Two core aspects of managed care — disease prevention and management — are strangers to many physicians. This style of medical care requires a set of skills and knowledge that is almost entirely at odds with what physicians learned in medical school: treating episodic conditions.
This too, is changing. Partnerships for Quality Education (PQE), a three-year effort funded by an $8 million grant from the Pew Charitable Trusts, brings teaching hospitals and medical schools together with managed care organizations to help residents learn to perform effectively in a managed care environment.
Capitulation? Hardly. Call it cooperation.
“There are mutual advantages to teaching hospitals and medical schools working with managed care, and vice versa,” says Gordon T. Moore, M.D., M.P.H., a Harvard Medical School professor and PQE director. For the academic side, he says, “It enriches their programs and makes them better for residents,” while managed care personnel “are finding the residents to be stimulating while they teach them about managed care and help them to get the most out of it.”
The program was launched last year when PQE funded eight “partnerships,” each between a managed care organization and a teaching hospital or academic medical center.
“This is not just a bunch of lectures,” says PQE Associate Director David Nash, M.D., M.B.A. Programs give medical residents hands-on experience with managed care medicine.
A sampling of those partnerships shows the depth of innovation PQE generated:
Cornell University Medical College-New York Hospital and Empire Blue Cross Blue Shield developed a rotation at Empire where residents gain experience in such areas as utilization management, quality planning and improvement, legal issues and pharmacy management.
The University of New Mexico School of Medicine and Lovelace Health System are training residents to manage the Medicaid and uninsured populations for which the partners are jointly at risk. Lovelace is training UNM faculty and residents to work at a jointly operated practice site.
Case Western Reserve University and Henry Ford Health System are developing a prototype outpatient clinic that will help students learn and practice in an environment that emphasizes interdisciplinary teamwork and proactive management of a given population.
“This is not just a bunch of lectures,” says David Nash, M.D., M.B.A, associate director for PQE. “Programs are required to give hands-on, practical experience, and to evaluate those experiences as well. This is a top-drawer effort. If we can’t make this work, we’re in a lot of trouble in medical education.”
What is being learned? “A lot,” says Nash, who is associate dean at Jefferson Medical College and director of health policy and clinical outcomes at Thomas Jefferson University in Philadelphia. “We’re learning about residents’ behavior in the clinical setting. The challenges of developing an ethics curriculum. We’re creating a handbook on residency training in managed care, so other programs can duplicate these programs.”
Nash says feedback from students has been phenomenal — so much so that PQE is mailing a brochure to all graduating medical students in the country, encouraging them to select a residency program that offers managed care training in managed care settings. The brochure lists the 66 partnerships with which PQE is working, 58 of which received $10,000 grants from PQE to begin residency training in managed care.
“Most young doctors are pretty realistic about managed care,” says Moore. “They want to know how to do it. They don’t spend their time complaining about it.”
That is a major shift in mind-set, when you consider medical schools’ focus on acute care. To succeed in managed care, physicians will need additional skills in public health and epidemiology, says Mark Vanelli, M.D., M.B.A, an instructor at Harvard Medical School and a former public health adviser. And to him, that means “a reorientation of the educational process.”
While pursuing his public health training at Johns Hopkins, Vanelli helped to develop training manuals for third-world health care pro?viders in what was called competency-based training. Using hypertension as an example, Vanelli says: “Rather than have them learn every fact about hypertension, we decided on the most critical core components they had to know to manage it well on a population basis. In medical school, we learned every detail about everything — in fact, they test for the minutia. But sometimes we missed the core stuff. The importance of clinical practice guidelines is that they get the core stuff. They teach you to look at populations as well as individuals. This has to be much more a part of medical training if physicians are going to feel comfortable with managed care.”
Moore, the Harvard professor and physician, says of PQE’s work, “I think the most eye-opening part has been for the academics, who tend to lump all managed care together — but are discovering that there is some very good medicine delivered and that a lot of good teaching can be done in those settings. When managed care is done well, it has real benefits for health care. And that’s one of the reasons residents are finding this interesting, too.”
PQE’s partners were told before they joined the program that replication was a prerequisite: “You had better be able to be self-sustaining when you’re done, so that when the grant is over, you don’t close your doors. And your products have to be exportable,” Nash recalls.
“That is not a trivial exercise,” he continues. “You have to understand the culture of academic medicine: It’s no good if it’s not invented here. We’re trying to overcome that way of thinking. I think the quality of the products, the enduring materials from the partners, is so good that the other schools will be able to take these right off the shelves and make hay with them.”
While it is hoped that the spirit of the program will live on as these programs proliferate, an effort is under way to secure additional funding to maintain PQE’s structure when the grant expires next June. “Right now, there isn’t a comparable project anywhere, which in many ways, I am ambivalent about,” says Nash. “It’s great to be involved with this. But you could argue, ‘Gee, it really took Pew and $8 million to make this happen? How come you guys couldn’t do this on your own?’”