Rakowski, a professor of community health, has developed an approach to teaching health care that mirrors the changing nature of consumers' relationship with their doctors. He starts his course with the ABCs, unraveling all those mysterious acronyms, then moves on to health insurance, managed care, and cost control - the central and most contentious (if somewhat general) issues in today's debates about health care. As the semester turns wintry, Rakowski leads students through the issues faced by those in the later chapters of life including Medicare and nursing homes. Then, with a few weeks left in the semester, Rakowski lets his students put their new-found knowledge to work by exposing them to some of the people the health-care system often has the most trouble providing for: veterans, Native Americans, and prison inmates.
The course is structured to "alert students to the size, scope, and complexity of the health-care system," Rakowski says. By covering the jargon at the beginning, he clears the way for students to understand more complicated topics as they move along. When students realize they have the tools they need, he notes, "you can see the lights go on" in their minds.
Figuring out how to structure so much material didn't come easy, Rakowski says. At first he worked with Melissa Clark, an assistant professor of gerontology health, to put the course together and to teach it. Then, four years ago, Rakowski and Clark realized their course was covering too much material, so they split it into two classes. Now, BC 32, Introduction to Public Health, takes a population-health perspective, while BC 31 sticks closer to what Rakowski calls the "nuts and bolts of the medical health-care system - what happens when people get sick, how do insurance, hospitals, and managed care work?"
Students have also played an important role in the evolution of Health and Society. Rakowski is quick to acknowledge the input he receives from the graduate and undergraduate teaching assistants who attend lectures and evaluate every session. Michelle Bank '01, a community- health concentrator who took BC 31 last year and volunteered to assist Rakowski this fall, is happy to be back in his classroom. "He really lets us get involved," she says. "It's not just grunt work. We can do research, determine lecture topics - we're there for him to play off of when he needs suggestions about lectures."
Health care may seem an unlikely interest for the under-twenty-two set, but this fall Rakowski had to cap enrollment to match the 112 seats available in Wilson 102, the packed-to-the-rafters setting for his course. "The full room reflects an honest interest," he says. "This is information the students will take with them and make use of for the rest of their lives."
Chase Hogoboom '03, for example, is a first-year student pondering a concentration in economics, but he has no plans to pursue a career in health care. "The U.S. health-care system is one of the most complex in the world," he says. "It affects everyone, yet no one understands it." His goal in taking BC 31 is simply to understand.
Fee for Service: The traditional system most of us grew up with. Under FFS, your doctor is reimbursed, by you or your insurance, for each medical procedure. In a fee-for-service health-care system, no restrictions are placed on your choice of doctors or on the number of treatments or procedures. If your doctor's fee is higher than what your insurance company will pay, you make up the difference.
Managed Care: A philosophy of health-care delivery that emphasizes the role of primary care. Your primary physician, chosen by you from a list provided by your insurance company, serves as a gatekeeper who refers you to specialists or services. Your physician will restrict, limit, or guide your service utilization in order to keep medical costs down. His goal (as well as that of the insurance company that pays his salary) is to eliminate unnecessary procedures and emphasize preventive care.
Health Maintenance Organization: The HMO is one variety of managed care. A staff-model HMO is a small health-care center unto itself, providing a comprehensive range of specialty treatments. Doctors are salaried employees of the organization, and they treat only HMO members. A contract-model HMO, by contrast, is an administrative unit that contracts with a network of physicians to provide care. Some HMOs provide both staff-model and contract-model options.
Point of Service: An option now available in most HMOs, a POS plan allows you to seek treatment from out-of-network providers in exchange for contributing a higher percentage of per-visit costs.
Preferred Provider Organization: In a PPO, a group of physicians agrees to accept a discounted fee-for-service payment schedule from an insurance company in exchange for guaranteed patient flow. A PPO can operate under a traditional fee-for-service system or under managed care. In a managed care PPO, you're assigned a physician gatekeeper who refers you for further services within the system; in a fee-for-service PPO, you're free to choose from among physicians who accept your insurance.
Prospective Payment System: Perhaps the most familiar example of a PPS is Medicare. In this system, an independent or government panel sets allowable payments for medical procedures up to a year in advance, and hospitals and participating physicians must accept assignment. Payments are made on a per-service basis after service has been provided, as in a fee-for-service system.
It's a Monday morning in Wilson Hall. Beyond the windows of room 102 the sun is making an urgent, unseasonable appeal, and students are responding - the Frisbees are flying everywhere. Inside, Rakowski is comparing managed care to something his students can all understand - Brown University.
"You deal with managed care every day of your life here. You're living with capitation every day," he says. "You're going to school in the concept of a staff-model HMO. Can anyone tell me how?"
From the middle of the tightly packed classroom, somebody tries to answer: "It's the meal plan."
The meal plan may be part of it, Rakowski agrees, but it's not the full picture. Brown is like an HMO, he explains, because "the University gets X dollars from each of you, but each of you uses University services differently." Some use the libraries, some don't; some take advantage of athletic facilities frequently, others not at all; some may eat three helpings at the Ratty, while others prefer the food elsewhere.
The relationship of Brown students to their professors, Rakowski adds, is much like the one that exists between patients and their nurses and doctors in many HMOs. Under what is known as capitation, doctors receive a set salary to care for a certain number of patients in a year and must figure out how to allocate their resources to afford the best treatment. Whether doctors provide a brief office visit, a full physical exam, an X-ray, or a PET scan, their compensation from the HMO will not be affected. During particularly hectic times, doctors may be able to spend only a few minutes with each patient, Rakowski notes, much like a faculty advisor at registration time or a professor teaching a class of more than 100 students. "I get paid my salary if I meet with each of you once, twice, ten times, or fifty times," Rakowski says. "I have to allocate my time among and across my panel of students."
In the fee-for-service health-care system that many older Americans grew up with, Rakowski adds, doctors were paid a separate fee for each service provided, and the patient's insurance company was usually who paid. Under capitation, doctors now take on the financial risks that insurers used to shoulder.
As the session wraps up, Rakowski gives his class another question to ponder. "How is paying for health care like a bathtub?" he asks. The students pack his Zen-like equation away with their notebooks as the hour ends.
Word puzzles and unlikely ex-amples are an important part of what makes Health and Society tick, Rakowski says later. The details of what gets covered in the classroom can be on the dry side, he adds. "I try to inject some humor - do things that make them remember. Even if you make a really bad joke, that might help them remember what we're talking about."
Rakowski learned to navigate the health-care maze while earning bachelor's and master's degrees in psychology from Notre Dame and a doctorate in human development and family studies from Penn State. He readily admits that the runic jargon of health care can be tough to penetrate for anyone who works outside the profession. Sometimes even he gets tripped up. "The terminology is not at all self-evident," he says. "I'll talk with my father about his Medicare bill, and I can't even figure out all of the codes and definitions. It can be really difficult to keep up."
Though he has never been a health-care practitioner himself, Rakowski deliberately shapes BC 31 to be useful for future doctors. To be a successful physician these days, he says, students need to keep up with more than the latest scientific headlines. They also need to understand the economic models and market forces that drive the profession they are about to join. "When my pre-med students go on their medical-school interviews," he says, "what they get asked about isn't science, it's managed care: 'How do you feel about working in a managed care system?' They can answer that question. That's where the gratification of the course comes in."
A few days later Rakowski is back in Wilson 102, this time explaining how health insurance is like a bath-tub. The principles are fundamental, he says. Insurance companies, government programs, and patients' own payments are the faucets; money to pay for health-care is the water that flows out of the taps. Medical and dental bills are the drain. The goal: to keep the resources flowing so that the tub doesn't empty.
Then, unexpectedly, he asks the students to find their own pulses. As the undergraduates grip their wrists, Rakowski tells them, "it's important to be able to take complex concepts from the health-care system and connect them to basic things. It all boils down to your heartbeat and everyone else's. It boils down to having the resources to pay for your care when the bills come due."
Most of his students are years away from worrying about big medical bills or getting the best service from their primary-care physician. But with Rakowski's help, by semester's end each of them will know what they're entitled to and how to ask for it.
