Specific Clinical Competencies for Managing Care: Title and subTitle BreakViews of Residency Directors and Managed Care Medical Directors FREE

Educators widely acknowledge the need to promote competencies essential to effective managed care practice.^{1 - 3} However, broad segments of the academic community appear to have negative attitudes about managed care,⁴ which may impede systematic efforts to develop consensus on priorities for training new physicians to be effective in a changing practice environment.

While educators have outlined domains of knowledge central to managed care practice,^{5 - 7} these prescriptions generally have failed to define specific tasks and behaviors in which residents and medical students should be competent. At the same time, leaders of managed care organizations (MCOs) also have identified key areas of competence that are lacking in many graduates of US residency programs.^{8 - 11} Residents themselves have indicated that they feel unprepared to work in managed care environments.^{12 - 13} Many residency programs have responded to these challenges by locating training in managed care settings, but there is growing recognition that training in these settings alone does not necessarily prepare residents for managed care practice.^{1 ,5 - 6 ,14}

We designed a study to identify managed care functions that leaders in education and practice may view as central to effective practice over the next 5 years. We first surveyed a group of residency program directors engaged in developing managed care curricula, and used their input to define specific managed care competencies and related tasks they expected residents to learn as a result of the new training. To partially validate that residency directors believed such tasks were sufficiently important to be emphasized in the implementation of their programs, we then surveyed the residents in their programs to assess whether reported mastery of these tasks differentiated those who received managed care training from those who did not. Finally, we surveyed a nationally representative sample of residency program directors and MCO medical directors to address 2 questions: (1) Do leaders in education and practice endorse the importance of these tasks to future medical practice? (2) To what degree is there agreement between these 2 groups of leaders on the managed care tasks new physicians should be able to perform?

In March 1998, we surveyed 63 residency program directors who had joined with MCOs in association with Partnerships for Quality Education (PQE) to develop models for training physicians to provide high-quality, cost-effective managed care and to encourage MCOs and academic medical centers to become partners in education and research. Our aim was to draw on their expertise to identify essential tasks associated with managed care competency areas.

To develop the survey, competency areas were initially identified from appropriate literature, relevant reports, and existing curricula. A content analysis of the funded proposals from the 63 PQE programs expanded the range. In the survey, we provided examples of managed care competency areas and associated tasks, grouped into 4 categories: patient care, performance monitoring, teamwork and coordination of care, and organizational issues in managed care. Taking account of their program mandate to initiate new training for effective practice in the managed care environment, respondents were asked, first, to add to the competency areas and to supplement and refine the associated tasks and, second, to indicate tasks for which performance would differentiate residents who participate in their new training from those who do not. Surveys were completed by 59 of the 63 residency program directors for a response rate of 94%.

To identify a set of exhaustive, mutually exclusive managed care tasks, responses of these 59 residency directors were subjected to content analysis. The emerging compilation was shared with a subgroup of residency directors as well as MCO medical directors who confirmed the relevance of the items.

In November 1998, residents in the 63 PQE programs were surveyed. To partially validate the importance attributed to these tasks by PQE program directors, we sought evidence that the tasks were emphasized in their training programs. The sample included residents from each program who completed the managed care training and a comparison group of non-PQE residents, matched by postgraduate year and specialty. In most cases, the comparison group consisted of residents in the same training programs who were scheduled to participate in PQE training at a later time; in a few instances in which this was not feasible, the comparison group was selected from other settings or programs, also matched by specialty and postgraduate year. The survey questionnaire asked residents to report their level of confidence in performing each of the managed care tasks identified by residency directors in the earlier survey as warranting new training (using a 4-point Likert-type scale; 1 = least confident and 4 = most confident). As many as 3 waves of questionnaires were distributed, and reminder telephone calls were made to nonrespondents. Completed questionnaires were received from 77% of the residents surveyed (186 respondents in the PQE group and 258 in the comparison group). Respondents and nonrespondents did not differ with regard to individual characteristics (eg, training site, postgraduate year, sex, race/ethnicity, marital status).

Differences in self-perceived confidence in performing the tasks among PQE participants and their comparison-group counterparts were assessed through a series of t tests. In each case, comparisons were made only among residents in programs that offered training that covered the task under consideration (ascertained from the survey of program directors); our intent was to maximize the extent to which differences may be associated with PQE training.

In July 1999, we surveyed managed care medical directors and residency program directors to elicit and compare their views of priorities for future training in population health. In designing the sampling frame, we matched residency programs and MCOs by region in 21 markets with high managed care penetration. This strategy was guided by the assumption that there may be distinctive needs or conditions confronting MCOs in a given market that may have implications for training priorities, which argues for selection of residency programs in the same region. Residents often seek their first jobs in the same region that they train; thus, surveying MCOs in the same market ensured that we elicited the views of their potential employers. Finally, emphasizing high market penetration ensured that we gathered the input of those who are actively involved in recruiting physicians.

We used a 2-stage approach to sampling. First, metropolitan statistical areas (MSAs) were selected based on the following criteria: (1) managed care market penetration in the top quartile (the ratio of the number of individuals enrolled in MCOs to the total population of the MSA, which ranged from 0.35 to 0.71); (2) broad geographic distribution; and (3) presence of academic medical centers. Market penetration data were provided by InterStudy Publications.¹⁵

Twenty-one of the 87 MSAs in the top quartile of managed care market penetration were selected, with broad geographic distribution and representation of mostly large and medium-sized markets (57% were large markets, with populations of more than 1 million, while 38% were medium-sized, with populations between 250,000 and 1 million). Within each selected MSA, directors of all residency programs in internal medicine, family medicine, and pediatrics (with the exception of those who directed PQE programs) were included based on current Accreditation Council for Graduate Medical Education lists. All MCOs in each MSA having an enrollment of 50,000 or more members (25,000 for MCOs serving primarily Medicaid populations) were included. Our primary source for identifying MCOs in each MSA was the online database of the Managed Care Information Center National Directory of Managed Care Organizations,¹⁶ which collects detailed information on MCOs through an ongoing national survey. This database was checked against the following sources for additions and deletions: InterStudy data on these MSAs¹⁵ ; lists provided by state and local health departments, Medicaid offices, and insurance departments; insurance industry reports; Health Care Financing Administration lists (for Medicaid MCOs); the National Committee for Quality Assurance Quality Compass; and the membership roster of the American Association of Health Plans. In addition, we contacted approximately 60% of the sample of MCOs directly by telephone to verify the accuracy of our information.

This process culminated in a final sample of 218 MCO medical directors; 7 from our initial list were eliminated because they no longer provided coverage in the MSA, 29 had gone out of business or merged with another MCO, and another 12 did not have a medical director. The final sample of residency directors included 193 potential respondents; 3 residency programs did not have a director at the time of the survey and were eliminated.

Self-administered questionnaires focused on the 26 managed care tasks incorporated in the earlier surveys; respondents were asked to assess the importance of performance of each of these tasks to effective practice over the next 5 years. Response options were posed on a 4-point Likert-type scale (1 = very unimportant and 4 = very important). Three waves of questionnaires were sent, accompanied by a cover letter explaining the purpose of the study and instructions to fax back the completed survey. After the first wave, follow-up telephone calls were made to all nonrespondents, and new copies of the questionnaire were faxed to those with whom contact was made. This procedure was followed with a second mailing and further telephone contacts. Research staff made an average of 6 attempts to reach each nonrespondent by telephone. A third and final wave of questionnaires was faxed to those who had not yet responded.

Surveys were completed by 67% of managed care medical directors (147/218) and 73% of residency program directors (140/193). Respondents and nonrespondents did not differ by relevant characteristics of each group (eg, type of MCO, region, managed care penetration for MCO respondents; size, specialty, location of residency program for training directors). Table 1 and Table 2 present descriptions of the 2 samples of respondents.

To assess MCO medical directors' and residency program directors' views on the importance of the managed care tasks, their ratings of individual tasks were compared (t tests), as were their priorities among the tasks. The relative importance of the tasks was determined using within-subjects analysis of variance followed by post hoc, matched t tests with Bonferroni adjustment.

Analysis of residency program directors' responses yielded 26 managed care tasks (associated with 22 competency areas) that residents could be expected to perform when given adequate training in these areas (Table 3). A majority of the training programs sought to promote mastery of each of the tasks. Overall, 40% of the programs addressed two thirds or more of the tasks.

Participants in the PQE managed care training programs expressed more confidence in their ability to perform all 26 tasks than their non-PQE counterparts, and for 20 of the 26 tasks, they were significantly more confident (P<.01). Confidence in performing those managed care tasks that training directors reportedly emphasize in their programs differentiated residents who participated in such programs from those who did not. Overall, residents in both groups were more confident (P<.001) in performing tasks associated with patient care (mean, 2.81; SD, 0.54) compared with teamwork and coordination of care (mean, 2.74; SD, 0.57), significantly less confident (P = .008) with regard to performance monitoring (mean, 2.68; SD, 0.62), and least confident (P<.001) with regard to organizational issues (mean, 2.22; SD, 0.65).

Residency program directors as well as MCO medical directors, on average, rated 65% of the managed care tasks to be either somewhat important or very important to future practice. Examination of their assessments of the importance of ability to perform each task yielded only 10 significant differences among their 26 ratings (Table 3). Residency program directors were more emphatic than managed care medical directors regarding the importance of tasks related to evidence-based medicine (P<.001) and time management (P = .02), whereas managed care medical directors placed more importance on tasks associated with patient satisfaction (P<.001), practice profiling (P<.001), collaboration (P = .04), "gatekeeping" (P<.001), referral management (P<.001), provision of managed care resources to colleagues (P<.001), adherence to the regulations of multiple MCOs (P = .04), and reconciliation of treatment plans with contradictory guidelines among MCOs (P = .03).

For all respondents, 10 tasks were rated as significantly more important than the remaining tasks (P<.001 by within-subjects analysis of variance and post hoc, matched t tests with Bonferroni adjustment). Among these 10 most highly rated tasks (Table 4), 9 were identical for residency program directors and MCO medical directors. Both residency program directors and MCO medical directors rated tasks associated with the following areas of competence as among the top 10: time management, case management, ethics, practice guidelines, cost-effective clinical decision making, clinical epidemiology, disease management, referral management, and patient satisfaction. The exception was that evidence-based medicine was a top priority for residency program directors, while practice profiling was more important to medical directors.

For managed care medical directors, there were very few significant differences in average importance of these tasks by size of enrollment (1 difference among the 26 tasks), type of MCO (2 differences), profit status (1 difference), and Medicaid/non-Medicaid status (3 differences); there were no consistent patterns evident in these differences. There were no variations by managed care market penetration (see Table 1 and Table 2 for the range within the top quartile). For residency program directors, there were only 3 differences among the 26 tasks by specialty, 0 by size, and 0 by market penetration.

Residency program directors who were engaged in introducing new curricula to address population health collectively identified 26 managed care tasks requiring new training. These tasks, as distinguished from broad competency areas, were behaviorally defined, potentially observable functions. This degree of delineation was designed to yield a basis for focused curricular interventions. Reports of the importance of such tasks were validated by our finding in an independent set of surveys that self-confidence in performing these tasks consistently differentiated residents who participated in new managed care training programs from those who did not. Furthermore, the importance of mastery of these tasks to effective medical practice was substantiated by the views of national samples of MCO medical directors and residency program directors.

Residency program directors and managed care medical directors, 2 groups who may be expected to have disparate perspectives on the future practice of medicine, were remarkably similar in their views of the importance of specific tasks to effective practice. Their priorities among these tasks—ranging from competence with respect to practice guidelines to disease management, prevention, utilization management, cost-effective clinical decision making, and ethical issues—were almost identical. This consistency of views, regardless of organizational and financing arrangements and specialty, lends further evidence of the robustness of these findings.

Some may find it surprising that tasks associated with ethics and managed care (eg, acting on ethical principles to resolve conflicts that may arise if a physician decides that a patient needs procedures or services that are not covered by an MCO) were third in priority for both groups and that MCO medical directors placed slightly more importance on them than did their academic counterparts. Similarly, cost-effective clinical decision making was as highly valued by residency directors as by medical directors.

Practice profiling, referral management, "gatekeeping" skills, collaboration with other practitioners, acting on data on patient satisfaction, providing managed care resources to colleagues, and adhering to the guidelines of multiple MCOs were all more highly valued by MCO medical directors. These differences may reflect a belief among residency directors that competency in these areas is more easily developed on the job, subsequent to residency training. Greater concern about evidence-based medicine on the part of residency directors is understandable since it is crucial to instill early in training the ability to locate and critically evaluate research evidence and apply conclusions in routine care. The lower valuation on the part of their MCO counterparts (between somewhat important and somewhat unimportant), however, may signal later problems since it is equally important to sustain this perspective throughout the professional lives of physicians. It is also possible that the 2 groups may have had different understandings of the role of evidence-based practice. Despite their differences regarding these tasks, neither residency nor MCO medical directors considered any of the tasks to be unimportant.

Our findings are most likely generalizable to leaders of MCOs and residency training programs in MSAs with high managed care market penetration (in the top quartile) and presence of academic medical centers. The subset of the total population delimited by these sampling criteria was selected for having particular salience to the topic of the study. Initial specification of managed care tasks was governed by the responses of 59 residency directors who were engaged in implementing new curricula for managed care practice. While this approach may have favored the perspectives of academic physicians in delineating the range of tasks to be assessed in subsequent surveys, the 26 tasks established through this process are inclusive of general domains of knowledge deemed central to managed care practice by educational leaders as well as MCO leaders.^{5 - 11}

In conclusion, while recent surveys have documented considerable disaffection toward managed care among academic physicians,⁴ this negativism does not appear to have carried over to their views on the importance of teaching specific managed care tasks related to population health. In spite of fundamental differences on other health care issues, our findings indicate that residency directors and MCO medical directors place high importance on specific clinical behaviors and that they share a similar vision of priorities for applications to future medical practice.