The people's business: management careers in the public sector.

As is true for many professions, physician executives tend to pursue career paths that are extensions of their past and current experiences. Whether new to management or looking for that next opportunity, people take the advice of Dorothy from the end of "The Wizard of Oz" and seek their hearts' desires in their own back yards.

Besides maintaining the thread of the familiar, this approach builds on past expertise, leverages current relationships and permits people to comfortably accrete influence and responsibility.

The downside is that it limits career possibilities and opportunities. Search firms understandably focus on successful performers in particular health sectors and many jobs are still filled by friends of friends through tried and true word of mouth networks. That means that you need to actively seek out fresh chances to learn and grow.

Sure, you might be a good academic health care executive, but maybe you would be a great medical device entrepreneur. Dorothy learned an awful lot on her trip to Oz, after all. It is very important to periodically assess the entire range of physician executive opportunities and consider what you might gain from spending some time in a different field of endeavor.

Going public

So what are the sectors of the health care world that offer opportunities for physician executives?

Hospitals, health systems and group practices quickly come to mind, as do insurance companies and managed care organizations. Academic institutions and pharmaceutical and medical device manufacturers are common choices. A growing number of physician executives are finding fulfillment in the high-tech realm of health informatics. There is, however, a frequently overlooked option--public service.

Public service?

Why would an aspiring physician leader want to do that? Because the public sector of health care is huge, growing and full of lots of opportunities with plenty of potential for upward mobility.

Within the public sector, the need for high quality physician leaders is great--in the last generation government has shifted from a dependence on clerks to reliance on technical information experts in the fields of information systems, finance, engineering and health care.

Work in government or affiliated non-governmental organizations involves a wide variety of scope and geographic options--from your county health department and state Medicaid program to the federal Agency for Healthcare Research and Quality and the World Health Organization. While most of health care is about helping others, public sector health executives often find they have job descriptions that center on making the world a better place for everyone.

As with the rest of health care, the public sector has a variety of management roles. Physician executives can work as elected officials, agency heads, government program managers, independent consultants or as part of contracted vendor organizations.

Having recognized the limitations of burdensome bureaucracies, government is increasingly using private sector partners or full-scale outsourcing to delivery a high quality, cost-effective product to the populations served. In many localities, government is the largest employer. Plus, public payers purchase the majority of health care used across the country. Opportunity abounds, if you know where to look.

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Plenty of possibilities

The public sector is heavily segmented. Here's a list of some of the major segments:

* Public Health -- The government agencies and non-governmental organizations (NGOs) involved with protecting and advancing the health of populations. In international health these include the World Health Organization (WHO) and NGOs like Doctors Without Borders and Catholic Relief Services. The Centers for Disease Control and Prevention (CDC), as the lead agency, coordinates and integrates the efforts of state, county and municipal health departments.

* Public Payer -- Government health programs are the largest purchasers of health care. The Centers for Medicare and Medicaid Services (CMS) coordinates an enormous network of payment systems, including carriers and intermediaries for Medicare, state Medicaid and S-CHIP programs; and a large number of contracted managed care organizations.

* Public Provider -- Many government programs fund, employ or manage practitioners involved in the direct delivery of care. The Veterans Administration runs what is arguably the largest integrated delivery system in the country and has been a pioneer in patient safety and formulary management. The Department of Defense uses an array of employed civilian and military providers as well contractors to meet the needs of service members and their dependents. State, county and city hospitals are critical safety net providers for many populations. Correctional health practitioners meet the complex needs of millions of prisoners. The Health Resources and Services Administration funds federally qualified health centers as well as rural and migrant health centers. The Public Health Service and the Indian Health Service deliver care to thousands of underserved individuals.

* Public Research -- The National Institutes of Health (NIH) leads the world of medical research with its in-house programs and funds much of the extramural research in the U.S. In the field of health services research, the Agency for Healthcare Research and Quality (AHRQ) plays a growing role in funding research into how delivery systems reliably produce high quality health care.

* Public Quality -- Government is taking an increasing interest in the quality of care delivered. State boards of allopathic and osteopathic medicine monitor the credentials and performance of licensed practitioners. Quasi-regulatory NGOs such as the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) promote a variety of performance measures in the public interest. Quality improvement organizations (QIOs) measure performance of providers and health plans for Medicare and Medicaid. States have increasingly turned to patient safety authorities and health data organizations to provide the data needed for targeted quality improvement interventions.

Public service isn't for everybody. The president and the governors make far less money than Fortune 100 CEOs. Public pay scales are generally at the lower end, but they still provide reasonable professional compensation. However, benefit packages are often generous, retirement is typically well funded and job security is quite high.

Some jobs are not pretty as it is government's role to step in where others do not care to go. At the same time, the intangible rewards can be quite fulfilling--the experience of working for your community and for your country is enormously gratifying. All medicine is about giving, but altruism looms large in public service.

If you are interested in learning more about becoming a physician executive in the public sector, there are a number of avenues to explore.

* First is networking. Government health care managers travel in different circles from other health care executives, so seek out people from your area of interest and ask for advice and information.

* Next, check out the contracting opportunities that are published in the Federal Register and state bulletins as well as on individual agency Web sites. There is no standard approach so this may take a little detective work.

* Finally, employment opportunities in government can be found through the state and federal civil service. The civil service jobs are different from the political and administrative appointees who are recruited by presidential and gubernatorial staffs. The executive office Web sites show how to go about indicating interest in these appointed positions, although the odds of landing a patronage job through an unsolicited inquiry are pretty remote.

Don't forget about migrant and rural health centers. This is an expanding program serving a growing population. These community-based organizations face enormous challenges with limited ability to attract the kind of clinical leadership they need.

Tired of malpractice worries? Community health centers have such good liability experience that the federal government provides them with coverage for their physicians. Maybe you won't spend the rest of your life in one of these organizations, but you could do an enormous amount of good in the three to five years it takes to get used to the new role of being a manager.

Have you noticed that most job ads for physician executives are looking for some experience? Consider community health centers--the Health Resources and Services Administration (HRSA) and the National Association of Community Health Centers (NACHC) maintain lists of community health centers and can assist in matching applicants with job sites. Most of these centers lack the resources to use standard recruiting processes. However, if you are willing to look, the jobs are out there.

Another advantage of many public programs is their respect for diversity. The head of NIH is an Algerian native. The directors of AHRQ and CDC are women. Government is often quite good at recognizing and advancing the careers of gifted leaders and skilled managers such as these individuals, regardless of gender or ethnicity.

It is considered important for government workforces to reflect the faces of the communities they serve. As well, it is not uncommon for people to enter public service as a second or third career, allowing the public to benefit from the wisdom and experience of senior physicians. While it would be naive to assume that the lingering biases that afflict our culture find no expression in public hiring and promotion, tolerance and openness to difference are the general rule.

Finally, if you are thinking about an advanced degree in management, consider whether you might be heading for the public sector. Government entities prefer masters degrees in public health or in public administration over business degrees and you need to consider which degree is most suited to your long range interests. In addition to degree programs, some agencies such as CDC and CMS sponsor fellowships and other training opportunities. It just takes a little digging to find them.

When your next transition approaches, maybe you should consider adding the intangible gratification of serving the public good to your list of desired benefits. Think about it.

By Christopher Gorton, MD, MHSA 

Christopher Gorton, MD, MHSA is faculty practitioner in negotiation at Johns Hopkins University School of Professional Studies in Business and Education, Baltimore, Md. Previously, he was chief medical officer of the Pennsylvania Department of Public Welfare. He also is a health policy and management consultant in private practice in Hershey, Pa. He can be reached at 717-533-8910 or [e-mail].

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