Health care economics, financing, organization, and delivery.

BACKGROUND The US health care system is in a state of rapid evolution, with changing payment, organizational, and management structures. To learn how to function optimally in a system in which care is increasingly managed and competitive, today's medical students must understand the structural and economic underpinnings of the system within which they will practice. At the outset of the Undergraduate Medical Education for the 21st Century (UME-21) project, the great majority of medical school curricula were lacking in areas of health care financing and organizational structure. The institutions involved in the UME-21 project sought to address curricular deficiencies in two broad areas: (1) the structure and financing of the US health care system ("health policy") and (2) the manner in which this system is reflected in the organization and activities of health care providers ("care delivery"). This article discusses the development, implementation, and evaluation of the first of the two areas. METHODS Data were abstracted from written reports provided by each of the UME-21 schools to the project's Executive Committee and sponsor. In selected cases, additional data were obtained by personal communications with project directors and evaluators. Local UME-21 project leaders verified all data presented. RESULTS Curricular philosophy and teaching methods varied widely, but health policy curricula were predominantly preclinical and didactic in nature. At the school level, much was achieved in terms of student knowledge, curricula were generally well received by students, attitudes toward managed care generally moved in a positive direction, and behavior may have been positively influenced as well. At the project level, many potentially interesting changes exist within the 18 schools and between the UME-21 and other schools, but it is not clear whether or what parts of the health policy curricula were responsible for these changes. Nonetheless, as measured by changes in health policy-related items on the Association of American Medical Colleges Graduation Questionnaire, it appears that UME-21 schools outperformed their non-UME-21 counterparts. All of the UME-21 schools were enthusiastic about their health policy innovations, and this extended across all key stakeholders. Most schools avoided focusing on managed care and instead adopted more neutral themes that introduced the same material. Integrating the new material in conjunction with the more traditional aspects of the curriculum was also an effective implementation strategy. CONCLUSIONS Health policy should be incorporated into both the preclinical and clinical years. The former emphasizes health care economics as one of the foundations of medical practice, whereas the latter provides the opportunity for its use on a daily basis in clinical settings. However, like any new curriculum, to achieve equal status with the traditional biomedical curriculum, it must be presented in a scholarly, rigorous, and reasonably comprehensive fashion. Mounting a scholarly health policy curriculum requires a wide-ranging, interdisciplinary faculty. If it is to become a central component of the medical school curriculum, creative approaches to faculty recruitment and development will be needed. This will require both careful educational policy formulation and new investment.