New research shows that medical school training in managed care practices has not kept pace with the marketplace reality. More than half of all Americans are now enrolled in managed care plans.

A special report on medical education in the September 4 Journal of the American Medical Association (JAMA) showed that only about 18 percent of the 125 medical schools surveyed in the last academic year required all students to have clerkships or other clinical experiences in an HMO.

Far more medical schools (85 percent) exposed their students to some type of managed care by requiring clinical experiences in ambulatory, community-based settings.

The JAMA research confirms the general perception that "academic medicine has been slow to respond to the challenges of managed care," write David Blumenthal, M.D., and Samuel Thier, M.D., of Harvard Medical School in Boston in an editorial in the JAMA special report.

James Scully, M.D., APA's deputy medical director in the Office of Education, commented to Psychiatric News that "while more traditional research-based schools have not shifted their teaching to managed care, community-based medical schools that are primary-care oriented are way ahead."

He cited the University of Minnesota-Duluth and Southern Illinois University as examples of community-based medical schools that are "less prestigious than Ivy League schools, but may be better positioned economically in the future."

The research shows that medical schools selected HMO's as managed care sites for rotations to meet clinical goals rather than teaching explicit managed care skills such as cost-effectiveness analysis or quality management.

However, in contrast to the fast-growing independent practice associations (IPA's) and preferred provider organizations (PPO's), HMO's now account for less than 10 percent of the total managed care market and are rare in the Northeast, Midwest, and South, according to the JAMA article.

"It is unclear to what extent students' educational experiences in HMO's are relevant to the managed care approaches they encounter in other practice settings, both as students, and later as physicians," note the researchers.

Ian Shaffer, M.D., chair of the American Managed Behavioral HealthCare Association (AMBHA), told Psychiatric News, "Behavioral health care is moving more toward IPA's, which we refer to as groups without walls, because these practices can cover a large geographic area."

By being exposed to different work environments, students can make better decisions about future employment opportunities, added Shaffer.

He encouraged teaching hospitals with managed care contracts or networks to expose medical students to meeting the requirements of managed care.

But who will pay for educating medical students? "The spread of managed care threatens both public and private subsidies for medical education," write Blumenthal and Thier. "Unlike the federal government, managed care organizations are not required to make GME payments to academic medical centers on behalf of their Medicare enrollees."

Academic medical centers have also had to reduce prices for private patients, eroding another source of subsidy, notes the JAMA editorial.

Scully commented, "Managed care leaders want physicians trained in the principles of managed care so they can be good employees, but they are reluctant to accept the responsibility for funding medical education."

Shaffer responded, "I agree that we want providers who understand our paradigms, but the patient pays the price for not having well-trained clinicians."

He also questioned why other private health care organizations are not targeted for funding medical education.

(Psychiatric News, October 18, 1996)