Tuesday, 4/8/97
Educational system beginning to realize need for integration of
managed care
Students recognize need to learn new cost-effective,
preventative medicine methods
By Hannah Miller
Daily Bruin Contributor
It’s begun to show up in the curriculum. It’s begun to affect
residency decisions. It’s begun to worry university
number-crunchers.
It’s managed care, the transformation of medicine from a science
to a business, and students at the UCLA School of Medicine have
already begun to feel its effects.
"Managed care has begun to impact the curriculum incredibly,"
said Mike Wilkes, Chair of UCLA’s Doctoring Program. "We have to
address new ethical issues such as: who are you working for? The
patient or the managed care company?"
Managed-care companies formed in the late 1980s as a way for
insurers and employers to contain rising healthcare costs,
introducing the principle of cost-cutting into a doctor’s everyday
duties – and now into the classroom.
Population health and outcome management are recent additions to
the curriculum, plus the idea of case-based learning, said
Wilkes.
Managed care stresses care of the patient as a whole. "Instead
of studying a particular organ system, a student would take the
case of say, a Mrs. Jones, who has heart disease," he said.
Managed care has been woven into the UCLA curriculum since 1992,
a trend that many other schools are only now beginning to
follow.
"The educational system is slowly beginning to realize that it
needs to be more progressive when it comes to this new system,"
said Andy Nowalk, president of the American Medical Students
Association.
As the birthplace of managed care, California has been forced to
deal with market changes a few years before the rest of the
country. By extension, the UCs have had to face managed care before
other universities.
These recent curricular changes have been met with some scorn
from teaching faculty, particularly when terms such as
‘cost-effectiveness’ begin to worm their way into the canons of
academic medicine.
Students say they are also ambivalent about being taught managed
care. On the other hand, they know that to find a job, they will
probably have to play along.
"A lot of students used to say that managed care companies
‘really didn’t practice medicine,’" said Daniel Delgado, a
fourth-year student. "But now that’s the standard everywhere."
For medical students, managed care has had its most obvious
impact on their choice of residency. In the 1970s and 1980s,
American medical students chose specialty over general-practice
residencies, by nearly a 3:1 ratio. This has begun to change.
Managed care organizations stress preventative medicine, simply
because it is cheaper to treat illnesses in the early stages. This
has created a new demand for primary care physicians that is
already reflected in the numbers. Fifty-six percent of next year’s
residencies are generalist positions, up from 44 percent in
1991.
Medical students are no different from other students in
choosing their profession – many make their career choices at the
gut level, but real-world limitations have started to encroach.
The question is: How much does managed care interfere? "A lot of
people complain, ‘I’m not going to be able to do what I want to
do.’ But that’s not right," said Delgado.
"If really wanted to, I could still be a neurosurgeon. I could
go through nine years of residency, make the political connections,
work the 120-hour weeks. I’d finish with all the prestige, but I’d
just not be able to find a job," he added.
Delgado will be entering a managed-care workplace that often
contradicts canonical hospital teaching. Traditional medical
education equips doctors to deal with late-diagnosis illnesses, to
focus on single diseases rather than the whole patient, on cushy
budgets and few time constraints.
The managed care environment is an ill fit for graduates
currently trained to perform ‘big procedures,’ but unequipped with
increasingly important skills, such as prevention and physical
diagnosis.
But if medical education becomes completely devoted to managed
care, the opposite problem may arise. "How will you prepare doctors
to work in big hospitals and do big procedures?" Nowalk asked,
pointing out that medical training may shift entirely out of the
hospital base to neighborhood clinics.
UCLA may have reached a balance between the two. "We’re in much
better shape than many other schools," said Neil Parker, senior
associate dean for Student Affairs. "We’ve gone out and solicited a
lot of managed care patients."
Now, UCLA medical students typically do more clinic-based rather
than hospital-based learning, explained Parker. The implication is
that students will be forced to learn the same information within
shorter time periods.
"In in-patient care, you had as much time as you needed with
each patient," explained Parker. "With (managed care), you have
20-minute appointments."
These ’20-minute-appointments’ are just one of the new rules of
managed care that have spawned a public outcry. Last month,
President Clinton formed a consumer-protection commission to guard
against the excesses of for-profit healthcare barons.
And according to many policy groups, medical schools themselves
are going to need equal protection.
Health care is a unique industry, one in which many businesses
educate their own workers. At least, the traditional financial
arrangement of teaching hospitals have made it so. Policy-makers
are concerned that the advent of managed care may endanger this
system.
In the budgets of many medical schools and teaching hospitals,
"tuition covers a very small part of the cost of medical
education," said Nowalk.
"What the hospital receives in fees-for-service and Medicare
reimbursements are poured back into education," Nowalk said.
Managed care has begun to decimate hospitals’ crucial
fee-for-service revenue, creating a significant budgetary crunch
for the educational programs at hospitals.
"Managed care companies are not completely willing to get
involved in funding medical education," said Nowalk. Since they are
largely for-profit corporations with no prior history of a
commitment to education, many experts have expressed worry over
their lack of accountability.
Although the idea of medical education being left in the hands
of corporations may sound dire, medical students and faculty may
have some say in shaping the future.
Nowalk, for one, suggests that the government mandate that
managed-care companies ‘chip in’ for the education of their future
work force. For many students, increased government involvement
promises to be the key to positive change.
"Students are slowly recognizing that the politics of medicine
are just as important as the biology," according to Amal Trivedi, a
second-year medical student and president of the UCLA-based Medical
Students Organized to Create Activism and Leadership.
Student medical groups are lobbying the federal government not
just for managed-care regulation. They also want to protect the
special Medicare fund dedicated to graduate medical education.
"Most students aren’t aware of how much government funds affect
their education," Trivedi said. In addition, Trivedi said, the
current crop of students have grown up within the managed-care
system, and are in a better position to deal with and affect
changes.
It is within national lobby groups like the American Medical
Association that medical students will be able to reshape the
system even as they find a place in it, Trivedi speculated.
"There’s a lot of change going on," said Trivedi, "But we must
realize that change can be directed."