Preparing residents for managed care practice using an experience-based curriculum

Many U.S. residency graduates will practice in various types of managed care organizations, where they will be expected to arrive skilled in managed care activities such as prescribing with formularies and adhering to preauthorization processes for procedures, referrals, and hospital admissions. Residency programs must prepare their trainees to negotiate for their patients' needs within such systems. This article describes a University of California, Los Angeles, UCLA School of Medicine curriculum that teaches managed care skills to residents in two internal medicine residency training programs. The residents in one program participate in a commercial health maintenance organization plan via a group-model faculty practice. Managed care activities for residents in this program were gradually introduced beginning in 1990. This reflected previous years' gradual yet enforced introduction of managed care activities that occurred for this program's faculty and most group practice physicians in California. Residents in the other program train at a public hospital where managed care practice is simulated. Managed care activities were not required by this program's institution but were voluntarily introduced for their educational value beginning in 1994. Responding to this program's trainee and faculty requests, these activities were rapidly implemented over two years with the goal of preparing residents for joining practices in a market with high managed care penetration. Since 1994, the centerpiece of the curriculum has been residents' participation in ambulatory utilization review and related activities. Residents learn managed care principles through problem-based learning, experiential exercises, and feedback on resource utilization. The curriculum has affected residents' attitudes toward managed care and changed their patterns of referrals and resource use. Residents trained with this curriculum perceive managed care practices as familiar and less intrusive. They submit fewer requests for referrals, perhaps with review in mind. However, precautions may be required to avoid undercare. The authors found that the reduction of referrals requested was greater than what they had expected. Residents may find scrutiny by colleagues intimidating. Also, this curriculum requires a substantial time commitment from residency training, with its already busy teaching agenda. The authors feel that initiating a managed care curriculum is an important investment in time for U.S. residency programs. Given that most graduates of residency programs will have their health care management decisions scrutinized while in practice, the authors feel it is important that residents' first exposure to managed care be while they are still in the supportive residency environment. They believe that early exposure will not only give residents the confidence to overcome the intimidation of colleague scrutiny, but may also give graduates the tools for involvement with the development of future managed care health policy.