The need for a new model of care: revisiting the archetype.

In the world of integrated delivery systems, the traditional academic health center (AHC) must change radically to maintain its mission. Restructuring includes bringing the hospital and other sites of care into partnership with the faculty physicians. Virtually nothing about the current model fits the needs of the future. Of the many changes that must occur, the care delivery paradigm is a major area that needs to be redesigned.

Current model of care

While there is some variation across the country, the essential elements of the model of care at most teaching hospitals are as follows:

* The focus is diagnostic, therapeutic, and curative; prevention is not a priority.

* The patient encounters are viewed as visits, not as part of a "covered lives" concept.

* Diagnostic and therapeutic plans are drawn up to fit facility-based outpatient and inpatient care, rather than by searching for the most cost-effective site to reduce expenses under capitation.

* While continuity of care delivery by the same resident or faculty member is the expressed goal, the mechanics of the rotation schedules make this an uncommon event.

* Coordination of diagnostic and therapeutic care, if present, is limited to hospital-related care.

Managed care organizations (MCOs) are refusing to accept this uncoordinated teaching model for their patients. They know that successful capitation can only be achieved when care is viewed from a population perspective, managed along a continuum, and coordinated at every point. In addition, MCOs require that physicians providing primary care are easily accessible to their enrolled members--for new patients on at least a 50-percent time basis. They must also be available to coordinate urgent care.

For medical school faculty, this is difficult because of its diverse interests and obligations. For residents, this is impossible--their training schedule is designed to optimize exposure to different primary care and specialty services, plus residents serve as a source of manpower. Worse, the current training model that enables students to gain experience working up new patients with rotating faculty preceptor supervision is an anathema to MCOs.

Academic health center care is also significantly more costly (perhaps 30 percent more[1]) without obvious benefit to the MCO or the individual. According to a recent report, networks with AHCs at the hub are 18 percent more expensive compared to those with non-academic hubs.[2]

Another factor, and one that is becoming more prominent each day, is that the patient as a customer is no longer willing to tolerate the difficulty of utilizing the AHC as a care site. Our teaching hospital campuses are plagued by a remarkably similar set of issues: lack of parking; poor signage; confusion about appointment scheduling; clinic cancellations; the absence of an identifiable physician in charge of the patient's care; difficulty in accessing personal medical records for medical, legal, or administrative use; amenities that are institutional and cold; and staff without a customer-focus orientation.

If academic health centers are to remain the primary teacher of residents, the model of care taught should reflect what practice will be like, for at least the decade after the residents finish their training. And unless AHCs improve customer service, they will continue to lose those patients able to get their care from a more service-oriented provider. Medicaid will no longer be their bailiwick. State by state, Medicaid is being privatized, and AHCs are not competitive. The uninsured, or badly underinsured, may keep using AHCs, further distorting teaching programs, and worsening the fiscal situation.

The new model

Population-based medicine reflects the integration of clinical care delivery and public health. Understanding the epidemiology of the community and the needs of groups of people helps identify the types of practitioners required to provide comparable care from quality and cost perspectives and is essential to managed care. Care delivery from this perspective should result in more emphasis on primary care including prevention, and greater understanding of the interaction of the community's health and that of the individual.

The clinical enterprise of an AHC needs to develop the capacity to provide care across the continuum, at all sites. One way to do so is by using teams comprising a portfolio of providers and staff fully supported by information technology to facilitate extensive communication. The idea of teams is not new. In the United Kingdom, "firms" were introduced 50 years ago to assure inpatient and clinic continuity. Firms are teams of faculty and residents assigned to specific inpatient units and their related clinics. The faculty assignment is permanent, while the residents rotate for six to 12-month blocks. Thus, the patient generally receives inpatient and hospital outpatient care from the same set of physicians. Unfortunately, the private practitioner is excluded. AHCs in the U.S. have had teams of many forms, but seldom were they created to manage all care with the patient's interests first, and they certainly did not have a focus on prevention.

Academic health centers should reorganize their faculty's fellows and residents into mini-group practices, and deliver care as part of multidisciplinary teams. The primary care team (and those specialist teams also providing primary care) needs to manage that care by coordinating with delivery staff at every site. Team composition should include care coordinators who are responsible for facilitating communication at all times- between the patient, family, and team members.

Although the degree of supervision depends on the resident's experience, the faculty physician should be involved in all significant clinical issues. The primary care faculty members on the team should work as a group practice, knowledgeable about each other's patients and covering for one another. Specialty faculty should also organize into teams to provide primary and specialty care to the more complex patients. For the less complicated patient, each primary care team should know by name the specialist from every major field primarily responsible for providing consultation. An obsession with communication is essential, and AHCs need to provide the systems to facilitate this.

Finally, prevention and early detection must be the cornerstone of this new care paradigm. Ideally, every member should go through an initial enrollment process when healthy, during which time an in-depth evaluation can generate a defined life care path. Members (not yet patients necessarily) can participate in reviewing risk, lifestyle, and available alternatives, and become partners with their providers in staying healthy.

Every encounter after the enrollment is an opportunity to modify the care path. The key to reducing cost is to have the member use more self-care that is safe and effective. Thus, members need to be advised on how to access and utilize the vast amount of

health care knowledge available, but not about uniform clarity. The team may need to include a navigator to help their members do this.

Training impact

Residents in training are concerned that this paradigm will reduce their exposure to various faculty and patient types. This is understandable, but illusory. Under the current system, they may draw the weakest attending physician for a whole rotation, learn inefficient habits because of absence of continuity in program design, and resort to overtesting. Episodic encounters may lead to poor relationships with patients. And basically, they learn a style of care that has died.

Conclusion

Under the new model, residents will learn how to provide true continuity of care, cost effectively and in a member-focused environment.[3] Prevention and early detection should be emphasized, as should the health of the community of which the individual is a part. The individual is a member to be kept healthy and, subsequently, a patient receiving care as needed. Overall, this focus should create better doctors.

Teaching programs need to resemble what the public wants: A doctor who takes primary responsibility, easy access to useful information and knowledge, and humane relationships with providers. The team concept provides the opportunity to do this, and enables the AHC to continue its mission of teaching, research, and care.

References

[1.] Prospective Payment Assessment Commission, Washington, D.C., 1993.

[2.] Matheny, Meg. "Preserving Teaching and Research in an Era of Managed Care: An Interview with Spencer Foreman, MD." Health System Leader, December 1994, pp. 17-21.

[3.] Griner, Paul F. "Residency Overwork and Changing Paradigms of Service." Annals of Internal Medicine, October 1995, pp. 547-548.

Michael Eliastam, MD, MPP, FACEP, FACP, is an Associate Partner at Andersen Consulting in Boston, Massachusetts. He can be reached at 617/330-4459. Over the past 20 years, Dr. Eliastam has served on the academic faculty of the schools of medicine at both Stanford University and Boston University, as well as in the roles of teaching hospital medical director and line administrator.