 15 percent of residents in all, many Internet users are visiting the Managed Care Education Clearinghouse (www.gwumc.edu/mcec), a site maintained by George Washington University Medical Center. And the Tufts Managed Care Institute in Boston is doing its darndest to train the trainers by providing programs for medical school faculty and curriculum modules neatly packaged in CD-ROMs.

A solid foundation in managed care, says Moore, includes an understanding of quality improvement, disease management, population-based and preventive medicine, evidence-based medicine, and medical ethics.

A close cousin to PQE is Undergraduate Medical Education for the 21st Century, a curriculum development project of the Health Resources and Services Administration of the US Public Health Service. Administered by the American Association of Colleges of Osteopathic Medicine, UME-21 has awarded $3.6 million to 18 medical schools since its launch in 1998. A new curriculum developed under the UME-21 banner is aimed at teaching medical students to practice "high-quality, population-based, cost-effective medicine."

How the new programs differ

Residency programs that have a managed care focus vary in their approach. Even the PQE programs are not carbon copies. In the Georgetown-Kaiser partnership, for instance, the medicine and pediatrics residents who train at Kaiser spend a year on its ethics committee. Unique to the Lovelace-University of New Mexico program is its integration of residents into a risk-sharing venture for Medicaid managed care. The Case Western Reserve-Henry Ford partnership emphasizes teaching new doc-tors how to function in inter-disciplinary teams and co-ordinate care across settings, allowing for a smoother transition when, say, a patient moves from the hospital to a skilled nursing facility.

But there are common threads. One is that these programs place greater emphasis on primary care training than do traditional residencies, which stress inpatient care. In the Brigham and Women's Hospital-Harvard Pilgrim Health Care Primary Care Residency, for example, residents devote 65 percent of their time to outpatient care, rather than the traditional 30 to 35 percent.

"It's not like I've learned a different set of skills, but the environment is really different," notes internist Anna Berkenblit, who graduated from that program this year. Also different are the conditions she encountered, the routine stuff of primary care. "I've gained the broadest training in internal medicine," she says.

"We have more real-world patients," adds internist Brian P. Burke, who trained at Portland's HealthFirst. "I don't know how else you'd get such an authentic experience. Outpatient training has been the poor stepchild of medical education, but that's where everything is shifting to in today's practice."

The programs train residents to consider costs and insurance rules related to reimbursement. Some programs even profile the residents and provide bonuses for being cost-conscious. Chart review is a routine part of the process.

Residents like Berkenblit and Burke also learn to take the patient's insurance into account when considering diagnostic tests, prescriptions, referrals, and treatments. Berkenblit, for instance, had to decide whether to hospitalize patients with deep vein thrombosis or treat them on an outpatient basis, using a heparin injection pioneered by Harvard Vanguard medical group. Few insurers cover the new treatment, which is far less expensive than the typical three-day hospital stay.

Burke has had to contend with the more than 50 different insurance companies HealthFirst contracted with. So he's encountered denials for diagnostic tests and been obliged to explain to patients who were doing well on a particular drug why they must switch to another that's on their insurer's formulary.

These residents are given the opportunity to see issues from the insurer's perspective. In Burke's program at HealthFirst, for example, residents spent two half-days per month inside Regence BlueCross BlueShield, sitting in on utilization review meetings or learning about preventive health or disease management initiatives.

Yet another difference is that preceptors in the new residency programs are more likely to champion evidence-based medicine. "We were always encouraged to take an evidence-based approach," says Burke. "We had good resources within the office, such as up-to-date textbooks and files we could use for common questions."

Does all of this add up to a different kind of doctor? PQE is barely 3 years old, so it's too early to say. Columbia University and New York University are evaluating the impact of PQE programs, but the research isn't complete.

Internist John S. Santa, HealthFirst's medical director until its clinics were closed Aug. 31, says the dozen or so residents who cycled through his organization's PQE program since the 1997-'98 academic year have emerged "much more comfortable with outpatient care and the business of medicine, but somewhat less comfortable with complex hospital patient care."

But Stacy Tribble strongly disagrees: "I feel quite confident in that area. We received just as much inpatient training as anyone on our program. The Pew grant program only changed our outpatient setting."

Berkenblit's preceptor, in-ternist Talia N. Herman of Harvard Vanguard, says the PQE residents she's observed are as skilled at caring for hospitalized patients as residents in more traditional programs. What's different, she says, is that PQE residents are better equipped to handle routine ambulatory care problems and are much more cost-conscious. She says these graduates tend to adjust far more quickly to office-based practice than traditional residency graduates.

Preventive medicine specialist Thomas S. Inui, professor and chairman of Harvard's Department of Ambulatory Care and Prevention, argues that PQE residents have an edge over their peers. "If I ran a practice today, I'd hire one of them," he says. "Not only do they provide good patient care, but they understand how systems run and how their choices affect those systems. They're clear on the ethical foundations of the work. I think they're ideal leaders."

Managed care critics have their say

Still, within the hallowed halls of academic medical schools, antipathy toward managed care runs deep. A recent survey published in The New England Journal of Medicine found that medical school faculty consider managed care inferior to fee-for-service on numerous counts. Those negative views were echoed by students, residents, and, to a lesser degree, deans.

That's true even at Harvard Medical School, which joined with Harvard Pilgrim Health Care back in 1991 to establish the Department of Ambulatory Care and Prevention, the country's first medical school department based in a freestanding HMO. "We have 8,000 faculty members at Harvard. By and large, they're highly subspecialized," says Inui. "They feel as though they've been hard hit by managed care."

The most vocal of these faculty members argue that exposing young physicians to managed care principles wastes valuable learning time and warps young minds. "Some say that managed care is such a restrictive, bad system that we should be bucking the trend," says New York Presbyterian Hospital psychiatry resident Ivan Oransky, the son of a physician.

As the study in The New England Journal shows, med school faculty members have been very effective at shaping students' and residents' views of managed care. Oransky, who entered medical school in 1994, remembers hearing at least one disparaging joke a week about managed care in lectures. "By the time you got to residency, you were anti-managed care," he says.

Some managed care plans don't help their own cause. In a recent column in American Medical News, Oransky recounted an experience from the first month of his internship at Yale-New Haven Medical Center. A managed care medical director questioned his decision to order a three-week inpatient rehabilitation stay. Although Oransky successfully explained that his treatment plan represented the best hope of preventing an expensive relapse, the experience unnerved him.

"To come into contact with an adversarial system during the first month of my internship was uncomfortable," he says. "If new doctors can be convinced that someone is going to call whenever they order an expensive or difficult-to-obtain treatment, maybe HMOs will win the war of attrition, and the average hospital stay will be reduced by 20 percent. It's an intimidation tactic, really."

Here, says Oransky, is where faculty attendings have an opportunity, "without being critical of all managed care," to teach physicians-in-training how to do the right thing for the patient--regardless of what the managed care plan says.

But there's a problem. While the job of helping young physicians develop the fortitude to do what's right falls to medical school faculty, there aren't enough who understand the issues, says internist David B. Nash, director of the office of Health Policy and Clinical Outcomes at Thomas Jefferson University Hospital, and associate dean at Jefferson Medical College in Philadelphia. Schools need to appoint more faculty who not only know the issues, he says, but can teach young doctors how to successfully advocate for patients when insurers refuse to authorize medically necessary treatment.

Changing the system from the inside

Some argue that residents who receive managed care training make better patient advocates. HealthFirst's John Santa recalls how one of his PQE residents responded when asked about the dictates of managed care companies: "That's not how it works," the resident said. "When a decision has to be made, my preceptor doesn't ask what the HMO says. He asks, 'What's the evidence? What are the ethics around it?' Once we have those answers, we'll indicate what we think should be done. If the insurer disagrees, we'll talk to them."

Says Santa: "It was great to hear that. I'm not saying that's how it always is. On the other hand, this is not an experience where faculty say you're going to learn how intolerable life is under managed care."

Does exposure to a solid managed care curriculum change young doctors' perceptions of managed care? Perhaps. "We did pre- and post-tests for students who came to us for our annual managed care rotation," says Rosalie Phillips, executive director of Tufts Managed Care Institute. "We saw a significant change. People moved out of the 'unsure' column, and from negative to positive in their views about matters such as clinical guidelines and the delivery of more cost-effective care."

As Portland internist Brian Burke puts it, "Without the program, I wouldn't have seen the breadth--or the upside--of this style of practice; just the paperwork." For him, the training has a long list of pluses: learning to practice efficiently and cost-effectively; assessing preventive care needs, like immunizations, at each visit rather than relying on an annual physical; and learning how to educate patients about their best options, through evidence-based medicine. "I needed to confront managed care, to see whether it was something I could do," he says. He has decided he can.

The same can-do attitude is prevalent in new med students. Philip Perilstein, a student at Jefferson Medical College and the son of a Reading, PA, rheumatologist, majored in political science as an undergraduate and came to school with an interest in health policy. That interest was in-creased by the summer he spent as a research assistant to Jefferson internist David Nash, an advocate of managed care education. "You have to understand how medical economics works to be the best advocate for your patients," Perilstein insists. "If you don't know the system, you can't work with it."

A resource for residency directors and attendings

Tufts Managed Care Institute in Boston is particularly active on the managed care education front. Indeed, it has taken a train-the-trainers approach, in addition to creating its own programs for medical students, residents, and physicians.

The nonprofit institute was formed in 1995 at the behest of two infectious disease specialists: Harris A. Berman, Tufts Health Plan chairman and CEO, and Morton Maddox, then dean of Tufts University School of Medicine. The institute has since conducted 120 programs and enrolled more than 5,500. Its mission, says Executive Director Rosalie R. Phillips, is to help physicians and other health professionals become more comfortable and productive working in systems that demand cost-effective care.

In June 1998, the institute rolled out "Preparing Residents to Succeed in Managed Care," a curriculum that had been piloted at 16 primary care sites across the country.

The curriculum, which includes a CD-ROM and instructor's manual, covers four main topics. "Understanding Managed Care: Learning the Essentials Through Case Presentations" is on CD-ROM and has four modules, each of which can be completed in 45 to 50 minutes. "Model Curriculum for a Managed Care Rotation" has three modules with 38 lesson plan outlines for preceptors; "Practicing Patient-Centered Care in the Managed Care Environment" has five modules; and "Evaluating, Adapting and Using Clinical Practice Guidelines" has three. A pharmaceutical grant will enable the institute to provide the first 1,000 copies free to primary care sites. Over 500 have been distributed so far.

"We intend to add more modules to the program," says Teresa Power Silverman, the institute's senior director of learning design and development. "Quite a list of competencies have been developed by regulatory agencies and professional societies. We're also putting together an online curriculum."

Tufts' own programs for medical students and residents include eight-week summer fellowships for medical students, which the school runs with the American Medical Student Association. Students undertake a specific project within a health plan or community health center. In past years, for instance, students investigated local referral management.

The institute also sponsors a one-week rotation where residents attend lectures and spend time learning about the workings of Tufts Health Plan's various departments. They may shadow a case manager, for example, or sit in on a marketing meeting.

"The residents get to meet people who feel passionate about managed care and implementing disease management and continuous quality improvement," says internist Jeffrey K. Levin-Scherz, associate medical director of the institute and vice president and corporate medical director of Tufts Health Plan. Most residents, he says, absorb the negative attitudes of managed care-hating preceptors in smaller practices. The Tufts rotation gives residents a chance to make up their own minds.

Links to managed care training organizations

Partnerships for Quality Education
www.pqe.org

Managed Care Education Clearinghouse
www.gwumc.edu/mcec

Tufts Managed Care Institute
www.tmci.org

Undergraduate Medical Education
for the 21st Century
www.aacom.org/UME-21

. Are new doctors learning to love managed care?. Medical Economics 1999;19:141.