Are new doctors learning to love managed care?

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

By Deborah Grandinetti, Senior Associate Editor

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

When internist Stacy Tribble interviewed for her first job out of residencytraining this year, she met with 10 practices and sparked strong interestamong them all. Part of her appeal: her managed care training. "I cansee 10 patients in a half-day," she told prospective employers--animpressive number for a new doctor. "I can dictate, chart, and codeappropriately. I know how to use formularies, and to make referrals consistentwith the guidelines of insurance companies."

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

It was a year of constantly being asked by her preceptors, "Whatis the evidence? Does it work? Is it worth it?" Tribble emerged notonly with practical skills, but with a fundamentally different orientationfrom 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 apportionedcarefully over a patient population, or that it's her job to do so. Andshe's comfortable communicating that to patients.

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

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

"I accept that the Hippocratic oath makes it difficult for doctorsto think about how we allocate resources," says infectious diseasespecialist Gordon T. Moore, director of the grant program that providedfunding for Tribble's residency. "But I think, inevitably, we'll haveto. Physicians can't remain outside the process."

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

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

Big plans, big names, big money

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

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

To date, PQE has awarded 66 grants, with plans for another 150 over thenext three years. The second wave of funding, $8.9 million, has come fromthe Robert Wood Johnson Foundation. All the grants have gone to partnershipsbetween academic health centers and managed care organizations. Each partnershipis developing a new and, ideally, reproducible approach to primary careresidency. In Portland, for instance, an academic medical center, LegacyHealth System, has joined with Regence BlueCross BlueShield of Oregon andtwo community practice sites, HealthFirst and MedPartners. They hope todemonstrate the benefits capitated community practices gain by participatingin 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 EmpireBlue Cross and Blue Shield; Harvard Medical School and Harvard Pilgrim HealthCare; Case Western Reserve University School of Medicine and Henry FordHealth System; University of Pennsylvania Health System and IndependenceBlue Cross; University of New Mexico Health Sciences Center School of Medicineand Lovelace Health Systems; University of California at Irvine Collegeof 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 about100 similar initiatives are in place regionally. While such programs reachonly about 10 to 15 percent of residents in all, many Internet users arevisiting the Managed Care Education Clearinghouse (www.gwumc.edu/mcec),a site maintained by George Washington University Medical Center. And theTufts Managed Care Institute in Boston is doing its darndest to train thetrainers by providing programs for medical school faculty and curriculummodules neatly packaged in CD-ROMs.

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

A close cousin to PQE is Undergraduate Medical Education for the 21stCentury, a curriculum development project of the Health Resources and ServicesAdministration of the US Public Health Service. Administered by the AmericanAssociation of Colleges of Osteopathic Medicine, UME-21 has awarded $3.6million to 18 medical schools since its launch in 1998. A new curriculumdeveloped under the UME-21 banner is aimed at teaching medical studentsto 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 Kaiserspend a year on its ethics committee. Unique to the Lovelace-Universityof New Mexico program is its integration of residents into a risk-sharingventure for Medicaid managed care. The Case Western Reserve-Henry Ford partnershipemphasizes teaching new doc-tors how to function in inter-disciplinary teamsand co-ordinate care across settings, allowing for a smoother transitionwhen, say, a patient moves from the hospital to a skilled nursing facility.

But there are common threads. One is that these programs place greateremphasis on primary care training than do traditional residencies, whichstress inpatient care. In the Brigham and Women's Hospital-Harvard PilgrimHealth Care Primary Care Residency, for example, residents devote 65 percentof 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 environmentis really different," notes internist Anna Berkenblit, who graduatedfrom that program this year. Also different are the conditions she encountered,the routine stuff of primary care. "I've gained the broadest trainingin 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 elseyou'd get such an authentic experience. Outpatient training has been thepoor stepchild of medical education, but that's where everything is shiftingto in today's practice."

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

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

Burke has had to contend with the more than 50 different insurance companiesHealthFirst contracted with. So he's encountered denials for diagnostictests and been obliged to explain to patients who were doing well on a particulardrug 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'sperspective. In Burke's program at HealthFirst, for example, residents spenttwo half-days per month inside Regence BlueCross BlueShield, sitting inon utilization review meetings or learning about preventive health or diseasemanagement initiatives.

Yet another difference is that preceptors in the new residency programsare more likely to champion evidence-based medicine. "We were alwaysencouraged to take an evidence-based approach," says Burke. "Wehad good resources within the office, such as up-to-date textbooks and fileswe could use for common questions."

Does all of this add up to a different kind of doctor? PQE is barely3 years old, so it's too early to say. Columbia University and New YorkUniversity are evaluating the impact of PQE programs, but the research isn'tcomplete.

Internist John S. Santa, HealthFirst's medical director until its clinicswere closed Aug. 31, says the dozen or so residents who cycled through hisorganization'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 inthat area. We received just as much inpatient training as anyone on ourprogram. 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 hospitalizedpatients as residents in more traditional programs. What's different, shesays, is that PQE residents are better equipped to handle routine ambulatorycare problems and are much more cost-conscious. She says these graduatestend to adjust far more quickly to office-based practice than traditionalresidency graduates.

Preventive medicine specialist Thomas S. Inui, professor and chairmanof Harvard's Department of Ambulatory Care and Prevention, argues that PQEresidents 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 goodpatient care, but they understand how systems run and how their choicesaffect 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, antipathytoward managed care runs deep. A recent survey published in The New EnglandJournal of Medicine found that medical school faculty consider managed careinferior to fee-for-service on numerous counts. Those negative views wereechoed by students, residents, and, to a lesser degree, deans.

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

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

As the study in The New England Journal shows, med school faculty membershave been very effective at shaping students' and residents' views of managedcare. Oransky, who entered medical school in 1994, remembers hearing atleast one disparaging joke a week about managed care in lectures. "Bythe 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 columnin American Medical News, Oransky recounted an experience from the firstmonth of his internship at Yale-New Haven Medical Center. A managed caremedical director questioned his decision to order a three-week inpatientrehabilitation stay. Although Oransky successfully explained that his treatmentplan represented the best hope of preventing an expensive relapse, the experienceunnerved him.

"To come into contact with an adversarial system during the firstmonth of my internship was uncomfortable," he says. "If new doctorscan be convinced that someone is going to call whenever they order an expensiveor 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 intimidationtactic, really."

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

But there's a problem. While the job of helping young physicians developthe fortitude to do what's right falls to medical school faculty, therearen't enough who understand the issues, says internist David B. Nash, directorof the office of Health Policy and Clinical Outcomes at Thomas JeffersonUniversity Hospital, and associate dean at Jefferson Medical College inPhiladelphia. Schools need to appoint more faculty who not only know theissues, he says, but can teach young doctors how to successfully advocatefor 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 betterpatient advocates. HealthFirst's John Santa recalls how one of his PQE residentsresponded when asked about the dictates of managed care companies: "That'snot how it works," the resident said. "When a decision has tobe made, my preceptor doesn't ask what the HMO says. He asks, 'What's theevidence? What are the ethics around it?' Once we have those answers, we'llindicate what we think should be done. If the insurer disagrees, we'll talkto them."

Says Santa: "It was great to hear that. I'm not saying that's howit always is. On the other hand, this is not an experience where facultysay 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 forstudents who came to us for our annual managed care rotation," saysRosalie Phillips, executive director of Tufts Managed Care Institute. "Wesaw a significant change. People moved out of the 'unsure' column, and fromnegative to positive in their views about matters such as clinical guidelinesand 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 preventivecare needs, like immunizations, at each visit rather than relying on anannual 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 decidedhe 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 withan interest in health policy. That interest was in-creased by the summerhe spent as a research assistant to Jefferson internist David Nash, an advocateof managed care education. "You have to understand how medical economicsworks 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 themanaged care education front. Indeed, it has taken a train-the-trainersapproach, 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 infectiousdisease specialists: Harris A. Berman, Tufts Health Plan chairman and CEO,and Morton Maddox, then dean of Tufts University School of Medicine. Theinstitute has since conducted 120 programs and enrolled more than 5,500.Its mission, says Executive Director Rosalie R. Phillips, is to help physiciansand other health professionals become more comfortable and productive workingin systems that demand cost-effective care.

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

The curriculum, which includes a CD-ROM and instructor's manual, coversfour main topics. "Understanding Managed Care: Learning the EssentialsThrough Case Presentations" is on CD-ROM and has four modules, eachof which can be completed in 45 to 50 minutes. "Model Curriculum fora Managed Care Rotation" has three modules with 38 lesson plan outlinesfor preceptors; "Practicing Patient-Centered Care in the Managed CareEnvironment" has five modules; and "Evaluating, Adapting and UsingClinical Practice Guidelines" has three. A pharmaceutical grant willenable the institute to provide the first 1,000 copies free to primary caresites. Over 500 have been distributed so far.

"We intend to add more modules to the program," says TeresaPower Silverman, the institute's senior director of learning design anddevelopment. "Quite a list of competencies have been developed by regulatoryagencies and professional societies. We're also putting together an onlinecurriculum."

Tufts' own programs for medical students and residents include eight-weeksummer fellowships for medical students, which the school runs with theAmerican Medical Student Association. Students undertake a specific projectwithin 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 attendlectures and spend time learning about the workings of Tufts Health Plan'svarious departments. They may shadow a case manager, for example, or sitin on a marketing meeting.

"The residents get to meet people who feel passionate about managedcare and implementing disease management and continuous quality improvement,"says internist Jeffrey K. Levin-Scherz, associate medical director of theinstitute and vice president and corporate medical director of Tufts HealthPlan. Most residents, he says, absorb the negative attitudes of managedcare-hating preceptors in smaller practices. The Tufts rotation gives residentsa 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.