REPORT OF THE COUNCIL ON MEDICAL EDUCATION

								CME Report 4 - A-99

Subject:	Training of Physicians Under Managed Care
		(Resolution 318, A-98)

Presented by:	Robert M. Daugherty, Jr., MD, PhD, Chair

Referred to:	Reference Committee C
		(James P. Marvel, Jr., MD, Chair)

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Resolution 318 (A-98), introduced by the Pennsylvania Delegation, was referred to the Board 
of Trustees.  Resolution 318 reads as follows:

RESOLVED, That our AMA promote legislation to prevent managed care organizations from limiting access by patients to clinics in teaching hospitals that are willing to contract with providers at prevailing prices.

Reference Committee C heard conflicting testimony about the extent to which medical students and residents were being excluded from participating in the care of patients enrolled in managed care plans.  Exclusion may occur when managed care organizations choose not to contract with a teaching hospital or a clinic associated with an academic institution, or referring all their patients to a non-teaching facility because of financial or other considerations.  Less commonly, a managed care plan may refer patients to a facility that participates in medical education, but with the condition that the treatment teams not include students and/or resident physicians.  Of great concern, particularly with expansion in the utilization of ambulatory sites for medical education, is that the productivity standards imposed (directly or indirectly through reduced compensation) by managed care on physicians will not permit them the time to teach in their offices and clinics.  

Data received from the 1997-1998 survey of medical schools conducted by the Liaison Committee on Medical Education show that 92 schools have managed care contracts for primary services and 98 have such contracts for specialty services.  Questions were not asked relating to exclusionary provisions in these contracts for medical students and resident physicians, but the number is believed to be small.  

Graduated responsibility for patient care is essential to the education of a physician. If there is limited opportunity during formal medical education and residency training to participate in the health care of patients, physicians will be less capable at the conclusion of their education.  Such an eventuality would have a profound impact on the future health of patients.

 Even if sufficient patients exist outside managed care systems to provide for clinical experience, it is important that physicians be exposed during training to the processes and procedures inherent in managed care if they are to care for increasing numbers of patients within such systems.  Existing AMA policy H305.943 (AMA Policy Compendium) “supports the concept that medical education programs and teaching institutions work collaboratively with managed care organizations and other health care delivery systems to develop educational opportunities for medical students and resident physicians that will prepare them for practice in the current health care environment.”  The 1997-1998 Liaison Committee on Medical Education Annual Medical School Questionnaire showed that in 22 schools, all students spent time in a managed care setting and in additional 76 schools, some students met these criteria.  Responses to the 1996-1997 AMA Survey of Graduate Medical Education showed up to 10 percent of resident physicians in some specialties had specific exposure to group/staff model managed care settings but did not ask about other exposures to managed care.

The issue for discussion is whether specific legislation is the correct solution to the problem and, if so, whether  such legislation should apply to both private and government entities.  Some improvements have already taken place.  Early Medicare contracts with managed care did not require that the portion of historic costs associated with Direct and Indirect Medical Education adjustments to teaching hospitals be passed on to teaching facilities.  This has now been corrected, although contractors will be permitted to phase in these payments over several years. Direct and Indirect Medical Education adjustment payments can now be paid to the entity actually providing the resident education, which should improve the potential to expand educational opportunities in ambulatory facilities.  Significant change in how the Medicare Trust Fund participates in graduate medical education is a matter of current discussion in both the Bipartisan Commission on the Future of Medicare and the Medicare Payment Advisory Commission.  Legislation will be introduced in both Houses of Congress this year to provide for an “All Payer System” to fund a trust fund for health care provider education that is compatible with the provisions of the Consensus Statement on Physician Workforce and AMA Board of Trustees Report 44 (A-95).

Several managed care organizations have entered into collaborative programs of education with academic health centers, in some cases funding specific curriculum initiatives in evidenced-based medicine and population-based health care.  Although the stresses on America’s medical education system caused by rapid changes in health care financing have been severe, compensatory changes are evident throughout the nation.

The Council has considered the option of promoting specific legislation to address the problems discussed in this report and has determined that this would not be the most prudent course at this time, given the ongoing and unpredictable events in both the public and private sectors.

Recommendations:

The Council on Medical Education recommends that the AMA adopt the following recommendations in lieu of Resolution 318 (A-98), and that the remainder of this report be filed.

1.	That the AMA reaffirm previous policy expressed in the Consensus Statement on Physician Workforce and AMA Board of Trustees Report 44 (A-95), relating to the establishment of an “All Payer System,” and AMA policy H305.943, which “supports the concept that medical education programs and teaching institutions work collaboratively with managed care organizations and other health care delivery systems to develop educational opportunities for medical students and resident physicians that will prepare them for practice in the current health care environment.”

2.	That the AMA monitor ongoing legislative initiatives and support specific language that would preserve the opportunities for medical students and resident physicians to participate in the care of patients under the supervision of the responsible attending staff.

3.	That the AMA monitor and promote mutually beneficial private initiatives between managed care organizations and educational entities that would preserve the opportunities for medical students and resident physicians to participate in the care 
of patients under the supervision of the responsible attending staff.

4.	That the AMA ask the Liaison Committee on Medical Education to survey those medical schools and academic health centers with managed care contracts for the presence of exclusion provisions that curtail the education of medical students and resident physicians.