Editor’s note: This is the final article in a series examining who pays for medical education and the economic changes in Minnesota’s medical community that impact the University’s Medical School.

In an afternoon course titled “Justice: ethics in managed care,” medical student Julie Hodapp contemplated a hypothetical ethical dilemma: Should her hospital absorb the cost for treating an uninsured patient, or should she let the patient go untreated?
“Of course you find the resources,” Hodapp said.
The class is one among the numerous courses tucked and wedged into the first year of the University’s Medical School program.
A first year schedule reads like the periodic table; small blocks denote the hours, crammed with important, complex information. But unlike neuroscience or anatomy, an ethics tutorial does not factor into the students’ final grade. Technically, the lesson doesn’t count.
But University educators are counting on revamping the curriculum, adding attention to insurance and medical economics, to help students like Hodapp prepare for the ever-changing — and sometimes competing — demands of managed care and patients.
Educators fear that without this knowledge, new doctors from the medical school will not be prepared to handle insurance restrictions, and they will not be able to provide the best possible care.
Nearly 70 percent of Minnesota’s doctors graduated from the University Medical School, and their knowledge of HMO policies affects most Minnesotans.
With health care costs peaking at 13.6 percent of the national gross domestic product in 1995, Minnesota policy makers and patients turned to health maintenance organizations and the promise that a market-based system could contain runaway costs.
Few contested the HMOs’ initial success. It was the organizations’ methods — strict oversight and regulation — that soon enraged care providers. Doctors argued their mission was in jeopardy because the HMOs trimmed services in their efforts to cut costs.
Educators are now struggling to keep pace with trends dictated for the first time in their profession, not by medical breakthroughs, but by economics.
The rapid onset of health maintenance organizations in the Twin Cities left doctors and educators dizzy as the cost-conscious groups siphoned away their financial surplus and autonomy.
Therefore, medical schools and teaching hospitals, reliant on income from academic physicians and hospitals to host students, quickly joined the confused casualties of America’s health care reform.
Administrators at the University medical school are working physicians, so they have firsthand knowledge of the changes HMOs impose. Their message is clear: Negotiating for the needs of a patient is no longer a matter of medicine, but a sticky economic web.
And though managed care maintains a tight grip on Minnesota’s medical market, which claims 32.7 percent of Minnesotans covered by insurance, its lock on the minds of tomorrow’s doctors remains slack.
Family tradition
Managed care, coupled with the drive for a balanced national budget, has sent students and faculty reeling from budget cuts.
Hodapp’s taste of economic ethics is the University’s latest effort to rework its curriculum to keep in step with chaotic times.
Students in Hodapp’s class last spring broke into small groups to evaluate their options based on hypothetical patients. Most choices seemed simple, said Hodapp. But a few years down the road, she said, her options and choices may not be so clear.
Managed care caught her father, Dr. Robert Hodapp, off guard.
Julie Hodapp is the fourth generation of Hodapps to attend the University Medical School. She will be the first female M.D. in the family.
Dr. Robert Hodapp, a family physician, received no ethics or economics tutorials at the University in the early 1970s.
Robert Hodapp said although medicine and technology have evolved beyond his grandfather’s comprehension, some of his patients can recall receiving treatment at the hands of all three generations of Hodapps.
Managed care is a glaring example of how medicine has changed, Robert Hodapp said. Graduates like his daughter will need to be more financially responsible while practicing medicine than his generation. HMOs arrived in Willmar, Minn., well after he established his practice there 16 years ago, he said.
Hodapp now treats patients who are insured by HMOs, and the abrupt mid-career introduction to managed care methods has been difficult for him, he said. Long-time patients of Dr. Hodapp’s have switched doctors as HMOs approve one provider or another.
Clients may return as their insurance coverage evolves, but as a family physician, Dr. Hodapp values close connections with his patients. Losing patients can be difficult for any reason, he said.
“I sort of think of it as getting fired by my patients,” he said.
His daughter will need to better understand the insurance organizations, he said. It is the University’s responsibility to prepare her and her colleagues for the reality of the medical market, he said.
“Where else is she going to learn it?” asked Julie Hodapp’s grandfather, Dr. Robert Hodapp. A 1946 graduate of the University Medical School, Dr. Robert Hodapp practiced in Willmar alongside his father from 1949 until his father’s death in 1960. Julie Hodapp’s grandfather, like her great-grandfather, made house calls and carried the physician’s traditional black bag.
“I had a black one, followed by a brown one. And I used it quite a lot,” he said. However, money wasn’t a factor in his prescriptions.
Julie might not have a traditional doctor’s black bag when she begins her practice, but all three agree that insurance payments and HMOs will be a significant part of her experience.
Drama, not substance
As University professors weigh economic education against the essentials of basic science, they are struggling to finds ways to work it into the school’s tight schedules.
Despite introducing the unorthodox ethics in managed care course in 1993, University faculty members share the same concern as community doctors, the state’s health care insurers and their students: The class only scratches the surface.
“A lot of drama, not a lot of information,” Julie Hodapp said of the ungraded freshman seminar. She has received no further ethics instruction in her second year, she said.
She said she remains at a loss as to how the insurers operate or how and why patients join. “It’s a huge gap in my understanding,” she said.
With no formal classes on navigating the health care marketplace, faculty have begun to carve time from their regular lecture hours to dedicate them to primers on insurance and rudimentary economics.
Progress has been slow, said Dr. Charles Boult, a family practice and community health associate professor.
As the chairman of the committee responsible for slipping more HMO information into the class schedule, Boult coordinated a small group of faculty, students and a representative from the Minnesota Council of Health Plans to find room within the existing curriculum.
It is not an easy task, he said, because resources are finite and students are unaware of the depth of the changes in medicine.
“In general, the medical students that I have been in contact with are very poorly prepared for this area,” he said. “They just don’t understand much about managed care or allocation of resources.”
Boult’s colleague Dr. James Pacala designed a three-hour lab on HMO education. When the two professors initiated the crash course, the associate professor could name only one other professor in the medical school who set aside two hours to address the issues of HMOs. Still, Minnesota claims the ninth-largest concentration of citizens of any state enrolled in managed care plans.
“That’s tiny. That’s five hours in four years to prepare people for the systems they’re going to be working in the rest of their lives,” he said.
Boult’s committee got a tentative green light for their recommendations this summer. Final approval from the school will mean faculty from pharmacology to human behavior will start to teach the ideas throughout the four years of medical school.
“The books aren’t written yet”
Nowhere is the strain of finding innovative ways to train doctors more acute than in residency programs. Treating patients for the first time, the students test their skills at handling patients against the new economics of medicine.
As a second-year student, Julie Hodapp has already trained at four sites in the Twin Cities area. As her education continues, her training will be at a blend hospitals and clinics, following the flow of patients.
Cost-conscious insurers and advances in technology have pushed patients from hospitals to the less expensive walk-in clinics. And where the patients go, the students will follow.
In addition, federal funding cuts have the Twin Cities teaching hospitals scrambling for funds to cover the costs of teaching and research.
Medicare cuts initiated by Congress will cost the county hospital $5 million over the next three years.
“There is nothing stable out here,” said Dr. William Keane, chairman of the department of medicine at Hennepin County Medical Center and the University medical department’s vice chair.
“The books aren’t written yet. We’re changing what our forefathers left us rather dramatically,” he said.
Keane, who is responsible for the medical center’s resident training, is acutely aware of the challenges medical educators face, he said.
It is not only financial pressures that have affected teachers, Keane said. Swelling lists of federal requirements and the resulting paperwork subtract from a physician’s time for mentorship and teaching.
“Accountability comes with a price tag,” he said.
Students witness the financial squeeze during their residencies and clerkships, said Dr. Steven Hillson, the associate director of the Hennepin County Medical Center’s graduate training in internal medicine. Faculty now teach residents how to make their knowledge and medical dollar go farther, Hillson said.
Doctors must work to compensate for lost funding and incomplete insurance with less expensive therapies, Hillson said. Treatments and prescriptions can become less convenient and sometimes less effective, he said.
“We are grappling with how to pay for what we do” as physicians, he said.
As primary care doctors become the front line of American medicine, today’s students need to learn common business sense to remain an effective patient advocate, said Ilene Harris, director of the Medical School’s Office of Educational Development and Research.
“It is essential that they become leaders in reforming health care systems so that they do accomplish what we want to have, which is high-quality care at an affordable cost,” she said.
The solution is for doctors to get more knowledgeable and savvy about how systems work, Boult said. The ideal graduate from the University would be a blend of physician, administrator and epidemiologist. Boult admits this is asking more from an already overtaxed group of students, but he said he believes it is a necessary step.
“We have to redefine our image of what it means to be a doctor,” he said. “How far do you take it? We certainly need to take it a little ways just to test the waters and see what we can absorb.”