Management of behavioral healthcare services continues to grow and have an impact on service provision. Notwithstanding concerns regarding staffing issues, physician autonomy, and other treatment-oriented issues, the provision of behavioral health services is changing to adjust to the increased demands being placed upon psychiatrists to provide more cost-effective care. Michael J. Bennett (1) summarized some of these changes when he wrote that the psychiatrist " is more likely to be valued for his or her proficiency as a psychopharmacologist, diagnostician, accessible and communicative collaborator, and an expert in the management of chronic and major forms of mental disorders." This change reflects the reallocation of direct provision of services by psychiatrists to that of leading and managing a team of practitioners of varying educational and skill levels.
Psychiatry residents traditionally receive limited training in how to work in a managed-care setting. Currently, limited resources hamper the ability of departments of psychiatry to acquire current state-of- the-art knowledge from managed-care experts. A comprehensive training experience should include both didactic and clinical activities. In this article, we describe one approach to overcoming these limited resources through the use of telemedicine in teaching managed care through the use of presenters at distant sites.
The changing health-care delivery environment has, and will continue to force psychiatrists to become familiar with the concepts and needs of behavioral health care organizations. Of interest, a recent survey (2) of managed behavioral health organizations (MBHOs) revealed that there was a critical need for the education of providers on the specific skills and knowledge critical to working successfully in a managed-care environment. This survey identified a number of skills and knowledge deficits that impeded a good working relationship with managed- care organizations. These included 1) designing, documenting, and implementing problem-oriented, goal-focused treatment; 2) developing realistic treatment plans; and 3) understanding the principles of quality management.
Interestingly, the respondent organizations agreed that behavioral health providers needed to be trained in the identified areas of knowledge deficits, but did not provide that training themselves or provide information on training resources other than in those cases where the need directly affected the providers' responsibility to the MBHO.
Some forward-looking psychiatric training programs have reported their, albeit limited, experience in training psychiatrists in the principles of managed care. The Harvard Longwood Psychiatric resident training program (3) conducted a 3-year experimental program at Harvard Pilgrim Health Care, a large HMO, regarding this need to provide training in managed care to its psychiatry residents. Third-year residents were placed on site at Harvard Pilgrim Health Care, a large combination staff- and group- model HMO, 20 hours per week, for a 6-month clinical rotation. This training focused on providing residents with on-site training in outpatient psychiatry in an integrated staff-model delivery setting. Residents were assigned a patient caseload and were provided supervision by psychiatrists on site. Also, residents participated in the observation of treatment provided by the non-M.D. clinicians and attended scheduled weekly team meetings to help them develop a better understanding of an integrated staff- model delivery system. Another approach developed to meet this need (4) utilized a combination of role- playing activities and case-oriented instruction to provide residents and medical students with training in the effects and origins of managed care. The principles of cost-containment and delivery of quality care were also taught. Evaluation of the seminar was conducted by use of a semistructured questionnaire that focused on what the participants learned, any change in attitude, response to the seminar format, and any behavioral changes noted as a result of the seminar.
These two earlier efforts identified the need to provide training and education regarding the impact of managed care on the practice of psychiatry but provided limited recommendations regarding specifically what areas of additional training would be of benefit. Recognizing this need to better educate psychiatrists regarding managed care and the shortage of experts available, the authors undertook a new teaching program utilizing experts in managed care, brought to psychiatric residents via a telemedicine interactive link-up. Using a consultative process between participants at Wake Forest University, University of Cincinnati, and East Carolina University, a core curriculum of 10 content areas was developed, incorporating some of the results of the survey of MBHOs (2). The following is a description of our initial experience with this program.
East Carolina University and Wake Forest University, utilizing telemedicine link-ups between its campuses and the individual presenters at their distant sites, provided 10 seminars to its third- and fourth-year psychiatry residents. Presentations were 1 hour in length, with each topic directed toward providing core information on a specific area of managed behavioral health care. Residents were provided with presentation outlines and required readings from the course text as well as related articles that they were to review before each presentation. The seminar text, "The Textbook of Managed Behavioral Healthcare," by Gayle Zieman, was chosen (5) because it offered a concise, comprehensive overview of many of the managed-care topics covered during the course.
Presentations, whenever possible, were interactive between sites, with residents able to ask questions directly to the presenter and residents at the other site. Also, both presenters and residents were able to directly observe one another during the presentation through use of the videoconferencing link- ups. These interactive two-way video link-ups utilized the telemedicine and distance-learning capabilities at East Carolina University School of Medicine and Wake Forest University School of Medicine. These two locations are part of a state-funded network, North Carolina Research Education Network (NCREN), that connects state universities with one another to foster research and education. NCREN functions as a bridge between the participating sites within the state and uses both a digital and/or analog connection over a dedicated microwave system that broadcasts at 30 frames per second. Seminar presenters that had access to this in-state system utilized sites at East Carolina University (ECU), Wake Forest University (WFU), and University of North Carolina— Chapel Hill for broadcasting their presentation to ECU and WFU. Presenters at sites located in other states utilized the systems available at their respective universities, and in two instances where presenters were not part of a university setting, local cooperative universities were used. ECU functioned as the bridge in these instances where multi-point video connections were utilized and provided the technical support to the presenters' site as well as the connection to MCNC for transmission to WFU School of Medicine. Types of connections between ECU and the presenters' site varied from Integrated Service Digital Network (ISDN) connections at 384 kps or T1 connections at 768 kps, depending on the technology available at each distant site. Individual presentations were also videotaped to allow for review at a later time and to accommodate those individuals who were unable to attend the live presentations.
Individual presenters were chosen on the basis of their specific interest and knowledge in related areas of managed behavioral health care and willingness to present over the interactive telemedicine link-ups.
This article describes a pilot teaching program (t1) designed to expose psychiatric residents to issues identified by MBHOs as critical to successful psychiatric practice in a managed-care setting. We report our preliminary experience in utilization of interactive telemedicine linkage of psychiatric residents to experts on managed-care concepts. Informal evaluation after the course showed that seminar topics and presentations were generally well received by residents. Problems were reported regarding some of the technical aspects of the telemedicine connections, with the quality of some video and audio connections being poor and difficulties with interactive discussions because of the slight time delays in the video and audio components between the multiple sites. Also, some residents felt that the telemedicine system was not as conducive to presenter/participant interaction as an in-person presentation by the speaker. Of interest, open discussion during the seminar tended to reveal frustrations that individual residents had regarding personal interactions with an MBHO, for example, "peer reviews" for inpatients, not understanding the MBHO's documentation/necessity of "need guidelines," as well as a lack of clarity regarding provider responsibilities and liabilities. At the conclusion of the series of seminars, residents remained confused and concerned about the effect managed care could have on their future income and how to negotiate and understand contracts with MBHOs; there was also a fear of losing control over the patient/physician relationship.
Presenter feedback regarding their experience noted some difficulties with the quality of both the verbal and visual connections. Presenters also noted their lack of familiarity with the use of interactive videoconferencing and a need to better understand its current capabilities and limitations. Also, they identified a number of additional topics that they felt would be relevant on the basis of the interactions that they had had with the residents at ECU and WFU. These included discussions related to credentialing, capitation, utilization management, the future of managed care, documentation, and the economics of managed care (6).
Costs related to use of the videoconferencing link-up varied depending on the location of the individual presenter sites. A majority of the presenters were part of a university system, and there were no additional costs associated with their participation because this activity was considered part of their academic duties. Presentations that originated from one of the in-state sites connected to the NCREN systems incurred no charges to ECU because the costs of use of that system is funded by state monies. Costs related to distant sites outside of this system varied from location to location and were primarily the costs of utilization of the telephone lines for the ISDN connections. These costs averaged approximately $284.00 per hour plus a bridging connection fee that ranged from an additional charge of $35—$65 per connection, depending on the participating telephone company. All but one university site provided us with use of their facilities without charge. This one site charged ECU a user fee of $480.00 for down-link services and use of facilities; these costs may have been related to the fact that the presenter was not part of the university system at that location. These costs were considerably less than the cost of bringing individual presenters to ECU for their presentation and the costs associated with honorarium fees and related travel costs. These potential honorarium and expense costs were estimated to be approximately $1,500.00 per presenter. The total costs per presentation ranged from no cost—associated with those presentations that originated from one of the North Carolina sites— to a high of $480 dollars, for the most expensive hook- up fees that we incurred. These cost savings of approximately 66%, or $1,000 per presentation, are increased when we consider that these expenses could be shared proportionally with each of the sites to which the presentation is broadcast.
The training of psychiatric residents in the area of "managed behavioral care provision" poses a significant challenge to academic programs. Few current faculty members are specialists in the field of managed care and are able to adequately educate residents on managed-care issues. Also, there remains substantial resistance from some academic practitioners to the reality of managed care. These problems are compounded by the complexity of managed behavioral care issues currently implemented, as well as those undergoing change under the forces of legislation and macroeconomic realities.
This pilot project suggests a model that helps alleviate the shortage of qualified managed-care specialists interested in teaching by using telemedicine and interactive participation across a variety of teaching settings. We propose that this program model represents a cost-effective and efficient method of educating psychiatric residents by overcoming the lack of local expertise in many academic settings, while still providing a quality educational experience.