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Monday, 6/30/97 Health care system reform group causes controversy EDUCATION: Managed care versus patient interest the crux to university doctoral faculty

By Kathryn Combs Daily Bruin Contributor While the American health care system rapidly changes to incorporate the efficient lessons of managed care, it is the physicians and medical students who are being left in the dark. The University of California, the nation's largest single provider of medical education and clinical care, houses more than 12,000 students annually who attend one of five UC medical campuses. The UC trains two-thirds of those entering the medical profession in California. As befitting the UC's significance, a Commission on the Future of Medical Education formed last August by UC President Richard Atkinsons is developing new initiatives to revamp medical education. The commission's recommendations are still under discussion, but have already met with some resistance from inside the system. The size, configuration and quality of California's health care workforce will be addressed by the commission, as well as ways that the UC could effectively fulfill the state's present and future health needs. The coming of managed health care in California is a pressing issue in health care, one that can not be ignored by either the medical schools or their students, said Dr. Charles Lewis, director of the Center for Health Promotion and Disease Prevention and a commission member. Managed care was first developed in the 1980s by companies who found the cost of providing health care for their employees to be too high. "General Motors (GM) and other companies started to realize that they were spending more on their health insurance than on their raw materials," Lewis said. Many corporations worked with insurance companies to provide medical benefits and health care for a preset number of employees, assigned to a specific group of doctors. Those doctors were paid a set amount of money per employee, regardless of services rendered. Many have condemned the results. "Cost control has occurred at the cost of doctor and patient autonomy," Lewis said, "and the constraints are being felt by all, particularly by physicians who have never operated in this environment before." Opponents of managed care argue that number-crunching priorities impinge on the traditional working of the medical profession. In the past, medical students have specialized, in fields such as neurosurgery or cardiology. But because of the nature of the managed care system, more primary care physicians are needed. "Primary care physicians (are) our gatekeepers," Lewis said. They keep the gate shut on access to high cost examinations and tests." Lewis, the only UC faculty member on the commission, said the preliminary findings of the commission released last October focused too much on managed care. "The commission's goals and outlines are overly influenced by the perspective that every graduate of the UC will end up working in a managed care program," Lewis said. He stressed that the commission needed to carefully consider the suggestions that they make to medical school faculty. "(According to) the bylaws of the university, only the faculty of the school of medicine may make changes," Lewis said. "(The faculty) has the responsibility to develop criteria for admission, establishing the curriculum and deciding who graduates," Lewis added. Michael Wilkes, chair of the UCLA doctoring curriculum and a professor of medicine, said that while the intent and purpose of the commission was appropriate, their awareness of the evolving health care system was weak. "The preliminary report had no connection with medical education," Wilkes said. "It would be like having an environmental policy for California drafted by people from the other 49 states without any clue as to what is going on first," he said. Wilkes stressed that managed care, although an important medical issue now, may not be as important in years to come. "Managed care is a fad, probably measured in single-digit years," Wilkes said. "We are doing an enormous amount in (teaching our students) the principles that underlie primary care," Wilkes said. "We would rather teach them the foundations of good practice ... but not teach them specific knowledge that would exclusively allow them to practice in a managed care institution," Wilkes said. "The message that we as medical students have begun to get is that health care is becoming more conscious of the market economy,"said Francis Chang,a third-year M.D. and Ph.D. student. "From talking to professors and other doctors, I've seen there are two sides. There are people who lament the passing of the golden age where you have doctor autonomy and the best interest of the patient at heart," Chang said. "And then there are others who believe that the system is bloated and that this will be an improvement of managing our resources,"Chang concluded. UCLA's medical students will be prepared to enter the medical field, according to Neil Parker, the associate dean of graduate school medical education. "The UCLA School of Medicine is already, and has been, teaching the students both about managed care and good management of care," Parker said. "The challenge that the students are going to face is an ever-evolving system of the economic care of patients," he said "Managed care is just another economic style of practice,"he said. "We've always managed care and existed with limited resources." Previous Daily Bruin Story Regents discuss ill health of UC med system, January 19, 1995