Xakellis, George C. Jr. MD, MBA; Robinson, Mark MSW
Dr. Xakellis is associate professor, Department of Family and Community Medicine, and interim director, and Mr. Robinson is manager of education, both at the Center for Healthy Aging, University of California Davis Medical Center.
Correspondence should be sent to Dr. Xakellis, 4860 Y Street, Room 2335, University of California Davis Medical Center, Department of Family and Community Medicine, Sacramento, CA 95817; telephone: (916) 734-2819; fax: (916) 734-5641; e-mail: 〈email@example.com〉. Reprints will not be available.
See the next article for information on a related topic.
The authors present a strategy for organizing and teaching the concepts of population-based health care for patients over the age of 65. The key ingredients are a case study based on a representative sample of 5,000 Medicare recipients and a student guide containing the sample group's demographics, clinical characteristics, and utilization patterns. As part of the case study, three subgroups within the sample are described: the basically healthy 50% that consume only 3% of medical resources, the most severely ill 10% that consume 70% of medical resources, and the moderately ill 40% that consume the remaining 27% of medical resources. These categories introduce the concepts of severity of illness, highlight the clinical challenges facing providers of care to the elderly, and contrast the divergent needs of individual health care consumers in an aging population. Armed with this succinct and manageable information packet, students are asked to play the role of an interdisciplinary team that is responsible for effectively managing the care of this population of 5,000 lives. Included in this article is a description of learning resources provided; sample group discussion questions; one strategy for caring for the population developed by a faculty-student group; and a brief description of the educational implications of the model. At the end of the article the reader is provided a Web address containing a description of the case and supporting materials (http://healthyaging.ucdavis.edu/education/continuing/ManagedMedicareTeachingCase.pdf). Readers are invited to view, print, and/or utilize the case in their own academic settings.
In this article, we present a strategy for organizing the concepts of population-based health care for patients over age 65. Central to this strategy is a case study that provides students a framework to learn about population-based issues so they can begin to discuss, grapple with, and plan for an aging individual's care within the context of a broader population.
The days when physicians were responsible only for the outcomes of the individual patient visit that focused on a very specific health concern are rapidly becoming a thing of the past. Physicians are increasingly being held accountable for managing populations of people and are being measured on population-based metrics such as the percentage of patients receiving mammograms or pap tests.1,2 One of the trends forcing this shift is the well-documented forecast in the rapid growth of the number of older persons in the United States and the corresponding alarming increase in the clinical needs and costs of medical care. Although a few medical schools have begun teaching population-based health care, their programs rarely focus on the 65-and-over age group.
One source of the reluctance or resistance to focus on this topic is worth mentioning. Interaction with each unique patient's presenting complaint or health problem has been viewed as the sole realm and responsibility of the clinician. The needs and problems of a “population” so overwhelmingly large and with such complex phenomena have been more closely associated with those holding positions of state and national policy experts. The problem-based learning strategy described here provides an effective way to bridge these two ends of the spectrum. It introduces future physicians to the process of creative solution finding that will be needed for the elderly population served by their health care systems.
ORIGIN OF THE CASE STUDY
In the fall of 2001, in affiliation with the California Geriatric Education Center, the University of California, Davis, School of Medicine hosted a three-day faculty development seminar entitled “Teaching Teachers How to Teach Managed Medicare.” One of the aims of this seminar was to create and field test an innovative educational resource developed by one of this article's authors (GCX) that would be placed on the Web at the conclusion of the project so others could download and use it. His vision was to make available a tool (in the form of a case study) that would not only introduce the principles and challenges posed by the entire Medicare-aged population, but also provide an effective platform for exploring creative problem solving to meet those challenges.
The case study was based on a representative sample of 5,000 Medicare recipients, and a group assignment was created that provides a dynamic vehicle for integrating a wide range of didactic material. Faculty attendees were asked to develop and test this educational exercise, which is now available on the Web for use by other faculty. It can be used as the basis for a one-time class discussion, a multiweek group project, or a complete master's thesis. The data, dynamics, and issues are relevant to students in nursing, social work, public health, health administration, and medicine. Rather than ask students to solve a common problem that exists within a health care delivery environment (e.g. access, delay in authorization), this case study allows the learner to grapple with the essential challenges of improving care provided to a Medicare-aged population in the current health care environment.
The Setting and the Problem
Students are asked to think of themselves as members of an interdisciplinary team charged with managing the health of a population of 5,000 seniors. They are instructed to design a systematic, improved method to provide for the optimal health care for this population. They receive $500.00 per month per person, for an annual budget of $30 million. They are not allowed to transfer responsibility for any individual senior to another doctor even if that senior becomes seriously ill or injured. They do, however, have at their disposal any type of physicians, hospitals, nurses, ancillary care providers, administrators, high-tech medical equipment, or information and data systems that they deem necessary to manage this group of patients.
Each student was provided with a student guide containing chart and graphs depicting three major categories of data (List 1, “Learning Resources”). These data are sufficient but not overwhelmingly detailed. In addition, students were provided with a series of discussion questions to guide their deliberations (List 1, “Group Discussion Questions”).
Sample Discussion Focus and Recommendations
Initially the “test group” of faculty and students focused on ways of creating the best organizational structure and health system culture. The test group wanted to minimize internal delivery system divisiveness by developing a shared vision of success. The group also wanted to facilitate a methodology whereby the delivery system could enter into collaborative rather than competitive and adversarial contracts with external partners (e.g., with insurers). The model care delivery strategy created by the “test group” included the clinical and organizational characteristics shown in List 2.
EDUCATIONAL IMPLICATIONS OF THE STRATEGY
Introducing the Concept of Severity of Illness
The strategy described above categorizes individual patients in a way that is essentially a rough severity-of-illness scale with three categories: basically healthy, moderately ill, and severely ill (Lists 1 and 2; Figure 1). It allows students to clearly differentiate and understand the clinical and financial issues faced by these three different groups of patients. The strategy provides a framework for understanding the different treatment approaches needed by individuals in the different groups. Although the science of severity of illness is much more developed than is shown in the material in the student guide, the guide's data provide a good “rule of thumb” that allows students to incorporate the concept of severity of illness into their overall clinical approach to individual patients. The three severity-of-illness categories provide a perspective that is complementary to the traditional disease-based nomenclature and allows students to better predict the intensity of services that are likely to be needed by an individual patient.
Highlighting the Clinical Challenges Facing Health Care Providers
The strategy highlights the notion that physicians will see three groups of people who want and need very different clinical services. For the basically healthy, physicians will need to provide preventive services that are delivered in an accessible, convenient manner and to provide health information on how to stay healthy and age in a healthful way. On the other hand, to control the health care costs of a population of Medicare enrollees, a physician must be able to optimally orchestrate the care of the 10% of patients who have severe medical conditions and who currently experience poorly coordinated and, at times, chaotic care for their chronic conditions. This group needs innovative strategies that provide coordinated, longitudinal care that better controls their chronic diseases, reduces complications, and decreases the number of avoidable hospitalizations. The conundrum currently faced by most physicians is that much of the infrastructure needed to provide this type of care is unavailable in their practice settings.
The teacher can emphasize to the students that coordinated care management requires significant reengineering of existing clinical care processes.7 Data systems to identify at-risk patients are needed. Disease registries to track patients with conditions such as diabetes are needed. Processes by which physicians could easily use these data to proactively plan care management are necessary. These innovations represent the steps needed for health care systems to move from a reactive posture, in which physicians respond acutely to patient-reported symptoms, to a more proactive posture in which at-risk patients are identified by database analysis, individualized chronic care plans are developed collaboratively with the patients, and continuity and follow-up are achieved by a care manager.
We believe that the case-based strategy we have described provides a useful tool to for a problem-based discussion of the prevalence of clinical disease and of the actual utilization of health care services by the entire Medicare population (i.e., persons over age 65). Additionally, the description of the distinctions of the three clinically relevant subgroups can lead to an appreciation of each group's unique problems and needs.
The strategy enables exploration of ways to develop more rational systems of care delivery. The use of a smaller, representative sample of patients provides a more approachable way for students to discuss methods of proactively applying population-based strategies to improve the care of individual patients. More information on the case study can be found at 〈http://healthyaging.ucdavis.edu/education/continuing/ManagedMedicareTeachingCase.pdf〉.
2. Gold M. Medicare + Choice: an interim report card. Health Aff. 2001;20:120–38.
3. Berk ML, Monheit AC. The concentration of health care expenditures, revisited. Health Aff. 2001;20:9–18.
4. Lubitz J, Greenberg LG, Gorina Y, Wartzman L, Gibson D. Three decades of health care use by the elderly, 1965–1998. Health Aff. 2001;20:19–32.
6. Kozak LJ, Hall MJ, Owings MF. Trends in avoidable hospitalizations, 1980–1998. Health Aff. 2001;20:225–32.
7. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20:64–78.