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Managed
Health Care - Continued, 6th Report
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Recommendations:
With the rapid changes taking place in the health care environment, medical schools, residency programs, teaching hospitals and managed care organizations are encouraged to collaborate and cooperate to produce physicians with in the requisite numbers, specialty mix and competencies to meet patient needs. In addition, public funds for medical education through Medicare and the Public Health Service must be targeted prudently to provide the right incentives in the medical education marketplace.
Recommendations are the following:
Medical Schools, Residency Programs, and Teaching Facilities:
- As medical schools, residency programs and teaching facilities restructure in order to be more competitive in patient care and at the same time preserve their academic mission, they will also need to reassess their roles and responsibilities regarding the physician workforce and medical education.
- Medical schools, residency programs and teaching facilities should share in the responsibility to train the number and types of physicians appropriate to the nation's needs.
- Medical schools, residency programs and teaching facilities need to evaluate their institutions and identify deficiencies that are barriers to achieving a more balanced physician workforce, and to train physicians for their future roles. These institutions should:
a. assure that the process selects applicants who are motivated, have the qualities and abilities, and who can be educated and trained to become the physician workforce which the nation needs;
b. assure that the curriculum educates students for their future role, including the "new basic sciences" of population-based medicine, epidemiology, and decision analysis; and
c.assure that the clinical curriculum provides an adequate education in ambulatory and managed care settings, preventive care, team care, and cost-effective patient care.
- The size, composition and competencies of the full-time faculty at medical schools and residency programs must be reviewed in order to assure that they are appropriate to train physicians for their future roles.
- Residency programs need to train residents in managed care environments, to review and revise existing residency curricula to ensure that the knowledge, skills and attitudes necessary for future physicians are included, and to adequately prepare both their primary care and specialty graduates for the scope of practice, coordinated relationships, and referral patterns found in managed care organizations.
- Additional training programs should be developed to meet the needs of the future health care delivery system, e.g. programs for retraining specialist physicians as generalist physicians; and fellowship training to develop physician leadership in managed care environments.
- Medical schools, residency programs and teaching hospitals need to identify and review their teaching costs, and make their educational programs more efficient.
- Evaluation at the medical school residency and continuing medical education levels should incorporate the knowledge, skills and attitudes that will be needed by future physicians, and should be reviewed as medical education and training becomes more decentralized.
- External certifying and accrediting organizations (e.g. the National Board of Medical Examiners, the National Board of Osteopathic Medical Examiners, the Accreditation Council for Graduate Medical Education, the American Osteopathic Association-Bureau of Professional Education, the Liaison Committee on Medical Education, the Residency Review Committees) need to address the new elements in health care delivery and reassess their structure, policies, and procedures in light of the findings in this report.
- Medical schools and residency programs (in cooperation with the government and managed care organizations) need to develop an infrastructure in primary care research, and to conduct and support primary care research.
Managed Care Organizations:
- Managed care organizations need to identify and define their needs as to the number, types and competencies of physicians, and should communicate this information and provide feedback to medical schools and residency programs.
- Managed care organizations need to work cooperatively and collaboratively with medical schools and residency programs in developing programs to address the physician workforce and medical education.
- Managed care organizations (and all other third-party payers) need to share in the cost of paying for medical education, through an all-payer fund, and by developing mechanisms to support and encourage training and evaluation of medical students and residents in their sites. This could include:
- bonus payments for teaching
- sponsoring preceptorships and clerkships
- residency program sin managed care environments or sharing sponsorship of a residency
- teaching residents about practice management issues
- collecting data regarding educational and training needs
- collaborative health services research
- collaborative development of standards of care
- developing managed care leadership programs
- innovative approaches and models of medical education.
- Managed care organizations should work with external certifying and accrediting organizations to help address the issues identified in this report.
Government:
- Continue to pay Medicare DME and IME for all residents who are graduates of US medical schools, but gradually reduce DME and IME for international medical graduate residents to 25 percent of the 1995 levels. Establish a transition program to assist institution providing essential services which are dependent on IMG residents.
- Upweight both DME and IME to encourage more generalist training and downweight DME and IME to discourage specialist training.
- Provide both DME and IME payments for teaching in non-hospital settings, including physician offices, community health centers and managed care practices. Funding should follow the resident to his or her site of training.
- Identify and remove the DME and IME components of the Average Adjusted Per Capita Cost (AAPCC) from Medicare capitation rates and utilize these funds specifically for GME purposes.
- Create demonstration projects to foster the growth of consortia to manage medical education policy and financing.
- Reauthorize, at 1995 pre-recision appropriated levels, the National Health Service Corps, Title VII (Health Professions Education), and primary care research funding.
- Reauthorize the council on Graduate Medical Education (COGME) to monitor the physician workforce and medical education system given the rapidly changing health care marketplace.
- The federal government should play a major role in the collection and analysis of data regarding the physician workforce and medical education. this should include current data on staffing patterns in specific organizational forms of managed care (e.g., independent practice associations), information on the cost of medical education (medical students and residents) in the ambulatory and managed care settings, and on the differences in the cost of training generalist and non-generalist physicians.
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