Can Pediatric Training Manage in Managed Care?

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SPECIAL

ARTICLE

PEDIATRICS Vol. 96 No. 6 December 1995 1143

Can

Pediatric

Training

Manage

in Managed

Care?

Laurel K. Leslie, MD

On January 18, 1995, the University of California

convened a special meeting to discuss the business

operations of its five academic medical centers in San

Francisco, Sacramento, San Diego, Los Angeles, and

hvine. Because of the rapid developments occurring

in the maturing and competitive managed care mar-ket in California, the academic medical centers are

facing unprecedented financial pressures. Charles

Townsend, of the accounting firm KPMG Peat

Marwick, stated that the medical centers’ staff would

need to be cut by at least 2500 full-time equivalents,

including physicians and nurses, by the year 1999.

Wiffiam Kerr, Director of the University of California

San Francisco Medical Center, forecasted a

compre-hensive restructuring and streamlining of services. Jordan Cohen, president of the Association of Amer-ican Medical Colleges, described the challenges

fac-ing these five academic medical centers and others

like them as “truly seismic.”

The rise of managed care medical systems during the last 5 years has led many researchers to question

whether the academic medical center will survive in

its current state.26 Market forces are changing the

provision of medical care at an extremely fast pace.

By 1998, an estimated 60% of people living in US

cities will be covered by managed care health plans.

Fewer hospital admissions, shorter hospital stays, and decreased reimbursements associated with

man-aged care have decreased hospitals’ operating gains.

Academic medical centers, such as those in

Califor-nia, are facing pressure to lower health care delivery

costs. The probable decreases in Medicare and

re-search funds under the current Congress also

threaten the financial revenues of academic medical

centers. As Blumenthal and Meyer eloquently ex-pressed, academic medical centers face “both mortal

threats and unparalleled opportunities.”2 Each

aca-demic medical center is searching for a means to remain financially viable; either as a highly special-i2:ed referral center for a large area, a health

mainte-nance organization (HMO) with its own primary

care referral base, or as a cost-efficient supplier for

several managed care systems. How these various

From the Division of Behavioral and Developmental Pediatrics, University of California, San Francisco.

Dr Leslie is the Immediate Past Chair of the AAP National Resident Section.

Received for publication May 19, 1995; accepted Aug 10, 1995.

Reprint requests to (LK.L) Division of Behavioral and Developmental

Pediatrics, University of California, San Francisco, 400 Parnassus Aye, Second floor, San Francisco, CA 94143-0314.

PEDIATRIS (ISSN 0031 4005). Copyright @ 1995 by the American Acad-emy of Pediatrics.

options will work in different parts of the country

remains to be seen.

The choices individual academic medical centers make will have implications for graduate medical education. Although the redefinition of the academic

medical centers’ role may provide an opportunity for

creative reshaping of residency training, educators

also need to watch for potential negative

conse-quences of these changes. Additionally, as more

phy-sicians participate in managed care plans, graduating

residents will need to know how to work within

managed care settings.7 During this time of unprec-edented change, training programs must monitor

how mature managed care marketplaces are influ-encing academic medical centers, residency training, and employment opportunities. Medical educators

wifi need to consider carefully the effects of managed

care on residency training as discussed below.

Managed Care Is Changing Where Residents Train

One of the major tenets of managed care is that

health care costs are curtailed by managing medical

problems primarily on an outpatient basis. As

in-creasing numbers of patients join health maintenance groups, there is a corresponding loss of hospital beds and a concomitant increase in outpatient procedures

and day surgeries. Patients who are hospitalized stay

for shorter periods of time and tend to have rare

diagnoses or uncommon complications. At present,

the theoretical underpinning of much of residency

education is the observation and treatment of

pa-tients’ illnesses in the inpatient setting. As medical

care moves to the outpatient setting, residency

edu-cation wifi need to follow the patients there.

The Pediatric Residency Review Commission’s

re-cent revisions of its educational guidelines call for

increasing ambulatory and community experiences.8

Implementing those goals involves addressing both organizational and financial barriers. Programs that

presently train residents in community sites,

practi-tioners’ offices, and HMOs should be actively

stud-ied as models for integrating residents into managed

care settings.9” As residency experiences move to

off-campus sites, medical centers also will need to address how community pediatricians are trained to provide graduate medical education.

This shift in framing settings raises funding issues

as well. Funding for residency education is currently

tied to hospitals and to inpatient service needs.

Ulti-mately, this funding must be restructured and

diver-sifted. Representatives of academic medical centers

proposed to Congress last year that all payers be

at Viet Nam:AAP Sponsored on September 1, 2020

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1144 PEDIATRIC TRAINING IN MANAGED CARE

required to participate in covering the cost of grad-uate medical education, research, and patient care. Although the current political climate in Congress may not favor such a pool of financial resources, the

Federation of Pediatric Organizations has supported

this proposal in the past and should continue to

advocate for its passage in the future.12

Managed Care Is Changing What Residents Learn

A fundamental premise of managed care is that

generalists provide less costly health care than

sub-specialists. Primary care physicians who have

train-ing in preventive care and are able to treat minor

surgical, dermatologic, and mental health problems

are in demand. Training in these areas already has

been identified by physicians as desirable and as

lacking in their professional education.13 Residency education will need to incorporate more practical

skills training, including dermatology, orthopedics,

and behavioral and developmental pediatrics.

Generalists are also perceived as providing more

cost-effective care than specialists because of their

focus on common causes of patients’ complaints and

their reduced use of tests and procedures.

Increas-ingly, managed care plans are requesting that

phy-sicians have the ability to meet the needs of the

individual patient while also practicing cost-effective

care based on population data and evidence-based

decision making. Combining both an

individual-focused and population-based model to care for

chil-dren and their families can be challenging for

phy-sicians, no matter what their level of training.

Moreover, training in population-based care is often

not addressed in residency training programs, which model a “rule out” or “did you consider” approach

as opposed to one based on epidemiologic principles.

Many of the patients followed have either rare

dis-eases or uncommon complications of common

dis-eases. Teaching about diagnosis and evaluation

needs to be based on a stepwise approach addressing

common causes of presenting symptoms first.

if the primary care physician is to serve as gate-keeper for subspecialty services, the physician must

have sufficient knowledge to initiate work-ups for

more complicated medical problems and to know when a referral is necessary. As more subspecialty patients are assessed and treated on an outpatient

basis, electives will need to be centered in the clinics

and less in the wards. Many subspecialty services, however, do not have the volume of patients to

maintain outpatient clinics on a daily basis. One

option is to provide residents with longitudinal elec-tives for several months, including a variety of

sub-specialty clinics. Alternatively, several of the

man-aged care groups in California have expressed

interest in hiring generalists with expertise in

partic-ular subspecialties who might spend a percentage of their time following the patients in their subspecial-ties. Under this scenario, residents would be allowed to tailor their elective time to develop expertise in a

specific area as opposed to having a broad but

su-perficial exposure to multiple subspecialties.

Residency training also may need to prepare

resi-dents better to function professionally in managed

care settings. Many managed care plans are promoting

clinical practice guidelines as a means of decreasing

variability in medical practice and providing

cost-effi-dent, effective care. Residency educators will want to

consider carefully how guidelines are perceived and

applied within training programs. Additionally,

mod-els for pediatric care are being proposed that use

in-creasing numbers of physician extenders. Residents

will need training in management skills that will enable

them to supervise and collaborate with other types of

providers. Furthermore, many physicians also have

lit-tie training in self-assessment of the quality of care provided.’4 As Starfield’5 recently suggested, managed

care settings could make important contributions to

graduate medical education by exposing physicians in

training to quality-of-care assessments and

practice-based research. A major task for residency educators

will be to incorporate these areas into residency

train-ing and to provide faculty with the necessary skills to

teach them.

The continuity clinic experience is another facet of

the residency curriculum that needs to be examined

closely. In the competition to attract patient

con-tracts, medical care is becoming more responsive to

the patient’s desires, at least as measured by service

satisfaction surveys. These trends have implications

for residents seeing patients in a continuity clinic

setting. Several reviewers have commented that

con-tinuity practices with resident physicians may be

attractive to patients who want extra time or

atten-tion during visits.16 Others have implied that resident

practices will not be as desirable to patients, because

residents are not necessarily as timely or accessible

for continuity of care and are available at most for a

3-year period. Residents also do not have the wealth

of clinical experience that a practicing physician

brings to the physician-patient encounter, which

the-oretically may have an impact on the quality of care

provided. If more clinicians are hired to provide

primary care services in managed care settings

affil-iated with academic medical centers, it could affect

the ability of residency programs to assure enough patient volume for resident training significantly.

Clearly, the role of residents in providing well child

care will need to be monitored closely. Residency

programs may need to change the structure of

con-tinuity clinics, by making residents more accessible

to patients, establishing attending-resident pairs that

comanage patients, and providing staff support and

space so residents can learn how to see more than

one patient at a time efficiently in the clinic setting. Educators will need to consider their role in

pre-paring residents to deal with ethical dilemmas that

may arise while health care systems evolve during

the next decade. The cost containment goals of the

managed care model pose a potential conflict of

in-terest between measures to limit health costs and

those to provide appropriate care.17 Managed care

plans allow for varying levels of flexibility in terms

of patient treatment. Physicians may feel increasing

pressure to balance their individual patients’ needs

within parameters set by managed care plans for

patient care.

Although residency training may need to change

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SPECIAL ARTICLE 1145

to prepare residents better to work in a managed care

setting, the setting itself may need to accommodate

the needs of physicians in training as well. There is a

fundamental conflict between the needs of trainees

and the efficiency mandate of managed care. The

physician in training learns on the job, and, when

confronted with a medical problem, needs time to

consider the full scope of any given differential to

develop his or her clinical acumen. Perhaps learning

how to be effective in a managed care environment

can only come later in training, after a period of

adequate supervision and educational exploration.

Models for residency training need to be generated

that meet both the educational needs of physicians in

training and the need to decrease the inefficiency and

costliness of the US health care system.

Managed Care Is Changing Health Care

Work Force Needs

First, market forces are affecting job availabffity for

residents after their training. Most experts have

pre-dicted that market changes will create a surplus of

specialists. Bradford Koles of the Advisory Board

Com-pany in Washington, DC, foresees an oversupply of

primary care physicians as well.18 Although few figures are available, recent graduates of residency programs

looking for prnnary care positions in California are

encountering hiring freezes and downsizing measures,

not just in academic centers, but in private practices

and HMOs as well. Physician extenders are also being

hired as low-cost alternatives to general pediatricians

and are contributing to this trend.

Medical schools and residency programs need to

address issues of employment opportunities with

residents more thoroughly. Discussions about job

availability should occur early in training to address

an individual’s career needs better. Rotations may

need to prepare residents better for jobs that are

available. For example, jobs may be obtainable in

rural areas, but many residents, even in generalist

training programs, are reluctant to seek jobs in rural

areas if they have trained in urban settings. Research

suggests that residents whose postgraduate training

provides experiences in rural medicine, are more

likely to consider practicing in rural communities.’8

Many of the recommendations recently suggested by

the American College of Physicians for encouraging

rural health careers should be actively explored and

implemented in pediatric training programs.’9 Issues

of work force needs and job availability should

con-tinue to be monitored closely by the American

Acad-emy of Pediatrics and other pediatric groups

in-volved in graduate medical education.

Second, the reduced financial flexibility and

in-creased need for productivity in academic medical

centers affects faculty members’ capacity to teach.

The downsizing forecasted for the University of

Cal-ifornia’s five medical centers no doubt will occur in

other centers across the United States and will

de-crease faculty time for teaching further. As research

funds continue to tighten, the question becomes,

who will provide quality teaching for medical

stu-dents and residents? Wifi there need to be three

clearly demarcated groups of faculty members:

clini-cians, dinician-educators, and researchers? if so, how wifi the dinician-educator positions be funded? Issues

of promotion and advancement for all three groups

also will need to be addressed. Last, who will be the

mentors and models for residents to encourage and

train them to provide high-quality primary care when

so few pediatric faculty members are generalists?

Market forces are changing how medicine is

prac-ticed, as both hospitals and HMOS struggle to remain

financially sound and to capture the health care

mar-ket in a geographical area. The most efficient and

cost-effective providers of health care, both in the

hospital and in the office, will survive. This has had

major implications for academic medical centers in

areas such as California that carry the extra costs of

the care of the poor and of patients with severe or

unusual diseases, as well as the charge to train

high-quality physicians. Many of these changes may

im-prove residency training and, by extension, patient

care by focusing on a preventive orientation,

reduc-ing inefficiencies in care, and teaching epidemiologic

principles, evidence-based decision making, and

high-quality outcomes. But there are also many

chal-lenges ahead. As the organization and practice of

medicine change, residency education will need to

choose how to respond, and quickly.

ACKNOWLEDGMENTS

The author thanks W. Thomas Boyce, Robert Kamei, Lane

Tanner, Allen Gifford, Susan Cummins, Lisa Henderson, and Errol Alden for review of this manuscript.

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1995;96;1143

Pediatrics

Laurel K. Leslie