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FORUM
How Does Harvard Pilgrim Health Care Crisis Affect Its Residency?Director Says Program Is Part of Long-term Solution, Not ProblemOne of the less publicized questions raised by the recent shock that Massachusetts had placed Harvard Pilgrim Health Care into receivership is the effect it may have on graduate medical education. The Harvard Pilgrim Health Care/Brigham and Women's Hospital Primary Care Residency is jointly run by the managed care organization and the hospital.
The concern is relevant not only to Harvard but to primary care residencies across the country. According to Jeannette Shorey, director of the Harvard program, training in new competencies necessary to manage care is making its way into graduate medical training. She says that 56 percent of Americans who are insured—and 87 percent of those who are employed—receive their care through a managed care organization (MCO). Despite this market penetration, the industry faces widespread financial difficulties. If some form of managed care—and there are many different models for managing care—is going to be present for the foreseeable future, graduate medical education should prepare new doctors for this kind of practice. But where does the money come from if the MCOs, who might share in the costs and training, are financially distressed? Balancing Cost, Care, EthicsComplicating the situation is the issue of health care quality, which may be compromised if the wrong costs are cut. In addition to patients and physicians, this dilemma is of particular interest to medical students and residents, who are learning the profession and may see mixing business goals with humanitarian aims as contradictory. To many practicing physicians, the practical challenge is determining how to treat a large population of patients in need using available resources without sacrificing quality of care or medical ethics.Despite the turmoil, Shorey says that both Harvard Pilgrim and Brigham and Women's are financially and philosophically committed to supporting the residency. The three-year program has been recognized as an important national innovation in primary care training by the American Board of Internal Medicine. Shorey was invited to give a presentation at its "Forum on the Future" last summer, discussing the importance of integrating the competencies of managing care into graduate medical education. The presentation is now on the Web and is also being published in print. The Need for Managing CareAccording to Shorey, the nation's most effective MCOs may offer the best hope for the seemingly intractable problems facing health care despite their current financial challenges. Echoing health care leaders like James Sabin, cofounder of Harvard's Center for Ethics and Managed Care, she says, "Once you get it that you must care for a defined population of people using finite resources, it becomes unethical not to manage that care."A primary care physician herself, Shorey says that young physicians cannot shy away from corporate medicine in our current practice environment—or they won't have jobs. "Corporations that have good core values are fabulous. You need to look at the values of the corporation. An ethical health care system has to think about being cost effective because it is responsible for distributing a very important service fairly." The current HPHC/BWH residency was established in 1994 in response to a challenge from the Harvard Pilgrim Health Care Foundation to graduate highly trained primary care physicians ready to practice ethically sound, cost-effective medicine. The ideas defining Harvard Pilgrim were envisioned in the early 1960s by Robert Ebert, then dean of HMS. Ebert and colleagues founded Harvard Community Health Plan (HCHP) in 1969, the first staff-model health maintenance organization in New England. By providing financially capitated and fully integrated medical care, emphasizing ambulatory care and prevention, this health care delivery system catered closely to the needs of its member population while making care more affordable and accessible. Considering the need for more primary care physicians, HCHP also provided graduate medical education opportunities to local medical residents. In 1992, the Quincy-based independent physician's association Pilgrim Health Care merged with HCHP to become Harvard Pilgrim Health Care. Shorey, who works for HPHC and HMS, explains the physician's perspective on the current model: "I'm a doctor in an office taking care of patients and trying to learn how to take care of populations. Doctors used to think about one patient at a time, and it was a stretch to think about groups. Technology and economics have come along to move us toward population-thinking. It's less expensive, and we can probably improve the health of more people that way." The HPHC/BWH residency is committed to training primary care physicians in settings similar to those where they will be practicing after they complete their training—60 percent of their time is spent within a managed care environment. The program also prepares residents to study and improve the local and national health care delivery system. Areas of training include health care economics, evidence-based medicine, communication skills, population-based practice, ethics, and systems innovation, much of which involves managing care. Training future leaders in managing care is necessary since money and medicine are inextricably connected in today's profession—as demonstrated by HPHC's current financial crisis. Shorey says, "It's a really big challenge to figure out how to use the most expensive services well. That's the tension. Our society has not alleviated that tension. It's still playing out." —Catherine Chu |
Jeannette Shorey says both Harvard Pilgrim and Brigham and Women's are committed to supporting the primary care residency.