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MD and DO Medical Schools Consider Major Changes to Education Model

Experts from allopathic medical colleges (those that graduate MDs) and from osteopathic medical colleges (those that graduate DOs) have been actively exploring ways to lower the cost of medical and graduate school without sacrificing the quality of the education.

Paul DeMiglio

Paul DeMiglio

Groundbreaking recommendations were issued Monday that seek to improve osteopathic medical education in the U.S. and help fuel a new generation of primary care physicians who will be equipped to meet the demands of today’s changing health care landscape. One out of four students headed to medical school this fall are attending osteopathic medical school.

Released by the Blue Ribbon Commission (BRC) – a medical panel comprised of some of the nation’s leading experts in osteopathic medical education – the report (“A New Pathway in Medical Education”) coincides with publication of a related story in Health AffairsBRC aims to find a solution to the primary care physician shortage by transforming the osteopathic medical education model, reducing inefficiencies and addressing high costs as well as rising student debt.

Osteopathic physicians, or DOs, emphasize “helping each person achieve a high level of wellness by focusing on health promotion and disease prevention” through hands-on diagnosis and treatment, according to the American Association of Colleges of Osteopathic Medicine (AACOM). Licensed to practice in all 50 states, DOs work in various environments across specialties.

MD education experts also recognize an urgency for changing medical education. Transforming the way students are trained to practice medicine is key to improving access to quality care for patients, according to an October 30th Perspective article (“Are We in a Medical Education Bubble Market?”) that appeared in the New England Journal of Medicine (NEJM). The article underscores why lowering the cost of health care and reducing the cost of medical education go hand in hand.

“If we want to keep health care costs down and still have access to well-qualified physicians, we need to keep the cost of creating those physicians down by changing the way that physicians are trained,” the authors are quoted as saying in a news release from Penn Medicine. “From college through licensure and credentialing, our annual physician-production costs are high, and they are made higher by the long time we devote to training.” 

Cleveland Clinic, Ohio University Heritage College of Osteopathic Medicine Lead by Example
The Cleveland Clinic’s South Pointe Hospital is partnering with the Ohio University Heritage College of Osteopathic Medicine (OUHCOM) to implement the BRC findings through a new pathway that has five components:

  • Focus on community needs served by primary care physicians.
    Emphasize primary prevention and improvement of public health to raise the quality and efficiency of care.
  • Advance based on knowledge, not years of study.
    Build a curriculum that centers on biomedical, behavioral and clinical science foundations so that the graduates’ readiness for practice can be better assessed through outcomes specific to medical education.
  • Boost clinical experience.
    Offer clinical experience from the first year instead of doing so later on. Increase responsibility throughout the training, and streamline training between undergraduate and graduate school to avoid redundancies and inefficiencies.
  • Require a range of experiences.
    These should include hospital, ambulance, and community health systems to provide the best learning experience.
  • Require modern health system literacy.
    Focus on health care delivery science including principles of high quality, high value, and outcomes-based health care environments.

Dr. Robert S. Juhasz, DO, president of South Pointe Hospital, says that Cleveland Clinic and OUHCOM will work to develop a curriculum that emphasizes early clinical contact to ensure “we are providing the right care, in the right setting for the right person at the right time.”

The partnership, Dr. Juhasz says, “will transform primary care education,” and go far to help shift the focus of medical education “toward competency-based rather than time-based education. We want learners to be engaged, practice-ready primary care physicians and be equipped to care for the communities they serve.”

South Pointe, which has trained DOs for 40 years, is renovating its facilities to now accommodate OUHCOM. Starting in July, 2015 it will train 32 osteopathic medical student residents per class.

The implications of BRC’s recommended changes, according to Dr. Juhasz, “will enhance our primary care base for delivery of care in a patient-centered model, increasing access and quality and reducing costs,” while also cultivating a learning environment that will “encourage more students to enter DO and find hope and joy in serving patients so that they will want to work in the area they train.”

Lead author of the NEJM article — David A. Asch, MD, MBA, Professor of Medicine and Director of the Center for Health Care Innovation at Penn Medicine — says that medical colleges can play a critical role in helping to avoid a burst in the “medical education bubble.” One solution is for schools to lower the cost of tuition and reduce high debt-to-income ratios that could discourage medical students from pursuing careers in fields where more physicians are needed, including primary care.

“Doctors do well financially,” he says, “but the cost of becoming a doctor is rising faster than the benefits of being a doctor, and that is catching up to primary care more quickly than orthopedics, and that ratio is close to overtaking the veterinarians.”

Now tell us what you think. What ways do you think medical school could be overhauled? What incentives can be provided to attract more students to study medicine and become doctors, particularly in primary care, to help reduce the rising provider shortage?

Cleveland Clinic’s Value-Based Care Team Improves Patient Wait Times, Saves Costs

Cleveland Clinic CEO and President Toby Cosgrove, MD, believes that the medical center is ready to “lead the charge” in delivering better patient outcomes and faster care, all at a lower cost.

Dr. Toby Cosgrove

Toby Cosgrove, MD

To that end, the Cleveland Clinic has established a Value-Based Care Team, made up of physicians, nurses and other experts who will work together to translate “better, lower cost and faster” into everyday practice. Services are rationalized across the network, with multi-specialty teams using system-wide resources to deliver the right care at the right place for every patient, at the right time with the right cost.

“Value is the centerpiece of Cleveland Clinic’s strategy,” said Associate Chief of Staff for Clinical Integration Development, Dr. David Longworth, who heads the Clinic’s Value-Based Care Steering Committee. “We are focused on two areas. One is to eliminate unnecessary practice variation by developing evidence-based care paths across diseases. The other is comprehensive care coordination to allow patients to move seamlessly through the system so that we reduce unnecessary hospitalizations and ER visits.”

According to Dr. Longworth, the TeamCare model helps to:

  • Increase throughput.
  • Reduce the cost-per-unit of service.
  • Improve patient and provider satisfaction.

“In the past, each physician had one medical assistant who simply roomed the patient and took vitals,” he explained. “All the chart work was done by the physician, often at home in the evenings, adding several hours of work to their day and extra time to the entire process. Now, physicians go home at the end of the day with all their charts closed.”

The TeamCare model helps the Cleveland Clinic improve its Patient Experience ratings in a number of measured metrics, including:

  • 22.8 percent improvement in wait time at clinic.
  • 10.7 percent improvement in wait time in exam room to see provider.
  • 8.9 percent improvement in the time the provider spent with the patient.

While the Value-Based Care Team may be a concept borne of the new world of health care, the Cleveland Clinic has a rich history of improving patient outcomes. In 2000, the Clinic became the first hospital in the U.S. to publish its outcome measures and now publishes outcome books for every department, comparing itself to the best available benchmarks.

The Cleveland Clinic further changed the way it delivers care by developing Institutes to house medical and surgical specialties, working under one Institute leader and one budget. In some Institutes, inpatient and outpatient care are co-located, and Institute leadership is charged with defining what diseases and conditions each Institute cares for, developing a set of shared outcome measures for which the team is jointly accountable. Leaders also identify the skills that need to be brought together to care for patients with the sets of conditions the team treats.

Institutes are given autonomy to pursue different implementation approaches and are expected to share insights with others. For example, the Neurological Institute created a website so that others at the Clinic could learn how it was developing performance measures and decide whether to use a similar approach.

In the case of a primary care pilot program, Value-Based Care relies on a team approach that leads to a higher-efficiency practice style. Responsibilities are shared among two medical assistants and the physician, with each individual functioning to the highest level of their scope.

For each patient visit, a medical assistant brings the patient to a treatment room and obtains vitals and additional medical history information, which they immediately enter into the patient’s electronic medical record. The medical assistant remains in the room during the examination, acting as a real-time transcriber for the doctor’s notes and orders, which are also sent immediately to the physician’s inbox for verification and signature so the assistant can schedule any follow-up tests or procedures before the appointment is complete. At the same time, the physician’s second medical assistant is getting the doctor’s next patient set up in another treatment room.

Value-Based Care also helps the Clinic reduce costs. In fact, in just under a year, the direct cost per patient encounter dropped by 7.5 percent while the number of patient encounters per day increased by 16.4 percent.

The hospital lowers costs in other ways as well, such as avoiding 12,082 lab tests in 2011 and 2012 for a savings of $1.2 million and lowering the cost of lung transplant surgery by 11 percent. Cleveland Clinic also is getting patients into treatment faster, with the total number of same-day visits increasing by 14 percent and the average emergency room door-to-doctor time reduced to 17 minutes.

These strides are helping Cleveland Clinic reach the Top 20 of the University HealthSystem Consortium’s (UHC) quality index, earning UHC’s Rising Star award by improving inpatient centeredness, mortality, equity, efficiency, effectiveness and safety.

The Cleveland Clinic model is a good example of how health systems can develop evidence-based models to generate higher quality care at a lower cost. What are other hospitals and health systems doing to redesign care delivery paths? Let us know what’s working.

Categories: Cost-Savings