By Christopher Guadagnino, Ph.D.

• React to this article in the Discussion Forum.

PND: What is Partnerships for Quality Education?

ER: Partnerships for Quality Education is large initiative begun by the Pew Foundation aimed at linking academic medical centers with managed care organizations in primary care resident education. There are seven funded partnerships of which we are one associate partner. The University of Pennsylvania found Independence Blue Cross interested in helping to train housestaff about caring for patients in a managed care setting.

PND: What does the partnership entail?

ER: In general, there has been very little information given to medical students about managed care, and very little experiential learning. We've never invited managed care insurers into medical schools to participate in the actual training of medical students. Independence Blue Cross does chart abtractions and patient satisfaction surveys, and the results are used to decide how much doctors get paid, which doctors continue to see patients provided by the plan, whether the doctor continues on the rolls of the plan. We've taken those tools and pulled appropriate pieces out for use with housestaff. The two major things that we're funded to do is to create report cards and study the best way to use report cards in an educational setting. The report cards are not linked to financial incentives, but are a learning tool that will allow housestaff to understand what it's like in the real world when they get these report cards in the future. Very few places have looked at specific elements of feedback to their housestaff before. Most housestaff get feedback like that based on observation of interaction with patients, conference participation, non-quality based measures.
The other major initiative that we're funded to do is rotation at Independence Blue Cross where, starting in July, our primary care housestaff are going for a month to work with the medical directors there attending upper level administrative meetings. It's an administrative rotation, not a clinical rotation, where they learn what the inside workings of the health plan are like and how that relates to the day-to-day life of practicing physicians. They'll be attending quality management conferences, utilization conferences, they'll be watching as the medical directors make decisions about approving or disapproving hospital stays and procedures. I think they will get a really unique view of the other side than what they get on their rotations here at HUP. We're planning on requiring it of the primary care residents and, if we have enough slots, offering it to a few of the categorical housestaff. We're piloting it this Spring with one or two senior residents and general medicine fellows and, starting in July, each year there will be eight primary care housestaff going through the program and probably a handful of categorical residents. The grant supports us for two years and we are about six months into it.

PND: Will the rotation component help IBC recruit physicians?

ER: Although that's not the goal of the project, I think that may very well be a side effect. Some of these housestaff may be attracted to the concept of working in the health care industry side rather than provider side. I think that it will also raise awareness about managed care in the housestaff as a whole; the housestaff may be more likely to work in a strictly HMO setting afterwards.

PND: Is there a risk for this partnership to allow managed care company interests to encroach upon the interests of the medical academy?

ER: The clear overall goal of this partnership is educating residents about managed care. Independence Blue Cross covers 84 percent of the privately insured lives in the Delaware Valley. If we're to prepare our housestaff to practice in an environment where they're working closely with a managed care organization that insures the vast majority of patients that they see, I don't think we're doing right by them educationally if we don't teach them about what that practice is going to be like. If it was just a managed care organization having residents go out to them without input from the academic side, then I would be more concerned. I think the people from IBC are very interested in the overall educational goals that we've specified. We specifically selected medical directors at Independence Blue Cross to work with us who have strong backgrounds in education. The medical director who's working with us did a Robert Wood Johnson clinical scholars fellowship here at HUP before he went on to work for Independence Blue Cross. The rotation is designed by both sides of the fence, not just by the managed care people. The interactions are discussed by both the academics and the managed care folks. So it's really a partnership. I think that this is going to bring the importance of education to IBC and allow them to better understand residency education and to help take a part in it. One of my overall goals would be that managed care organizations begin to contribute in a meaningful way with both time and financial effort toward cooperating with education.

PND: How have the residents reacted to the partnership?

ER: I was afraid when I started this undertaking that the housestaff would be very resistant to getting report cards, that they would be afraid that their results would be used in an evaluative way. We've asked them whether they want their report cards to be confidential or not, that the results shouldn't come to their program directors. They're not afraid of that. The housestaff have been uniformly excited and have been real actors in the planning of this process. Insurers' report cards are based on certain sources of information that may or may not be appropriate for the housestaff. When they get a report card we have a seminar that is co-led by me and one of the medical directors from IBC, and we openly discuss the sources of the data, the number of patients that were surveyed, the number of charts that were abstracted, the difficulty of doing chart abstraction. They ask questions of me about how our data was generated and then generalize and talk about how Independence Blue Cross generates their data that they use for their physician profiling. We've had more people than we probably are going to be able to accommodate ask to try to do this rotation next year at Independence Blue Cross. The housestaff have been clamoring for more real world medicine over the past few years and I think this is giving it to them.