Franklin Square Hospital Center Department of Family Medicine ” “’Tales From the Other Side’: Partnering with a Managed Care Organization in Residency Education Netra Thakur MD MPH Franklin Square Hospital Center Department of Family Medicine Patryce Toye MD Medical Director MedStar Family Choice Baltimore, MD

BACKGROUND How do we give residents adequate skills to function in a managed care environment?

BACKGROUND RWJ funded initiative PQE (Partnerships in Quality Education) Why It Didn’t Sustain? Backlash at Managed Care Unstable Partnerships Crowded Curriculum Stretched Faculty Did it really improve outcomes? http://www.rwjf.org/reports/npreports/pqe.htm (Accessed on April 24 2008) This initiative has morphed over the years. Din’t succeed because of 1) faculty negative view of Managed Care and therefore perceived low priority to connect with 2) perception from the academic sidethat there wasn’t enough time or resources to devote to teaching

BACKGROUND WHY? RRC requires… Alumni request… Systems Based Practice competency Prepare residents for the real world MCO’s motivation to have prepared physicians enter the network Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: o work effectively in various health care delivery settings and systems relevant to their clinical specialty; o coordinate patient care within the health care system relevant to their clinical specialty; o incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate; o advocate for quality patient care and optimal patient care systems; o work in interprofessional teams to enhance patient safety and improve patient care quality; and o participate in identifying system errors and implementing potential systems solutions. [as further specified by the RC]

BACKGROUND WHO? Unique partnership between FSH Family Medicine and MedStar Family Choice Community Hospital Family Medicine Residency Program A Medicaid managed care only MCO covering 22,000 patients FHC covers 4,000 of these patients Engaged MCO Staff in residency education

METHODS HOW? Scheduling into the Residency Curriculum Third year residents Two 2 hour sessions during 2 four week ambulatory rotations Developing the Curriculum MFC director and residency faculty met to establish important core concepts MFC staff chose topics based on their assessment of residents’ needs

METHODS WHAT? Content divided into four modules Each module lasts 2 hours, with approximately 4 content areas each

CONTENT MODULE C MODULE A MODULE D MODULE B Follow the Claim from Encounter to Check Prior Authorization InterQual and UR Denials and Appeals MODULE D Delmarva, PIPs, HEDIS, NCQA Outreach Initiatives in Support of QA The Diabetes Initiative Momma and Me Value Based Purchasing and P4P MODULE A Types of MCCs Risk Contracting, Carveouts and Networks The Role of the Medical Director Case Management MODULE B Structure of a Health Plan Credentialing and Contracting Outreach Pharmacy and Formulary Disease Management

CONTENT Assigned Reading: Managed Care: What It is and How It Works: Peter Kongsvedt

LESSONS LEARNED Scheduling Issues Not all residents can complete all four modules Modify module content to cover important goals 2007-2008 resident schedule went from monthly to “block rotations”

LESSONS LEARNED Class of 2006 Resident Feedback: “participate with actual patient interaction for outreach program” “less information per session” “pre and post test” “make it 10-12” “don’t need book unless you want to pursue... this as a career” Did your experience improve your understanding of: The resources of a Medicaid MCO, importance of partnering with case managers, roles of staff at MedStar FC, did you read the text? For each component of the modules, we asked whether they agreed on the usefulness

LEARNER ASSESSMENT 2007-2008: Pre and Post Test: Short answer vs. multiple choice? Post-Grad survey of Class 2006 and 2007 8/16 responded Class 2006: no exposure Class 2007: 1st class to undergo curriculum

POST-GRAD SURVEY 2006-2007 1) Realizing the importance of partnering with case managers to improve health outcomes and system performance: 2007 N=3 1.6 2006 N=5 2.6 1 2 3 4 5 Very Comfortable Very Uncomfortable 2) Understanding the resources and benefits a Medicaid managed care organization can offer a population: 2.0 2007 N=3 2.4 2006 N=5 1 2 3 4 5 Very Comfortable Very Uncomfortable

POST-GRAD SURVEY 2006-2007 3) Understanding risk contracting, carve outs and networks: 2007 N=3 2.6 2006 N=5 3.2 1 2 3 4 5 Very Comfortable Very Uncomfortable 4) Negotiating contracts with third-party payors: 2007 N=3 4.0 2006 N=5 3.4 1 2 3 4 5 Very Comfortable Very Uncomfortable

POST-GRAD SURVEY 2006-2007 5) Practicing with awareness of formulary restrictions: 2007 N=3 1.3 2006 N=5 2.6 1 2 3 4 5 Very Comfortable Very Uncomfortable 6) Processing/initiating appeals and streamlining the prior authorization process: 2007 N=3 1.3 2006 N=5 3.0 1 2 3 4 5 Very Comfortable Very Uncomfortable

POST-GRAD SURVEY 2006-2007 7) Understanding the flow of billing: 1 2 3 1.6 2006 N=5 3.0 1 2 3 4 5 Very Comfortable Very Uncomfortable

STRENGTHS Ease of Partnership Flexibility of MCO staff to tailor to individual resident Protected place in curriculum for important content Clinically relevant to patients in residency training program Personal relationships develop with insurance staff

FUTURE PLANS Try to make early assessment of resident’s needs Emphasize contracting with third party payors within overall curriculum Allow easy flow of topics for residents to accommodate different schedules Offer to other residency programs within the hospital (OB and IM)

FUTURE PLANS Arrange a workshop for senior residents that addresses practical concerns Assign a case manager to resident in beginning of training Introduce important concepts into curriculum earlier

THANK YOU Netra.Thakur@medstar.net