The Health of the Public Program at the University of Washington: a new role for academic medical centers

Managed health care and resident education

OBJECTIVE

We wished to determine the impact of managed health care on resident education in obstetrics and gynecology.

STUDY DESIGN

A multiquestion survey was mailed to program directors of the 267 obstetrics-gynecology resident training programs in the United States. The questions ascertained departmental philosophy regarding the role of obstetrician-gynecologists as primary care versus specialist physicians, the extent of involvement with managed health care companies, educational curriculum content, the effect of managed care on patient volume, faculty time available for resident teaching, and the effect of managed care on resident education.

RESULTS

Completed surveys were received from 210 (79%) program directors. One hundred twenty-six (63%) program directors responded that obstetrician-gynecologists should be primary care physicians for women, and 120 (60%) believed that the role of subspecialists will be reduced in the near future. In 1996, 177 (94%) programs had managed care contracts; many (57%) had >20 contracts. All programs participate with other specialties to teach primary care to their residents. One hundred twelve (59%) programs have had a decrease in patient volume, prompting 90 (45%) programs to increase their number of teaching sites. Of concern, 54 (26%) program directors noted that managed care companies discourage but do not restrict resident participation in the care and treatment of managed care patients, and 41 (20%) programs had some restrictions placed on such resident involvement. Budgetary constraints have decreased resources to 97 (47%) programs and threaten the time available for faculty teaching.

CONCLUSIONS

Managed health care is having an effect on many resident teaching programs. Program directors are integrating managed care concepts into the educational curriculum and are negotiating with managed care organizations to involve residents in the care and treatment of managed care patients.

Assessing compliance to antihypertensive medications using computer-based pharmacy records

Systematic approaches for compliance problem detection and intervention are needed if the benefits of prescribed drug therapy in chronic disease management are to be optimized. As with all measures of compliance, computer algorithms based on refill patterns have advantages and disadvantages. They are unobtrusive and easily determined, but they measure the timeliness of prescription refills, not actual drug-taking. Computer-generated algorithms for assessing compliance based on refill patterns should be used by practitioners with caution, because they are not only markers for potential drug taking compliance problems, but also for discrepancies between the medical chart, pharmacy records and verbal advice given to the patient. Because patients may obtain refills before depleting their supply, compliance rates using this methodology are best determined across several refills. In particular, we urge caution in applying them over time periods of less than 60 days. Longer minimum time periods further decrease the likelihood of "false positives" but limit the number of patients for whom a compliance measure can be computed. For the health professional (eg, the pharmacist) responsible for monitoring drug-taking compliance of patients, the message seems clear: when reviewing computer-generated noncompliance "flags," the first task is to fully explore the possibility of discrepancies in drug records before initiating compliance-related interventions.

Supporting primary care medical education

A number of fundamental issues must be considered in preparing the education system to produce more primary care physicians. Governmental controls and redirection of resources will force significant changes in the structuring of approaches to both undergraduate and graduate education in primary care. Particularly challenging will be restructuring and funding medical student programs in primary care, given a nearly certain requirement that more than 50% of medical school graduates enter primary care disciplines. Institutions will need to make strategic resource allocations to compete for the funding once the allocation process begins. Educational institutions will also face a cultural adaptation to primary care as an educational priority. This paper presents a model to study costs and funding for residency programs as they move from the traditional inpatient orientation to an outpatient focus. The authors suggest that for medical student education, the development of large academic health care systems may make funding primary care education more feasible.