Curriculum Development
Committee Members
(in alphabetical order)


Karen Edwards, M.D., M.P.H. -- Co-Director of Primary Care Education in
    Pediatrics, Center for Primary Care Education and Research, New York Medical College
Martha S. Grayson, M.D. -- Associate Dean for Primary Care, New York Medical College
Martin Klein, M.P.H. -- Assistant Dean for Primary Care, New York Medical College
Elizabeth Krajic Kachur, Ph.D. -- Director of Primary Care Curriculum and Evaluation, Center for Primary Care Education and Research, New York Medical College
Eliot P. Moshman, M.D. -- Director for Continuing Medical Education, Kaiser Foundation Health Plan of New York
Barney D. Newman, M.D. -- Group Medical Director,  Associate Regional Medical Director, Kaiser Foundation Health Plan of New York


In Appreciation:

This project was made possible by a generous grant from the 
Josiah Macy, Jr.   Foundation.



Copyright  ©  1995  by
New York Medical College & Kaiser Foundation Health Plan of New York
Curriculum  Reviewers:
(in alphabetical order)

Dipak Chandy, M.D. -- Chief Resident, Internal Medicine Department,  Westchester County
    Medical Center/New York Medical College
John Emy, M.D. -- Attending,  Section of General Internal Medicine,  St. Vincent’s Hospital 
    and Medical Center of New York/New York Medical College
Helen Hammer, M.D. -- Director of Graduate Medical Education,  Kaiser Foundation Health Plan,
    Northern California Region
Mark Josefski, M.D. -- Co-Director for Primary Care Education in Family Medicine, Center     for
    Primary Care Education and Research,  New York Medical College
Daniel C. Kombert, M.D. --  Chief Resident, Internal Medicine Department,  Westchester     County Medical Center/New York Medical College
Daniel Korin, M.D. -- Associate Dean and Medical Director,  Lincoln Medical and Mental Health     Center/New York Medical College
Stephen J. Peterson, M.D. -- Program Director, Internal Medicine Residency Training Program,
    Westchester County Medical Center/New York Medical College
James  E. Sabin, M.D. -- Associate Director, Teaching Center, Harvard Community Health     Plan;      Assistant Professor of Clinical Studies, Harvard Medical School
Lucia S. Sommers, Dr.P.H. -- Co-Project Director, The Curriculum Project: Building a Curriculum    for Physicians in Practice: Clinical Decision Making and Managed Care
Stephen Weseley, M.D. -- Associate Dean for Graduate Medical Education,  New York     Medical College


Other Acknowledgments:
(in alphabetical order)

A. Bartley Bryt, M.D. -- Pediatrics Department;   Chairman, Quality and Resource Management
    Committee, Kaiser Foundation Health Plan of New York
Ellen F. Carr -- Director of Public Relations, New York Medical College
Raymond Fink, Ph.D. -- Director of Health Service Research,  Professor of Health Services     Management and Policy, Graduate School of Health Sciences,  New York Medical
    College
Margaret Hutcoe, R.N., M.S. -- Director of Clinical Services,  Kaiser Foundation Health Plan of     New York
Nina  M. Lane -- Director,  Library Services,  Group Health Association of America, Inc.
Bella Pace, M.D. -- Pediatrics Department, Kaiser Foundation Health Plan of  New York
Nancy L. Renick, M.S., C.H.E.S. -- Curriculum Specialist, Graduate Medical Education, New York
    Medical College  (formerly Patient Health Educator, Kaiser Foundation Health Plan of      New York)
Marjorie Roberts -- Assistant Director of Public Relations, New York Medical College
John Peter Seward, M.D. --  Pediatrics Department;  Kaiser Foundation Health Plan of New York
Paul K. Woolf, M.D. -- Program Director, Residency Training Program in Pediatrics, Westchester,     County Medical Center/New York Medical College
Table of Contents
                                                                                                                        Page

    Curriculum Development Committee ....................................................................................              i

    Curriculum Reviewers and Acknowledgments .....................................................................            ii

    Table of Contents ...................................................................................................................           iii

    Mission Statement ..................................................................................................................           iv


A.    INTRODUCTION ............................................       1

        Content Areas Important to Managed Care Education ...........................................           5

        Organization-Specific Factors Affecting the Curriculum .........................................           8

        References ...............................................................................................................            9

B.    EDUCATIONAL AIMS .....................................        11

        Educational Goals .....................................................................................................         13

        Educational Objectives..............................................................................................         14

C.    IMPLEMENTATION PLAN ...............................     19

        Implementation Matrix ..............................................................................................         21

        Learning Activities ....................................................................................................          23

        Educational Resources ............................................................................................         43

        Scheduling ................................................................................................................         46

        Implementation Opportunities and Problems .........................................................         51

D.    EVALUATION PLAN .......................................     55

E.    APPENDIXES ...............................................     63
       


MISSION  STATEMENT



    The dramatic increase in the proportion of Americans receiving health care through Managed Care (MC) systems and the certainty that these numbers will rise call for physicians in training to acquire the knowledge, skills, and attitudes necessary to function effectively in a MC environment.  Yet most graduate medical training programs do not provide educational offerings in this area.  New York Medical College and the Kaiser Foundation Health Plan of  New York  have designed a curriculum for residents in Primary Care programs who have little or no exposure to MC.  

    The curriculum consists of a lecture series and a month-long block rotation to a group model Health Maintenance Organization (HMO).  The lectures are geared to Primary Care residents in all three years and the rotation is oriented to advanced-level trainees.  In combination these educational offerings will provide a thorough foundation for working in and with the MC system.   Although group or staff model HMOs are not the most prevalent form of MC, they do provide the most intense exposure to MC principles and thus represent a unique setting for such educational programs.






A.  INTRODUCTION






Managed Care (MC) is both a health insurance system and a mechanism for delivering care to a clearly defined population.  It is playing a major role in the evolution of health care from a fragmented industry to an organized, integrated delivery system which efficiently and effectively manages the processes and systems of medical care.  The goal is to provide the highest quality of care to the population it serves within the limits of available funding.  Special emphasis is given to coordinated and comprehensive services, fact-based decision making, population-based planning, ambulatory and home-based care, prevention and cost containment.  The Primary Care physician coordinates care by entering into a close relationship with the patient and controlling resources.  The translation of these MC principles into health care programs is not always optimal.  Clancy and Brody (1) went as far as evoking the images of “Jekyll” and “Hyde” to illustrate MC at its best and at its worst.  Despite the controversies Weiner (2) estimated that by the year 2000, 40% to 60%  of Americans will be receiving their health care through integrated MC plans.

    In light of these dramatic health care changes, physicians in training must acquire the knowledge, skills and attitudes necessary to work with as well as within MC environments.  The intricate relationships between academic health centers and MC agencies have been explored in numerous articles (3, 4, 5, 6, 7) as well as in a 1994 conference convened by the Association of American Medical Colleges (AAMC) and the Group Health Association of America (GHAA) (8).  Commonly cited benefits for the academic centers include an increase in the number of teaching sites and the availability of MC experienced teachers.  For MC organizations this becomes a good way to prepare their future physician work force in addition to gaining community prestige for their academic affiliations.  The barriers on both sides are primarily financial (e.g., possible reduction in productivity and lack of remuneration for teaching) and attitudinal (e.g., prejudices about MC and defensive postures in response to it).  Beyond opportunities and problems, many educators feel that programs have a duty to expose trainees to the health care systems of the 21st century.  In turn, MC organizations are being challenged to consider teaching as part of their social responsibility (6).

    The impact of medical education on patients, or members as they are called in many MC settings, has been reported to be positive.  Kirz and Larson (9) found from consumer surveys that medical student training resulted in increased “perceived” quality of care and improved patient satisfaction.  Ott (10) stated in his description of the George Washington University Health Plan experience that although it is important to provide patients with an option to refuse contact with a trainee, the overall response has been very reassuring.  Patients appreciate the extra time a student can provide and might even feel less inhibited in asking uncomfortable questions.  Sheets et al. (11) noted that although obstetric HMO patients did feel more satisfied with faculty care than with the services provided by second-year residents, these differences were not significant enough to affect overall satisfaction with care.  A non-MC study (12) found that the acceptance of students by obstetric patients depends on balancing the desire to contribute to a student’s education and the need for privacy.  Other influential factors were past experiences with trainees and the expectation that students would have a passive role.  As one of the New York Medical College Generalist Clerkship community preceptors once put it so well, “[My patients] are proud that I am teaching but they are afraid of being handed over to a student.”

Some of the most notable examples of “institutionalized exposure to MC” are:  the required six-week HMO rotation for junior medical students at George Washington University (10); the Internal Medicine residency collaborations between Kaiser Foundation Health Plans, Northern California and the University of California at Davis that goes back to the 1970s (13), and between Harvard Community Health Plan and Brigham and Women’s Hospital (14); and the MC Internal Medicine fellowships at Long Island Jewish Medical Center (15).  A 1990 GHAA survey of HMOs (16) indicated that 15% of the respondents were involved in graduate medical education.  This percentage has undoubtedly grown in the last few years but nonetheless, the educational programs that have evolved are still showcases rather than standard.  It is the aim of this project to create a curriculum that will permit MC education for residents to become a routine event.

    The curriculum presented here was jointly developed by New York Medical College (NYMC) and Kaiser Permanente (KP) - New York.  Due to site-specific circumstances, the emphasis here is on Internal Medicine and Pediatrics.  However, with some adjustments Family Medicine should also be able to utilize it.  In general this curriculum should provide the following:

Comprehensive coverage of the subject
Inclusion of didactic as well as hands-on learning activities
Learner-oriented educational approaches
Ease of implementation
Compatibility with Residency Review Committee curriculum guidelines
Mechanisms to permit Quality Management of the educational program
Portability to Family Medicine and other training sites

To accomplish these goals a variety of planning methods were employed:

A committee was established consisting of four NYMC and two KP representatives.  While the former contributed the medical education perspective, the latter provided the MC expertise.  The group consisted of three internists, one pediatrician, one medical education specialist and one academic administrator.  The committee met in three- to six-week intervals over a ten-month period.
A review of published and unpublished materials was performed.  These documents were identified through GHAA and MEDLINE literature searches, conferences attended by committee members and personal communications with specialists in the field.
Site visits were held to explore learning opportunities at the HMO site.  After a facility tour, one committee member shadowed a pediatrician for a half-day and another committee member did the same with a general internist.
Focus groups were organized to survey the needs of residents, HMO and non-HMO faculty as well as HMO nursing staff.  In addition to defining MC, these groups identified curriculum content areas as well as opportunities for and challenges to the implementation of the training program.
Residency program directors were interviewed to assess their needs for MC teaching as well as to gain their collaboration in the pilot and implementation phase of the project.
Consensus building methods (e.g., Delphi-type processes) among committee members were employed to determine curriculum emphasis.
A final draft was distributed to distinguished reviewers for comment and critique.  To assess applicability to Family Medicine, a family practitioner was included in the reviewer team, and a pertinent question was incorporated in the survey instrument.  See page ii. for the reviewer list and Appendix A. (pages 64-65) for the review form. Most of the recommendations have been integrated in the document.

Curriculum Topics
Important to Managed Care Education


    A survey of existing MC educational efforts as well as focus groups with residents, faculty at the academic institution, HMO nurses and HMO physicians helped establish what topics should be included in the curriculum.  Table 1. illustrates the coverage specific content areas received in the following seven MC documents and projects:

The GHAA recommendations (17) detail competencies needed by Primary Care physicians to practice MC medicine.
The “Curriculum Template” (18) was developed by a group of MC and education experts. It represents part of a project that was organized by the Center of the Health Professions at the University of California at San Francisco (UCSF) and sponsored by the Pew Memorial Trust.  The curriculum focuses on decision tasks practicing physicians face as a result of their relationship with a) MC organizations, b) MC patients, c) MC physician and non-physician colleagues as well as d) their personal expectations, aspirations and values regarding the practice of medicine.
The HMO clerkship is a requirement for juniors at George Washington University (GWU) (10).
The three-year MC internal medicine residency program was developed by the Harvard Community Health Plan (HCHP) (19).
The MC teaching syllabus (20) which was compiled by a task force of The Society of Teachers of Family Medicine (STFM) is tailored to provide residents with an overview of MC systems.
“The Physician’s Guide to Managed Care” by Nash (21) is a book which has been recommended for curriculum development by the US Health Resources and Service Administration (22).
“Essentials of Managed Health Care” by Kongstvedt (23) is a book that educates physicians about the practice of MC medicine.

    Since the sources are quite varied, only a few subject areas are covered uniformly (i.e., referrals, ethics, cost containment).  Cclinical training programs include more practical issues while books focus on more theoretical issues.  This curriculum is designed to address both components and thus care has been taken to include all extrapolated subject areas.






The NYMC/KP curriculum includes all the above content areas.

Focus groups were the second form of needs assessment.  A total of eight sessions were held: two for HMO physicians and two for HMO nursing staff, two for generalist faculty in academic health centers (Internal Medicine and Pediatrics) and two for residents (one per specialty).  At the outset, participants were asked to juxtapose MC with other health care delivery systems.  Such distinctions helped answer questions about the essence of MC that needs to be captured in the curriculum.  Table 2. (on page 7) provides a summary of the aspects of practice mentioned by the eight different groups.  Type of ambulatory care model, medical decision making, financial reward and referral systems were noted most frequently.  Most focus groups also addressed the wide variations among MC health care plans (e.g., HMOs, IPAs) in terms of organization as well as quality of care.  These incongruities complicate the definition of MC.  Interpersonal relationships, too, are viewed as different in the MC system.  They include physician-patient relations, intra- and interprofessional associations as well as rapport between attendings and residents.





Focus groups were also encouraged to offer specific suggestions for curriculum content areas.  The result is listed in Table 3 (on page 7).  It was generally concluded that the rotation should focus on “system issues” (e.g., record keeping, resource utilization) rather than providing another month of ambulatory care clinical training.  The non-MC focus group participants further stressed that it would be crucial to avoid a sole focus on group or staff model HMOs.  Although they are universally seen as the settings where MC principles are practiced most intensely, they are a less prevalent form of health care delivery.  Thus it will be important to teach about other MC organizations as well.  A comprehensive survey will also assist trainees with career decisions.

    Beyond an introduction to the basics, participants repeatedly mentioned topics such as quality management, integration of services, utilization of ancillary personnel and member relations.  Exposure to non-urgent care (e.g., how complete work-ups can be performed in an outpatient setting) and telephone medicine was also recommended.  Additionally, there was some expectation that this educational intervention would lead to more informed, and possibly more positive opinions about MC.

Organization-Specific Factors
Affecting the Curriculum


    In order to facilitate the transfer of this curriculum to other specialties and other training sites, it is important to consider the factors that contributed to the formation of the model presented in the following pages. They are:

Geographical considerations (e.g., distance between residency training program and HMO)
Availability of services and faculty at the MC site (e.g., 24-hour telephone advice line, schedule and teaching interest of specialists)
Training program requirements (e.g., New York State “Upweighting” regulations for continuity clinics, post-call release time required by New York State)
Residency program needs for providing certain educational exposures (e.g., adolescent care, dermatology)
Malpractice insurance (e.g., limitation of coverage to certain clinical sites)
Level of Primary Care and MC focus in the residency training program (e.g., what principles of Primary Care and MC are residents already exposed to in their usual rotations)
General attitudes of residents and faculty towards MC (e.g., how interested and open are they towards a MC rotation)
Inter-institutional relationships (e.g., past and current experience with other collaborative training endeavors, collaboration for curriculum development)
Interest and ability of the MC system to incorporate an educational program (e.g., expend time for teaching, allocate space to provide trainees with clinical practice opportunities)
Available incentives (e.g., financial remuneration, faculty appointments)
Local and national health care environments in general (e.g., prevalence of certain types of health care systems, health insurance trends)

     In this curriculum the limitation to Internal Medicine and Pediatrics was determined by three local circumstances:  a) the NYMC Family Medicine residency is not in proximity to the HMO site, b) it already has a MC education program in place, and c) KP currently does not have family practitioners on staff.  Even if such conditions are not in effect at another institution, transferring the program to Family Medicine will necessitate serious consideration of the general training requirements.  Qualifying factors stipulated by the Family Medicine Residency Review Committee demand one half-day practice session for first-year residents, three half-day sessions in the second year and five half-day sessions in the third year of training.  Furthermore, family medicine programs have extensive exposure to a very integrated type of health care delivery that spans all age groups, includes OBGYN and stresses practice management.  Thus many of the learning opportunities offered here may be too repetitive for third-year residents and result in boredom.  Given these conditions the rotation could be more suitable for first-year graduate trainees. 

    Other site-specific characteristics include the emphasis on adolescent care, which was driven by the participant residency program’s need to provide additional educational experiences for their trainees.  Limitations in malpractice insurance coverage required a reduction of hands-on learning activities during the hospital rotation and an elimination of rotations to satellite clinics.

    Although all efforts have been made to make this a thoroughly planned model for residency education in MC, it has to be viewed as a work in progress.  As the program is piloted and trainee and faculty feedback is received, and as residency education and the general health care scene changes, adjustments may have to be made in order to maintain relevance, effectiveness and efficiency.

References


1.Clancy CM, Brody H.  Managed care: Jekyll or Hyde?  JAMA, 273(4):338-339, 1995.
2.Weiner JP.  Forecasting the effects of health reform on US physician workforce requirement: Evidence from HMO staffing patterns.  JAMA, 272(3):222-30, 1994.
3.Corrigan JM, Thompson LM.  Involvement of health maintenance organizations in graduate medical education.  Acad Med, 66(11):656-661, 1991.
4.Fox PD, Wasserman J.  Academic medical centers and managed care:  Uneasy partners.  Health Affairs, 12(1):85-93, 1993.
5.Moore GT.  Health maintenance organizations and medical education:  Breaking the barriers.  Acad Med, 65(7):427-432, 1990.
6.Haesler WK.  Why we should care about medical education.  HMO Magazine, 34(5):20-23, 1993.
7.Weitekamp MR, Ziegenfuss JT.  Academic health centers and HMOs:  A systems perspective on collaboration in training generalists physicians and advancing mutual interests.  Acad Med, 70(Suppl. January):S47-S53, 1995.
8.Training the generalist:  Developing partnerships between academic medicine and HMOs. Report on the Association of American Medical Colleges and the Group Health Association of America Symposium, Leesburg, VA, April 10-12, 1994.
9.Kirz H, Larsen C.  Costs and benefits of medical student training to a health maintenance organization.  JAMA, 256(6):734-739, 1986.
10.Ott JE.  Medical education in a health maintenance organization:  The George Washington University Health Plan experience.  HMO/PPO Trends,  5(2):6-11, 1992.
11.Sheets K, Caruthers B, Schwenk T.  Assessing patient’s satisfaction with care provided by  residents in an academic HMO setting.  Acad Med, 65(7):482-483. 1990.
12.Magrane D, Gannon J, Miller CT.  Obstetric patients who select and those who refuse medical students’ participation in their care.  Acad Med, 69(12):1004-1006, 1994.
13.Wolfe ES, Jones HW.  Graduate medical education in an HMO:  An internal medicine residency program.  J Med Educ, 57(6):468-471, 1982.
14.Moore GT, Inui TS, Ludden JM, Schoenbaum SC.  The teaching HMO - A new academic partner.  Acad Med, 69(8):595-599, 1994.
15.Resnick J.  An HMO-based internal medicine fellowship.  HMO Pract, 2(4):139-142, 1988.
16.Corrigan J, Thompson L.  Involvement of health maintenance organizations in graduate medical education.  Acad Med, 66(11):656-661, 1991.
17.Primary Care physicians:  Recommendations to reform medical education to increase the supply of physicians trained to practice in managed care.  Group Health Association of America, 1993 (position statement).
18.Sommers LS, Marton KI (project directors).  The curriculum template:  Building curricula for clinical decision making in managed care settings.  UCSF Center for the Health Professions.   April, 1995  (submitted to JAMA).
19.Adult primary care residency training in managed care.  Harvard Community Health Plan and Brigham and Women’s Hospital.   Draft 2 - 7/14/1994 (unpublished).
20.Eidus R, Warburton SW (eds).  Managed health care:  A teaching syllabus. Kansas City,  MO: The Society of Teachers of Family Medicine, 1990.
21.Nash DB.  The physician’s guide to managed care.  Gaithersburg, MD:  Aspen Publishers, Inc, 1994.
22.Managed care:  Educating medical students and residents in primary care and preventive medicine.  Division of Medicine, Health Resources and Services Administration.  May, 1994.
23.Kongstvedt PR.  Essentials of managed health care. Gaithersburg, MD:          Aspen Publishers, Inc, 1995.




B.  EDUCATIONAL
                    AIMS

This training program is meant to provide a basic understanding of  MC principles for Primary Care physicians.  The focus is on learning about the health care system rather than on adding an extra ambulatory patient care rotation.  The following eighteen core goals are kept sufficiently generic to permit an application to Internal Medicine and Pediatric residency training programs as well as an expansion into Family Medicine.  The personal learning goal (XVIII) was designed to enable residents to identify their own strengths and weaknesses and to participate in the development of a learner-centered educational plan.  On subsequent pages (in Table 4.), each goal is further broken down into knowledge, skills and attitude objectives.



Educational Goals


Goals                                               Emphasis

MC Fundamentals                                       15%
I.    To provide an overview of  MC principles and types of MC organizations       
II.    To enhance the understanding of  population-based medicine
III.    To sensitize trainees to ethical considerations concerning MC
IV.    To strengthen the knowledge base necessary for informed career decisions

Systems within MC                                       35%
V.    To provide a working knowledge of quality management
VI.    To enhance cost/utilization management knowledge and skills
VII.    To stress the benefits of continuity of care
VIII.    To highlight the role of Primary Care physicians as coordinators of care
IX.    To improve referral and consultation skills
X.    To gain a MC perspective on hospital care
XI.    To provide an understanding of performance evaluation mechanisms

Interpersonal Skills                                       15%
XII.    To enhance the ability to develop effective patient-physician relationships
XIII.    To strengthen the ability to work effectively in a team   
       
Diagnosis & Treatment                                       30%
XIV.    To teach the MC approach to common outpatient conditions
XV.    To enhance the integration of prevention into general medical practice
XVI.    To improve residents’ patient education skills
XVII.    To strengthen telephone medicine skills

Personal Learning Goal                                                5%
XVIII.    (to be determined jointly by resident and faculty)

                C.  IMPLEMENTATION                          PLAN



To accomplish the aforementioned goals and objectives, the training program will consist of two parts.  First, residents will attend an ongoing lecture series that will be offered to all trainees and faculty at the participating residency program sites.  Second,  third-year residents will attend a one-month rotation at a group-model HMO.  They will experience first-hand how MC principles are put into practice and will engage in a variety of learning activities to gain competencies necessary for working in and with MC organizations.  A quality management (QM) project addressing a disease of their own choice will be a major focus of the month-long rotation.  The selection of a personal training goal will further underline the learner-centered approach of this educational program.

    The combination of  lecture program and rotation will result in a variety of benefits:

Residents will receive a theoretical introduction to MC before beginning their rotation
MC topics can easily be expanded to other, non-group model HMO issues
By inviting lecturers from the HMO, residents, academic program and HMO faculty have an opportunity to get acquainted
Residents who have completed the rotation can add an account of their experience to the lecture presentation

    The Implementation Matrix in Table 5. (on page 22) identifies how educational goals relate to learning activities.  It is followed by a detailed description of each learning activity, as well as elaborations on the HMO, the participating educational programs, faculty and other teaching resources.  Scheduling guidelines and a discussion of implementation opportunities and challenges are also included in this chapter.

The Implementation Matrix


    The matrix correlates the 13 educational goals outlined on page 13 with the 12 learning activities detailed on pages 23-42.  It provides reassurance that all goals are addressed multiple times and that no activity is designed to serve only a single purpose.  It also permits one to assess how the loss of one specific learning activity would affect the overall curriculum.  The lecture series, QM project, syllabus and resource library as well as the supervision sessions address all or almost all goals; the orientation, patient education and telephone consult sessions will cover the fewest topic areas.  Since the personal goal will vary from resident to resident, the pertinent learning activities  cannot be entered in the table uniformly.  It is expected that residents will customize this matrix to reflect how their personal training needs are met and how scheduling limitations affect the coverage of the educational goals.

Table 5. Implementation Matrix:  Educational Goals (I-XVIII) and MC Learning Activities (1-12)

Since the Personal Goal will vary from resident to resident,
the pertinent learning activities cannot be entered in XVIII uniformly

Abbreviations:
            Depts.    = Departments                Orientat. = Orientation
            Educ.     = Education                PCP       = Primary Care Physician   
            Hosp.     = Hospital                Proj.     = Project   
            MC        = Managed Care             Prom.     = Promotion
            MD        = Physician                Pt.       = Patient
            Med.      = Medicine                QM        = Quality Management


Learning Activities


    Residents will be offered 12 different learning opportunities:  a lecture series before, during as well as after their month at the HMO; an orientation to the rotation; work on a quality management (QM) project; a series of 12 patient care sessions, each focusing on a particular topic; participation in patient education and telephone consultation programs; rotations to various specialty and subspecialty services; exposure to hospital rounds; visits to selected HMO departments; attendance at several HMO committees; and a syllabus and resource library as well as regularly scheduled supervision sessions.

    The coverage of educational goals was structured so densely to permit adequate flexibility concerning the amount of exposure to each activity.  Partly, variations between residents will be dictated by their individual learning needs.  For example, one resident may have a special interest in enhancing telephone medicine skills and will therefore attend more than the recommended number of sessions.  Another resident may be specially interested in improving knowledge and skills in Dermatology and may therefore select some additional specialty exposure.  Time commitments at the residency program itself, release time, vacations and holidays will further impact on the intensity of immersions into a particular topic.  Naturally, all scheduling decisions will need to be made in collaboration with the rotation director and other pertinent faculty to ensure an appropriate educational balance as well as the availability of teaching resources.

    All residents will have equal exposure to the orientation, the QM project, the syllabus and the associated library of resources as well as the supervision sessions.   By utilizing the Implementation Matrix it will be easy to ascertain what effect the individual choices and scheduling requirements will have on the overall achievement of  the educational goals set forth by the curriculum development committee.


 1    Monthly Lecture Series   (Before, During and After the Rotation)


    The purpose of this didactic program is to provide a consistent exposure to MC concepts and issues throughout the three years of training.  All curriculum goals will be addressed and special attention will be given to an adequate coverage of knowledge objectives.  Thus at the time of the rotation, residents will already be equipped with the basic concepts and terminology.  The inclusion of HMO lecturers will give residents a chance to get to know some MC faculty before they actually start the rotation.  Since the rotation occurs at a group model HMO, it will be important to provide an overview of other MC systems through this medium.  Following is a list of 20 lecture topics which are to be offered in a two-year cycle. Below each are a few subject areas worth including in the presentation.


1.    “Managed Care 101”
    Definitions, historical development, key concepts, types of MC organizations, integrated health care delivery models, contrast to other health care systems

2.    Introduction to Insurance Systems
    Fee-for-service versus prepaid plans, benefit design variations for patients/providers/
    payers, cost sharing, Medicaid and Medicare, un- and underinsured populations

3.    The Structure and Function of HMOs
    HMO types, open versus closed panel plans, in-house versus contracted     services,     working within an HMO,  corporate structures, committee work, effective team work,     relationship to community, member recruitment

4.    The Impact of IPAs on Private Practice
    Definitions and terminology, types of contracts, capitation, hospital-based IPAs, cost and     benefit distributions, authorization systems, profiling, performance reviews

5.    Development of  MC Group Practice Models
    Types of provider networks, physician ownership models, economic, psychological, and     legal aspects of  group developments

6.    MC and Hospitals
    Vertical integration of health care, contracts between MC organizations and hospitals,     admission criteria, justification and authorization procedures, lengths of stay and other
    utilization issues, alternatives to     acute care hospitalization, outcome studies, centers of
    excellence

7.      MC Organizations that Serve Special Populations
    AIDS, substance abuse, mental health, geriatrics and Medicare, Medicaid

8.      MC and the Government: Moving Towards the 21st Century
    Government proposals, efforts by medical organizations, changing focus of health care,     Medicaid and Medicare populations

9.    The Role of  the Primary Care Physician (PCP) in MC
    Role obligations and expectations, coordinator functions, authorization systems, ethical     considerations, utilization reports, managing utilization of ancillary and emergency     services, negotiating and contracting with providers and hospitals

10.    The Patient-Physician Relationship in MC Systems
    Overt and covert contracts between physicians and patients,  effects of prepayment and
    entitlements, conflicts of interests, patient education efforts to improve the health care
    encounter, effects of mid-level providers     and ancillary personnel on the patient-
    physician relationship

11.    Patient (Member) Satisfaction
    Definitions, types of measurement,  factors influencing patient satisfaction, utilization of     evaluation results, MC patient advocacy

12.      Evidence-Based Medicine and Practice Guidelines
    Critical review of the medical literature, decision analysis related to outcomes in MC,     proof of therapeutic value, development of guidelines for diagnostic and therapeutic
    modalities, value of and adherence to guidelines, quality management, legal and ethical     considerations

13.      Cost-Containment and Resource Management
    The calculation of health care costs, cost-effectiveness analyses,  competitive cost
    structures, capitation, budgeting, right sizing, cutting costs by eliminating waste,     ambulatory care productivity, changing processes and content of care

14.    Quality and Risk Management
    Principles of Continuous Quality Improvement (CQI) and Total Quality Management     (TQM), methods for assessing quality of care, the relationship between process and
    outcome, internal versus external audits, credentialing

15.    Population-Based Medicine
    1:1 versus N:1 orientation, utilization of epidemiological and service-generated data,     types of prevention (e.g. primary, secondary),  community-responsive services,
    development of prevention guidelines, cost-effectiveness of  prevention

16.    Ethical Considerations in MC
    Ethical assumptions, benefits/burdens to patients/health care providers/payers, conflicts     arising from constrained or rationed resources, effect of profit motives
 
17.    Therapeutics and MC
    Formulary development and use, patient education to optimize drug effects, home care,     cost containment measures

18.    Performance Assessment Methods in MC
    Individual versus team performance, physician profiling, peer review, compilation and     utilization of  performance reports, membership satisfaction, efficiency in changing
    behaviors, rewards and penalties

19.    Continuing Medical Education to Change Behavior
    CME requirements, quality management and CME, the effect of CME3 on physician
    behaviors

20.     Careers in MC
    Practice environment, lifestyle, new roles for physicians (e.g., physician executive),
    advancement opportunities, research opportunities, income expectations, work contracts with MC organizations

Speakers will be drawn from three sources: a) the HMO  b) the residency program faculty and c) the professional community at large.  Some presenters should come from the HMO to strengthen the link with the academic program and affirm their credibility as faculty.  Lectures on HMOs, the role of Primary Care Physicians, patient satisfaction or performance assessment methods may be easily covered by physicians and other health care professionals working for the MC organization.

    The involvement of  faculty from the residency training program will indicate their interest in the subject and generally help legitimize MC as a pertinent topic for graduate medical education.  Evidence-based medicine, ethical considerations and practice guidelines might be subject areas non-MC faculty already have expertise.  Thus an adaptation to the MC situation would be relatively effortless.

    Furthermore, it will be important to involve some external speakers who can represent  the “outside world” and thus help anchor the lecture series as an important educational event for today’s health care environment.  One might consider a politician to cover the MC and government lecture, hospital planning staff to address MC and hospitals, an economist to review cost-containment and resource utilization, and insurance experts to provide an overview on such matters.  Some academic institutions are affiliated with schools of public health which can considerably expand the lecturer pool.

    Since the lecture material is relatively generic, Internal Medicine, Pediatrics and, if pertinent, Family Medicine programs at the same institution can be combined to maximize resources.  With new technologies it will be possible to teleconference presentations or at least videotape them for dissemination amongst medical school affiliates or consortia.  A telephone hook-up with the lecturer after the video presentation will permit a question and answer period.