The changing role of physicians in hospital governance.

Beginning in 1994, a process was undertaken to determine the attitudes of physician leaders on key issues confronting the health care field and most specifically its physician component. A questionnaire was developed over a two-month period. Several experts reviewed the questionnaire. All samples were taken from the membership of the American College of Physician Executives at the time. A small sample of physician leaders was surveyed to gauge the effectiveness of the questionnaire. As a result, the tool was modified, and a larger sample of 500 physician leaders received the questionnaire. Several weeks later, a follow-up request was sent to physician executives who had not yet returned a completed questionnaire. All told, 147 completed questionnaires were returned, a response rate of 29.4 percent.

Institutional Demographics 

Most responding institutions were not for profit (79.6 percent). Most institutions had senior vice presidents for medical affairs (74.8 percent). The latter figure is somewhat misleading, however, as members of the American College of Physician Executives are, one might hypothesize, more likely to come from institutions with senior vice presidents for medical affairs. Two-thirds of the senior vice presidents for medical affairs report to hospital chief executive officers. The other common reporting relationship is to a hospital vice president (6.8 percent).

Most hospital surveyed already had full-time salaried physicians on staff in addition to anesthesiologists, pathologists, and radiologists. They included, in virtually equal proportions, internists, general surgeons, cardiothoracic surgeons, pediatricians, and obstetricians/gynecologists. Hospitals made a variety of financial arrangements with these physicians prior to their coming on staff full time. The most frequent arrangement was practice purchase. While the medical director of the hospital was often involved in the financial arrangements with the physicians, fully 50 percent of the time there was no medical director involvement. In terms of evaluations of these employed hospital physicians, most were evaluated on the basis of the quality of care they provided, even though ability to generate sufficient revenue did form a portion of the evaluation in about one-third of the responses.

Hospital/Physician Partnerships

Medical director opinions on hospital-physician partnerships were divided into three categories:

* Based on medical director's hospital size.

* Based on whether or not the medical director's hospital has physicians (other than anesthesiologists, pathologists, and radiologists) in full-time salaried positions.

* Based on whether physicians in full-time salaried positions are also in private practice settings outside hospitals.

Compared to larger hospitals (500-999 beds), smaller hospitals are not attempting to protect their competitive positions by acquiring individual or group medical practices (table 1, above). On the other hand, strategic alliances are being undertaken by hospitals of all sizes. The reasons are virtually the same across hospital size. The responses to the questionnaire on this point are summarized in table 2, above. Similar results were obtained when the responses were viewed in terms of whether hospitals had physicians on full-time staff.

Of significant interest were medical directors' attitudes toward the power of admitting physicians. Physician power has declined, regardless of the variable (hospital size, hospital location, presence of full-time physicians on hospital staff) that is correlated with physician attitudes. Across the board, medical directors do not believe that the number of patient admissions to the hospital for a salaried physician should be a key ingredient in job performance evaluation (only 10.9 percent replied that it should be considered). The response to the physician power question, coupled with the ingredients for performance evaluations, leaves one wondering what ingredients medical directors would like to use that would simultaneously gain credibility in the hospital financial office.

Conclusions

While no firm conclusions should be drawn from this preliminary questionnaire, the responses are thought-provoking and should stimulate administrative evaluation on the part of medical directors. Physician practice purchase activity was significant at the time of this questionnaire in 1994. It has almost certainly increased in the ensuing months. The reasons largely pertain to protection of hospitals' financial positions. Despite this purchasing binge of medical practices by hospitals, medical director involvement is spotty at best. Part of the reason may lie in the not unexpected reluctance on the part of medical directors to include explicitly financial considerations, such as hospital admissions, in evaluations of physician performance. It is important to gauge physician attitudes on such nonclinical issues if medical directors are to prepare themselves for active involvement in the rapidly changing health care market.

Norbert Goldfield, MD, is Medical Director, 3M/HIS, Wallingford, Conn. He may be reached at 100 Barnes Rd., Wallingford, Conn. 06492, 203/949-6330, FAX [phone].