As the federal government explored a variety of educational, practice, and regulatory incentives to modify the composition of the nation's health care workforce, Nova Southeastern University's College of Osteopathic Medicine (hereafter Nova Southeastern) proposed to develop an academic partnership with a managed care organization to assign first- and second-year students to work with generalist physicians in the clinical setting. This would provide the students with role models of community-based generalist physicians in family medicine, general internal medicine, and general pediatrics.
Nova Southeastern proposed to expose students to managed care with a focus on generalist physicians and managed care organization (MCO) operations. The intent was to provide the students with an understanding of managed care strategies for balancing cost and utilization while ensuring access to good health care. The expectations were that the students would gain clinical experience, develop an appreciation for primary care, and acquire an understanding of managed care through mentorships with primary care physicians affiliated with a partner MCO.
First- and second-year students were to be assigned to private offices of MCO-affiliated primary care physicians. Each first-year student was to spend two hours a week shadowing an assigned mentor physician in his or her private office. Each second-year student was to spend four hours a week in the program: two hours shadowing the mentor physician, and two hours rotating through various departments of the MCO headquarters under physician supervision. The MCO headquarters rotation was to include computer-based patient rounds conducted on-site by the MCO medical director, as well as rotations through claims processing, medical utilization, benefit administration, provider contracting, enrollment and billing, and other departments.
An orientation for the students was required at the beginning of the program, feedback sessions midway through each semester were expected, and an interactive seminar at the completion of the program was planned. Total curriculum time to be devoted to this project over the two years was 220 hours, of which 132 hours involved direct patient contact. As illustrated in Table 1, learning objectives for the IGC Project were developed from an initial list of proposed areas to be addressed. Table 1 compares the areas initially proposed to be addressed with the actual learning objectives as they stand today. The objectives addressed medical decision making, interviewing and problem-solving skills, the use of laboratory tests, dealing successfully with a variety of patients, the concept of “whole patient” care, information resources and information management, self-directed learning; community resources, managed care plans, health care costs, and career options in primary care.
HOW RESULTS DIFFERED FROM WHAT WAS PROPOSED
Partnerships with Multiple MCOs
Because of an unanticipated corporate merger between the initial managed care partner and another health plan, Nova Southeastern's partner MCO withdrew from the IGC partnership just prior to program implementation. A decision was subsequently made to negotiate training partnerships with multiple MCOs. This was done both to broaden the experience base of the students and to minimize the risks associated with developing a dependent relationship with one exclusive managed care partner.
Building teaching relationships with multiple MCO partners reduces the dependence on any one partner whose participation could be suddenly compromised by unexpected managerial decision making or organizational/managerial change. Of the eight MCOs with which partnerships were developed during the 1997–98 academic year, two have since declared bankruptcy, three have had major changes in top-level administrative positions, and several others are struggling to remain viable in the highly competitive and rapidly consolidating South Florida managed care market-place. Given the unique challenges inherent in such a volatile industry, Nova Southeastern has remained vigilant in opening new doors for future managed care teaching partnerships.
Different Focus of Managed Care Curriculum Components
The IGC Project proposal included rotations through a variety of MCO departments and experiences. Some of the onsite rotations (i.e., provider contracting, enrollment, billing, claims processing, and benefit administration) were later substituted for campus-based lectures. An initially proposed headquarters-based utilization management rotation was replaced by a more interactive utilization management session at a hospital and a skilled nursing facility. Other MCO departments or experiences, which were not in the initial proposal, have become mainstream rotations. These include quality management, disease management, catastrophic case management, medical director operations, and physician committee dinner meetings (e.g., peer review, quality improvement, pharmacy and therapeutics).
Different Structure of Managed Care Rotations
In the initial proposal, the managed care rotation model consisted of assignments to one department per session, as well as assignments to one MCO for the academic year. In order to enhance student learning, hybrid training models were developed that consist of combinations of experiences within a single MCO session. For example, at one MCO, the headquarters-based session consists of case management, catastrophic case management, disease management, and in-house utilization management. Another MCO has a combination of medical director operations with case review rounds and quality improvement. Some students are assigned to a single MCO, whereas others are assigned to two or more MCOs. There is a fine balance between identifying the strongest learning experiences at each MCO and diversifying each student's overall learning experience. Some managed care partners are able to provide their exclusively assigned students with a full range of core rotations, while other MCOs focus on smaller numbers of more select learning experiences and, therefore, share their students with other MCOs. In the latter scenario, students would be assigned to two or more MCOs in order to experience the full complement of services. Because of the diversity of managed care partners, student rotations are tailored to take advantage of the unique strengths and resources of each MCO.
Reduced Training within MCO Headquarters
A large portion of MCO training now takes place at field-based sites outside the MCO headquarters or after normal business hours. Quality management sessions, for example, evolved from a headquarters-based experience to a clinic-based experience where students accompany nurse reviewers on quality audits and reviews. The same holds true for utilization management, which has evolved from headquarters-based prospective review to hospital-based concurrent review. Many Nova Southeastern students now have the opportunity to attend actual MCO physician committee meetings, which typically take place during the evening hours.
Different Time Allotments
The time allotted for physician mentor and managed care rotations has also changed. First-year students rotate four hours every other week rather than two hours weekly. Second-year students spend an average of four IGC sessions per year at their assigned MCO(s), compared with 23 sessions with their physician mentors. Although the original proposal allotted half of the on-site training time to managed care, it was determined that four field-based MCO sessions were quite adequate. In addition, it is not feasible to have in excess of 180 students simultaneously rotating bimonthly at MCOs in one geographic area. Despite the reduced allotment of MCO rotation time, the managed care project is much more time-consuming and challenging for the IGC office to administer than the physician mentor project. In addition to the rotations at MCOs, there has been a notable didactic component of the managed care curriculum that takes place on the Nova Southeastern campus. Many of the topics that are no longer covered at the MCOs are addressed in the form of symposia, lectures, seminars, or small-group discussions.
Different Recruitment Strategies for Primary Care Preceptors
Nova Southeastern's IGC Physician Mentor Project currently has a network of more than 135 community-based primary care preceptors. These preceptors are recruited through various means, and not just through MCOs, as was originally intended. Affiliation with MCOs continues to be a requirement for physician-mentors, to ensure that students are exposed to the managed care issues inherent in that clinical experience, and to help in pre-credentialing the preceptors (most MCOs have extensive credentialing standards). Recruitment efforts have included the use of a wide range of strategies and sources to identify prospective preceptors, including county-wide mailings, medical society listings, alumni listings, referral development (i.e., by faculty, students, physician mentors, and MCOs), and managed care provider listings.
Different Physician-Mentor Retention Issues
To help manage the challenges associated with implementing a volunteer-driven physician-mentor network, the IGC team closely monitors the performances of all preceptors and continuously make changes and adaptations to the network. Based on qualitative and quantitative assessments, preceptors whose performances are substandard are replaced with new preceptors. This ensures high levels of instruction and consistency. The focus of preceptor retention has become one of “adverse selection” or program-driven termination as opposed to the seemingly more common problem of self-termination.
The Nova Southeastern curriculum that preceded the introduction of the IGC Project consisted of individual didactic courses and simulated patient practicums. The year one curriculum consisted of basic science courses, humanities courses, and a clinical practicum course where physical examination skills were taught. The year two curriculum consisted of didactic courses in the clinical sciences (internal medicine, pediatrics, surgery and its subspecialties, pharmacology, pathology, and psychiatry), a small-group, case-oriented, problem-solving course, and a simulated-patient physical assessment course. The didactic courses in the year one and year two curricula were not directly correlated with the problem-solving or physical assessment courses. Osteopathic manipulative medicine was taught throughout the first two years of the curriculum.
At the time of implementation of the IGC Project, the curriculum committee approved the establishment of an interdisciplinary and integrated year two curriculum that was consistent with the principles of the IGC Project proposal. It consisted of a “systems” rather than a “subject” approach to the didactic component. Lectures in pediatrics, internal medicine, pharmacology, pathology, surgery, and obstetrics and gynecology were logically sequenced and presented in association with the appropriate physiologic systems. The contents of the clinical practicum (simulated patient examination) and clinical correlation (small-group clinical problem-solving) courses, which ran parallel to the systems courses, were correlated with the lectures of the systems courses. In addition, the IGC preceptors were encouraged to complement the didactic learning with real-life clinical cases that correlated with the physiologic systems under discussion. This integration has been well received by students, who have described this curriculum as applied and meaningful.
The establishment of a managed care curriculum within the context of the IGC Project provided the students with an understanding of the managed care system and two major perspectives of managed care—that of the primary care physician and that of the managed care administration, through whose services they rotated.
These curricular changes were consistent with the initial proposal and plans for the IGC Project.
The IGC Project goals and learning objectives evolved as the project matured. The learning objectives address medical decision making, interviewing and problem-solving skills, use of laboratory tests, dealing successfully with a variety of patients, holistic patient care, psychosocial and ethical issues, information resources and management, self-directed learning, community resources, managed care structures, health care costs, and career options in primary care. As the program has progressed, the learning objectives have become more clearly defined.
The “unintended change” was that there was a void in initially specified managed care “areas” from which objectives could later be developed. Because a significant portion of the IGC was to be allocated to managed care, objectives needed to be developed for each component of the managed care headquarters experiences and campus-based education. These objectives are described in List 1.
The “proposed” versus “current” goals of the IGC Project were significantly altered. The emphasis is not so much on preparing students for jobs “within” managed care as on preparing students to have a working knowledge of managed care principles and practices as they would apply in virtually any medical field and setting. Also, the fourth item under “Current Goals” was added only recently. In addition, the long-term goal became broader as it included language relative to surviving in a managed care environment in addition to the initial goal of increasing primary care graduates. The overall initial and final goals of the IGC Project are compared in Table 1.
The first three years of federal funding provided seed funding that gave impetus to the development of an early clinical experience and a managed care curriculum. This curriculum is now a vital part of Nova Southeastern's overall medical curriculum.
The American Medical Student Association (AMSA) recognized Nova Southeastern as the 1997 recipient of the Paul R. Wright Excellence in Medical Education Award for its exceptional integration of interdisciplinary education into the training of tomorrow's physicians. The IGC Project, viewed as the flagship of these interdisciplinary curricular changes, has been incorporated and integrated into the foundation of undergraduate medical education at Nova Southeastern. First- and second-year students will continue to rotate with community-based physician mentors, while second-year students will continue to rotate at MCOs to learn about the unique challenges and systems that are developing in the managed care arena. The clinical correlations and clinical practicum courses will also remain as essential components of this integrated curriculum. Nova Southeastern has long been known for its innovative approaches to education, incorporating state-of-the-art and realistic community-based instruction. The IGC Project is entirely consistent with that mission.