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In July 1995, the American Osteopathic Association (AOA) Board of Trustees passed new regulations regarding the accreditation of osteopathic graduate medical education (GME) by establishing the Osteopathic Postdoctoral Training Institutions (OPTI) system. This system must be phased in by July 1999. The principal changes resulting from the OPTI system include establishing requirements for college cosponsorship of GME programs and for the number of residency programs, interns, and residents to be trained by the OPTI. In essence, OPTI is an osteopathic acronym for consortium. Each OPTI must include at least one college of osteopathic medicine (COM) and one AOA-accredited hospital. The OPTIs will be subject to interval AOA inspections and will be required to demonstrate a governing system, mission statement, organizational structure, and the presence of faculty development programs. The first article in this two-part series, published in the October JAOA, provided a general blueprint for OPTI building and presented both positive and negative issues germane to the formation of OPTIs. Part 2 reinforces the considerations outlined in Part 1 by describing the formation of a large OPTI--the Ohio University College of Osteopathic Medicine (OU-COM) Centers of Osteopathic Regional Education (CORE) system. Key features are described, including the mission statement, organizational structure, committee system, governance, GME programs, operations, and budget.

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Calls for medical education reform focus on four major criticisms directed at curricular content and context, infrastructure fragmentation, specialty mix, and the lack of integration with community and public health. In the previous article in this two-part series, authors from the osteopathic medical education community focused on uniquely osteopathic reforms for the curriculum and the fragmented educational system. That article documented the leadership position of osteopathic medical education in implementing reforms with respect to these two criticisms. The authors of this second article tackle the osteopathic contributions to workforce issues related to the generalist-to-specialist imbalance, the opportunities to move from a community-based profession to a profession accountable for community health, and the potential for technologic advances to aid in reform in all four areas under consideration in both articles. They conclude that the osteopathic medical profession can lead medical education reform in the United States with visionary leadership in place.

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Medical education has not kept pace with the evolving healthcare system. Criticism from industry and policy observers focuses on four major areas requiring reform: the curriculum, the fragmented educational infrastructure, the specialist-to-generalist mix, and the alienation from community and public health. The dominance of managed care organizations in the delivery and financing of healthcare is forcing a new set of physician competencies to the fore and changing projections of physician manpower and specialty needs. The authors address the four major criticisms from a uniquely osteopathic point-of-view. In this first of two articles, the authors describe the evolving osteopathic medical education model, and then employ a medical analogy to diagnose the causes of and propose treatments for curricular issues and infrastructure fragmentation. In the second article of the pair, they explore the causes of and propose strategies to address the generalist-to-specialist imbalance and the alienation of medicine from community and public health; the article also explores the role of technology in support of reform. In each article, the authors propose treatments to correct the problems in the osteopathic medical education model, and conclude that the profession is well-positioned to lead medical education reform.

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The evolution of the healthcare marketplace to a managed care-based system requires dramatic changes in the fragmented medical education infrastructure and curricula to more adequately train the physician workforce needed to staff and support the new system. Graduating physicians, in large numbers, feel poorly prepared to function effectively in the very areas adjudged to be essential to a successful transition, such as cost-effective care and caring for patients in outpatient settings. Managers of the new systems, such as health maintenance organizations, have expressed dissatisfaction with the skill levels of many of the practitioners whom they are hiring. Many physicians who have made the transition to a new practice paradigm by restructuring their practices are dissatisfied with several aspects of the new practice environment and equally concerned about the quality of care they can deliver. The conflict between rhetoric and incentives, and the difficulty of reforming a fragmented academic system pose barriers to effective change as the nation's academic health centers prepare to respond. Osteopathic medicine is better positioned to change because of its community-based education, its track record in primary care, and its national move to create a vertically integrated continuum of education from undergraduate through graduate study. Medical education and workforce issues are essential components of the cost, quality, and access triad. Without reform in medical education, the ability of the new paradigm to adequately address these other issues is critically compromised.

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With Republicans and Democrats agreeing to strategies that move the resources and responsibilities for healthcare reform to the states, the Employee Retirement Income Security Act of 1974 (ERISA) presents even greater barriers than surfaced in federal planning. The single most formidable obstacle to state healthcare reforms, ERISA's preemption clause supersedes all state laws that "relate to" employee benefit plans. The authors trace the history of pension legislation that led to the strong ERISA protections and explain the interpretations of the law which affect healthcare. They explain the history of the Hawaii plan's waiver; the continual refinement of the law through legislation; and the growing body of case law that interprets ERISA's application through the "relate to" requirement, the "savings" clause, and the "deemer" clause. Finally, they point out that the political solutions being acted out in Congress are leading to poor healthcare policy. Overriding or waiving ERISA would not lead to national health policy solutions and could endanger millions of workers' pension and benefit plans. Meanwhile, the only relief for states comes in slow and incremental steps through the court system.

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After reviewing the history of antitrust legislation and established zones of safety for providers and the application of antitrust laws to the healthcare industry in two earlier installments, the authors explore the consequences of the vigorous application of antitrust laws to physician networking, with an emphasis on rural communities. They review common exemptions to antitrust laws that maintain the uneven distribution of power in the evolving healthcare market. Acknowledging the tenuous ground that providers hold in the struggle for control of the healthcare industry, the authors argue for greater consideration of the unique circumstances and barriers that tend to prohibit the formation of strong, physician-sponsored, integrated healthcare networks. The authors have tested the climate for relief from the antitrust enforcement agencies in Washington, DC, and have found no easing of antitrust legislation forthcoming. However, following the resolution of several antitrust cases in recent months, barriers to physician-led organizations appear to be lessening. The authors close with a review of several strategies to minimize the risk of antitrust challenges.

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The move toward managed care initiatives and multiprovider networks has intensified in recent years in response to escalating healthcare costs and increasing market dominance by the insurance industry. As a consequence, the antitrust laws have played a significant role in defining the limits of physician cooperation. An understanding of the application of antitrust laws to evolving healthcare delivery systems and a knowledge of the specific areas where providers must exercise caution are essential to physicians' strategic planning. This article looks at the major areas of innovation emerging in the healthcare delivery market and details some of the most important guidelines for safeguarding physician collaborations. The authors compare the ability of physicians and insurers to organize integrated care systems and question the continued protection of the insurance industry under the McCarran-Ferguson Act.

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As physicians explore areas of diversification and networking that can position them favorably for the changing health-care environment, their fear of running afoul of antitrust legislation handicaps them. A basic understanding of the intent of antitrust legislation and its application to healthcare is essential to physicians' strategic planning. This article traces the development of antitrust legislation and the regulatory agencies charged with its oversight. The authors review the first application of this legislation to the professions; distinguish per se violations from the rule-of-reason process; and summarize recent attempts by the Department of Justice and the Federal Trade Commission to provide useful guidance to healthcare providers in the market revolution.

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Physicians have identified malpractice reform as their first priority during the recent flurry of national reform initiatives. Their focus on malpractice, however, tends to obscure the relationship between malpractice and the systemic problems wracking our healthcare delivery system. Because malpractice has an impact on all three foci of comprehensive reform--quality, cost, and access--it is reasonable to expect healthcare reform to include some manner of tort reform. However, it is important to realize the tangential nature of the relationship and keep the focus of reform on the underlying issues of system reform. The authors define the areas of physician liability under tort law (both malpractice and product liability), point out the misperceptions that inform physician behavior, and review the individual reforms proposed. They identify the stakeholders and their positions on each proposal, while imploring a cooperative, systemwide approach to tort reform.

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Medical students are major stakeholders in the changing world of healthcare. Initiatives to change the specialty makeup and geographic distribution of the physician workforce, changes in the organization of healthcare delivery systems, and financing systems for healthcare will profoundly alter their practice environment while they are in school and just beginning to make career decisions. The decisions of osteopathic medical students, who currently make up 30% of the profession, will shape the profession's response to the new initiatives and determine its place in emerging healthcare systems. The authors surveyed first- and second-year osteopathic medical students to ascertain their perceived knowledge, opinions, and intentions as they relate to healthcare reform. They discovered that increasing numbers of students intend to practice in primary care fields. The student respondents support some of the major changes proposed by reformers in greater numbers than physicians as a whole, and have different priorities that they would like to see addressed in reform. This study reveals links between respondents' intentions to practice primary care and support for specific reform items, but the results show no link between anticipated indebtedness and respondents' intentions to enter primary care or specialty fields. The authors conclude that healthcare reform, although still in debate, has already exerted an influence on the decision-making processes of medical students.

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Policymakers agree that cost-containment in healthcare delivery cannot be attained unless the incentives for providers, patients, and payers can be changed. The authors review the existing incentives that have led to escalating costs and conflicting interests for providers, patients, employers, third-party payers and taxpayers. They examine the current incentives for each group and explore the changing incentives that the new integrated healthcare systems and managed care present. They conclude that the new systems are not a simplistic solution to the "healthcare crisis" in cost, access, and quality, but they emphasize that these new systems have already introduced new incentives for provider collaboration and cooperation. The traditional ties of the osteopathic medical profession allow a quick response to creating new integrated systems, but require collaboration to add tertiary care to the profession's strong primary care and community hospital base.

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The scandalous disparity between the health indicators for minority and nonminority and poor and nonpoor populations is of such long standing that it has lost th power to shock. The authors review the landmark studies of the past year which document discrimination in the healthcare system. They reiterate the most compelling statistics of mortality, birth, the AIDS epidemic, destructive health habits, and poverty. They trace the impact of healthcare policy on these vulnerable populations and address the myth that malpractice claims are filed more frequently by the poor. They conclude that equality is instrumental to the improvement of the nation's health demographics; the persistence of economic, social, and political discrimination will continue to create barriers even if financial access is assured through a pluralistic approach to healthcare reform. Ultimately, they predict that any healthcare reform that does not address minority issues is doomed to fail if all three areas driving the national "crisis"--access, cost, and quality--do not encompass minority-specific healthcare strategies.

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Osteopathic specialists enjoy the unique advantages of practicing in a profession with the recommended mix of generalists and specialists as healthcare reform heats up. Ironically, market reforms, driven by cost-containment, challenge the infrastructure of osteopathic physician practice, hospital care, and osteopathic education, all of which support the generalist/specialist mix that healthcare reformers are trying to attain. The authors trace the development of specialties in the osteopathic medical profession in response to persecution and isolation, and explain the differences between allopathic and osteopathic medical specialists. They document the rationale of a physician mix favoring an increased proportion of generalists. Finally, they argue persuasively that no one has a stronger motivation to help position the osteopathic medical infrastructure for survival than the osteopathic medical specialist.

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While healthcare reform proposals are debated at the national level, states continue to propose and implement reform measures to address Medicaid, health insurance, universal coverage and access, medical liability, and cost-containment. The authors examine the shared responsibility of the federal and state governments for healthcare regulation and the surprising number of powers that reside with the states. They review the major barriers to state reform represented by restrictions within Medicaid and the Employee Retirement Income Security Act of 1974 (ERISA) legislation. Established state programs in Maryland, Hawaii, and Arizona are revisited, and innovative reforms in Oregon, Tennessee, and Washington are examined. Finally, the authors concentrate on the reform measures under way in the five most heavily DO-populated states, pointing out the potential for one of the big three (Michigan, Pennsylvania, and Ohio) to emerge as a model for the larger states. They urge osteopathic physicians to exert influence, based on their record of serving the Medicaid and other underserved populations, in state settings where they can be most effective.

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Healthcare reform proposals introduced in the House and Senate, put forward by foundations, professional associations and study groups, all call for medical schools to train more generalists. As these agents make recommendations for change, they are studying the osteopathic medical education model with fresh interest because of its success in maintaining more than 60% of its graduates in primary care practice. Most students of reform place the blame for producing too many specialists and sub-specialists squarely on the academic health centers. The authors trace the development of academic health centers and compare and contrast the models developed in the osteopathic and allopathic medical settings. They enumerate the strengths in the osteopathic education model which have contributed to our favorable balance of generalists to specialists. However, they argue that specific changes in the osteopathic academic health center are essential if we are to retain leadership in generalist education under healthcare reform.

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Established in 1965 to provide medical care for the impoverished, the Medicaid program has pitted state governments against the federal government, and made adversaries of the providers. The authors examine the legislative history of the program and the rapid growth of expenditures that have led states to cut benefits, tighten eligibility requirements, and slash payments to providers. The call for comprehensive healthcare reform and universal access put Medicaid at the forefront of proposed changes. The osteopathic medical profession, which already provides a quarter of the care in the program, has an opportunity to lead in innovation to promote program efficiencies, and to affirm the profession's commitment to serve vulnerable populations.

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