Medical educators are under considerable pressure to reform the training of their students for what is needed and desired in the health care marketplace. With a physician surplus building, the graduates of residency programs are having increasing difficulty finding jobs, especially in their desired locations, and are finding themselves queried and evaluated on their preparedness and attitudes toward practice in a managed care environment.
A further set of challenges derives from the rapid shifts in the medical marketplace and the commensurate shifts in the sites of care and training from the inpatient hospital to the outpatient community setting. These shifts require changes in the types of clinical teaching and their training, as well as in the content and timing of clinical teaching.
Managed care systems have achieved impressive growth in recent years. Membership is rising more than 11 percent per year, and is projected to approach 65 million persons by the end of 1996 (Group Health Association of America, 1995; Johnson, 1996). There has also been substantial growth in enrollment in managed care Medicaid and Medicine. The growth in size, number, and variety of managed care systems, and increased competition, has further increased pressure on the medical education system to produce physicians better prepared for working in and collaborating with managed care organizations.
COGME's Sixth and Eighth Reports (Council on Graduate Medical Education, 1995,1996) reviewed the current and projected shifts in the marketplace and their workforce implications for the future. The Sixth Report in particular reviewed the implications for training for the future and presented one listing of desired physician competencies. The purpose of this report is to review the current and developing state of knowledge in the area of needed Physician Competencies, and to present findings and recommendations to the medical education and the managed care communities. The report should be of comparable importance to health care policy makers; health care providers; business, labor, third-party payers; and the community at large.
We used a variety of methods in preparing this report. First, we conducted literature searches and reviewed the prepared bibliographies of others regarding skills needed by physicians who practice in managed care dominated environments. Second, we collected and reviewed information from training programs that have implemented innovative curriculum or curricular segments related to managed care. Third, we contacted and interviewed experts in education in managed care and in key skill areas, defined below. Finally, we asked local and national experts to review and suggest revision to a draft of this document. Two key findings emerged from this process. First, numerous groups and organizations have engaged in similar work, often citing the same literature and arriving at similar conclusions. Second, although there has been tremendous energy and thought given to this area in many residencies and academic health centers, little has been implemented. It was the rule that "experts" we called would tell us that "nothing has been written yet" or that the curriculum is "still in my head."
This report is divided into five sections. Section 1 defines managed care and its potential contributions and threats to improving the health of the public. Section 2 synthesizes the opinions of authors regarding the desired competencies of physicians and presents content recommendations in each area. Section 3 presents a more global set of recommendations for residencies with regard to integrating these skill areas for faculty development in these areas. Section 4 presents brief descriptions of a few sentinel programs that have implemented innovative programs for learners in managed care. The final section presents selected bibliographic materials for those wishing to construct curriculum in the areas discussed above.
What is Managed Care?
Managed care encompasses a variety of different financial and organizational arrangements. Simply put, however, managed care merely links the responsibility for the delivery of care for a defined population (the enrollees of the managed care plan) with the insurance or financing mechanism, or the assumption of financial risk (lgiehart, 1992). The practice of managed care consists of "the body of clinical, financial and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner" (Alpha Center, 1996). Managed care plans are in different stages of evolution in different areas of the country. At their onset, most managed care plans focus on managing cost, usually through utilization control mechanisms. However, the increasing development of vertically integrated systems has emphasized managing care by linking outpatient, inpatient, home and long-term care in a single, coordinated system. In doing so, many plans, often through case management and care management programs, attempt to "manage" the health of individuals by assuring that they receive appropriate preventive care and that the care they receive for chronic medical conditions is both coordinated and efficacious, maximizing their chances for good outcomes.
More mature plans often view their enrollees as a "population," and see their role as manager and promoter of the health of their "populations." This implies not only managing health of an individual through the one-on-one doctor-patient encounter, but the implementation of population-based strategies to improve the health of their enrollees. In contrast to more traditional public health approaches, the population-based strategies are defined by and targeted to an enrolled population, rather than a community. Nonetheless, these strategies include monitoring for preventive care among an eligible population (e.g., the proportion of female enrollees over age 50 who have had mammograms or the proportion of diabetics who have had a retinal exam), using educational interventions (mailings, reminders) and offering group sessions (e.g., smoking cessation, coping with arthritis, stress reduction). Finally, in some areas in which managed care systems have significant market penetration, plans are beginning to see that it is in their interests to promote the health of the communities from which their enrollees are drawn, thus moving beyond managing the health of enrollees to managing the health of their communities.
It should be stressed that not all plans have evolved to this somewhat idealized description. Many still focus solely on controlling costs and utilization, and do so via a variety of mechanisms ranging from utilization review to financial arrangements with physicians that put them "at risk" for the utilization of their enrollees. These are well summarized in Section III of the Sixth Report.
What are the implications of this evolution for medical education? First, learners will need to conceptualize their roles as physicians not only for individuals but for populations. Doctors of the future will need to evaluate and balance both the needs of the patient (who presents for care in a one-on-one encounter) with the needs of a population for whom they have responsibility. This implies caring for those who visit a health care provider, as well as for those who may not present for care ( Greenlick, 1992). Doctors will need to learn non-office based approaches to keeping their patients healthy. They will also need to be equipped to address the variety of financial and organizational arrangements with which they are confronted, and have the skills to fulfill their responsibilities to individual patients and populations in the face of sometimes conflicting incentives.
Many of the skills required to practice sound medicine in a managed care context are also those required for being a capable and responsible physician, regardless of whether that physician is a generalist or a specialist. However, primary care training programs have been active in addressing many of these areas over the past decade, and in fact, have developed model curricula for primary care physicians that overlap with model curricula for practice in managed care environments (Bureau of Health Professionals, 1995; Gorrell & Morrison, 1995; Bureau of Health Professions, no date; Association of Teachers of Preventive Medicine, 1996). Thus, the skills for an excellent clinician of the future include capabilities in most of the areas presented below, regardless of the specialty of the physician or organizational and financial environment in which s/he practices.
Competencies for Practice in a Managed Care Dominated Environment
It has long been recognized that effective medical education must address more than content: it must attend to the 'Who," or the kinds of patients and populations our students are exposed to; the "what," or the core knowledge, skill and competency they acquire; the "when," or timing the delivery of curricula at different levels of training; and the "where," or types of settings they are exposed to. Explicit decisions about the "when" and "where" will need to be made by each program. This report addresses the "what." In doing so, we acknowledge that learning occurs across a continuum, ranging from pre-medical education through post-residency continuing medical education. Further, because the relationship between medical school and residency training varies widely across schools, individual programs will need to decide about the proper placement of different content and experiences within their training programs.
Regardless of when the training occurs, it is critical to realize that simply sending students to rotations at community sites and exposing them to more common problems in medicine will be insufficient to provide the needed competencies. "Learning managed care" will not happen by osmosis. Numerous authors and expert bodies have listed desired domains of expertise which learners should achieve. While many have different labels, or use different terminology, most have core elements in common or contain substantial overlap. These are synthesized in Table 1 and the resultant learning objectives can be grouped in the following domains: Health systems finance, economics, organization and delivery; Evidence-based and epidemiologically-sound practice; Ethics; Physician-Patient relationships; Leadership and the promotion of teamwork and organizational change; Systems-based Care; Quality measurement and improvement; lnformatics. In addition, students must understand how to choose an appropriate practice environment and understand basic issues related to practice management.