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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?

Experts Say More Med Students Good News for U.S. Health Care

Fresh data released just last week demonstrates that new student enrollment at medical schools is on the rise nationwide.

Paul DeMiglio

Paul DeMiglio

The Association of American Medical Colleges (AAMC) announced Thursday that the total number of those who applied to and were accepted into medical school grew by 6.1 percent this year to a record 48,014. This figure beats out
— by 1,049 students — the previous all-time high set in 1996. The AAMC, which represents U.S. hospitals, health systems, Department of Veterans Affairs medical centers, academic societies and 141 accredited U.S. and 17 accredited Canadian medical schools, also found that:

  • The number of first-time applicants climbed to 35,727 (5.5 percent increase).
  • The number of students enrolled in their first year of medical school went past 20,000 for the first time. 

“At a time when the nation faces a shortage of more than 90,000 doctors by the end of the decade and millions are gaining access to health insurance, we are very glad that more students than ever want to become physicians. However, unless Congress lifts the 16-year-old cap on federal support for residency training, we will still face a shortfall of physicians across dozens of specialties,” AAMC President and CEO Darrell G. Kirch, M.D. said in a statement. “Students are doing their part by applying to medical school in record numbers. Medical schools are doing their part by expanding enrollment. Now Congress needs to do its part and act without delay to expand residency training to ensure that everyone who needs a doctor has access to one.”

Record-breaking enrollment is also being seen at colleges of osteopathic medicine, where 20% of medical students are enrolled. Although they make up a smaller number of students, their growth rates increased even faster. In an announcement released Wednesday by the American Association of Colleges of Osteopathic Medicine (AACOM), experts say this trend will help offset the looming primary care crisis that will result from a growing shortfall in the number of doctors.

Enrollment at colleges of osteopathic medicine has almost doubled over the past decade, with the number of students who applied this year hitting 16,454. Other key findings, according to AACOM, show that:

  • Osteopathic medical colleges saw an 11.1 percent increase in first-year student enrollment for 2013, bringing total enrollment to 22,054.
  • 4,726 new osteopathic physicians graduated this past spring, representing an increase of more than 50% over the number of such graduates 10 years ago.

“Because large numbers of new osteopathic physicians become primary care physicians, often in rural and underserved areas, I’m hopeful that the osteopathic medical profession can help the nation avoid a primary care crisis and help alleviate growing physician shortages,” Stephen C. Shannon, DO, MPH, President and CEO of AACOM, said in a statement. “Interest in osteopathic medical education is at an all-time high.”

Primary care physicians are expected to be hit harder than any other specialty, with a projected shortage of about 50,000 by 2025. 

So what exactly is osteopathic medicine and osteopathic physicians (DOs)? According to AACOM, which represents the nation’s 30 colleges of osteopathic medicine at 40 locations in 28 states, DOs offer a comprehensive, holistic approach to medical care.

One in five medical students are now enrolled in osteopathic medical schools, and this percentage will grow even more as new campuses open and colleges continue to expand to keep pace with more students.

Now it’s your turn. What are potential advantages and disadvantages of more medical school graduates – to cost, care and access? Will the rise in new enrollment be enough to offset expected physician shortages? Tell us what you think.

(Medical) Home is Where the Care and Cost-Savings Are

The word “home” has many connotations: the building in which you live, the place you come from, and even the end point of a game. Now, there is a new type of home: The Patient-Centered Medical Home (PCMH).

Linda Barlow

Linda Barlow

PCMH is a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety. It has become a widely accepted – and cost-effective – model for how primary care should be organized and delivered, encouraging providers to give patients the right care in the right place, at the right time and in the manner that best suits their needs.

“The magnitude of savings depends on a range of factors, including program design, enrollment, payer, target population, and implementation phase,” explains Michelle Shaljian, MPA, Chief Strategy Officer of the Patient-Centered Primary Care Collaborative (PCPCC). “Most often, the medical home’s effect on lowering costs is attributed to reducing expensive, unnecessary hospital and emergency department utilization.”

When the Affordable Care Act (ACA) was signed into law in 2010, medical homes got a boost because of numerous provisions that increased primary care payments, expanded insurance coverage and invested in medical home pilots, among other programs.

The model has been adopted by more than 90 health plans, dozens of employers, 43 state Medicaid programs, numerous federal agencies, hundreds of safety net clinics and thousands of small and large clinical practices nationwide since then. Among the results:

  • In Michigan, Blue Cross Blue Shield – the nation’s largest PCMH designation program — saved an estimated $155 million in preventative claim costs over the first three years of implementation.
  • CareFirst Blue Cross Blue Shield in Maryland reported nearly $40 million savings in 2011 and a 4.2 percent average reduction in expected patient’s overall health care costs among 60 percent of practices participating for six or more months.
  • In New York, the Priority Community Healthcare Center Medicaid Program in Chemung County saved about $150,000 or 11 percent in the first nine months of implementation, reduced hospital spending by 27 percent and reduced ER spending by 35 percent.
  • In Pennsylvania, Pinnacle Health achieved a zero percent hospital readmission rate for PCMH patients versus a 10-20 percent readmission rate for non-PCMH patients.

The PCPCC is the leading national coalition dedicated to advancing PCMH. According to PCPCC, the medical home is an approach to the delivery of primary care that is:

  • Patient-centered: A partnership among practitioners, patients and their families ensures that decisions respect patients’ wants, needs and preference, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: A team of care providers is accountable for a patient’s physical and mental health needs, including prevention and wellness, acute care, and chronic care.
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients access services with shorter wait times, “after hours” care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

According to Melinda Abrams, Vice President of Patient-Centered Primary Care Program at the Commonwealth Fund, to have the greatest impact, a medical home must be located at the center of a “medical neighborhood” inhabited by hospitals, specialty physicians, physical therapists, social workers, long-term care facilities, mental health professionals and other service providers. She notes that it is the role of the primary care provider to coordinate care and make sure that patients don’t slip through the cracks, or receive tests or procedures they’ve already had – a particular concern for patients who see multiple doctors.

The National Committee for Quality Assurance (NCQA) – a non-profit, independent group dedicated to improving health care quality – accredits and certifies a wide range of health care organizations and is the leading national group that recognizes PCMH with the most widely adopted model. Currently, there are almost 5,000 NCQA Recognized PCMHs across the country.

Other organizations with PCMH recognition programs include Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), the Joint Commission, and URACVideos from the American Association of Family Physicians (AAFP) feature family physicians who discuss practice redesign aimed at lowering costs, maximizing staff expertise and improving patient care.

“Practices seeking to initiate a patient-centered medical home will find that an assessment process is very helpful to understand where they are,” said Shaljian. “Some practices have electronic health records, a very strong history of team-based care, and strong connections with specialists, hospitals, and other stakeholders in the community, while others do not. Some are deeply affected by an internal culture of quality improvement, which makes a huge difference in how successful some medical homes are.”

Want to learn more about PCMH? Visit the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality content-rich Resource Center.

How can health care continue to move the nation to PCMH? And how can the model tackle its number-one challenge: the current fee-for-service payment system?

Striking the Right Balance for Better Patient Outcomes

A recent article in Health Affairs reports that ChenMed – which serves low-to-moderate income elderly patients primarily through the Medicare Advantage program – is achieving better health outcomes for Medicare-eligible seniors, including those living with five or more major and chronic health conditions.  Dozens of Chen and JenCare Neighborhood Medical Centers are helping tens of thousands of seniors live better, longer: 

chris_chen

Dr. Christopher Chen, ChenMed CEO

  • Total hospital days per 1,000 patients at ChenMed in 2011 were 1,058 for the Miami area in comparison with 1,712 total US hospital days per 1,000 patients in the same year (Centers for Medicare and Medicaid Services Office of the Actuary).
  • Just one year prior, according to Dartmouth Atlas of Health Care, the Miami Hospital Referral Region was above the 90th percentile in inpatient hospital days.

Why is ChenMed so successful?

Dr. Christopher Chen, CEO of the organization, says its patient care model integrates cutting-edge medical expertise in a way that empowers physicians to ensure patients receive personalized attention and optimal care.

“People always ask, ‘What is your secret?’ There really is no secret,” he says. “It comes down to having the right incentives, the right physician and staff culture, and the right philosophy of care. My goal at the end of the day is to be cost-effective through improvement of outcomes by changing the philosophy of care. We care about results.”

The group practice’s popularity also attests to its effective one-stop-shop approach to patient-centered care through multi-specialty services. Smaller physician panel sizes of 350-450 patients spur intensive health coaching and preventive care, and prescriptions are given to patients during their visits at all Chenand JenCare Neighborhood Medical Centers.

This aspect of ChenMed’s model makes the biggest difference in boosting medication adherence, followed by strong one-on-one doctor-patient relationships that help to change habits for the better. Receiving meds within 3-5 minutes of ordering drugs not only means patients don’t have to wait for the treatment they need, but that they receive their medications while having face-to-face interactions with their primary care doctors.

“In our model we aren’t looking for high-income patients,” Dr. Chen says. “People ask, ‘Are you saying that patients like you because you give more attention to them and provide more access to doctors than those who pay for concierge service?’ I would say yes.”

ChenMed continuously employs top specialists from a variety of fields to conveniently provide fully integrated medical services to patients.  It effectively combines services like acupuncture into its portfolio of care, and improves outcomes and patient experience with customized end-to-end technologies enhancing its daily operations. For example, all the medical assistants and staff are equipped with iPads and can offer physician support tailored to each patient. This fuels collaboration, enabling doctors to work side by side with patients and providing a significant convenience to all parties as a result.

Primary care physicians at Chen and JenCare Neighborhood Medical Centers also meet three times a week, engaging in thoughtful ongoing discussions that generate numerous enhancements to care and delivery for better outcomes.

“We discuss whether a hospitalization could be improved through better outpatient care. We ask, ‘What can we do to improve patient outcomes while the patient is in the hospital?’ We innovate to improve outcomes and can achieve great things for patients because of our small panel sizes. These meetings have saved many lives and continue to do so,” explains Dr. Chen.

When interviewing prospective doctors to work at ChenMed, they are asked whether they like spending time with patients and whether they love the complexity of medicine. If they say no to either of those questions, then this group is probably not the best place for them, Dr. Chen says, underscoring that:

“We want you to practice medicine the way you thought you would when you graduated from medical school. It’s not about how many patients you see, how many procedures you do, or how much you bill. You should want to be a doctor to make people feel better.” 

ChenMed, through its Primary Management Resources subsidiary, also provides behind-the-scenes consulting services to enhance medical practice operations nationwide.  Physicians interested in end-to-end solutions that streamline operations while enhancing patient health outcomes and the patient experience should contact ChenMed at (305) 628-6117 or go to ChenMed.com.