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Ascendancy of primary care will create role intensification for physician executives.


The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensifted. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians "commodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.

In the years ahead, the physician executive must be ready for rapid, continuous change. The health care system as we have known it is rapidly disappearing. Private fee-for-service medical practice is becoming a historical footnote. The traditional division of health care services into easy packages - physicians, groups of physicians, hospitals, clinics, nursing homes, and the like-is giving, way to conglomerated and consolidated package that would have seemed unlikely, at least in its present fonns, even a few years ago. And most of the new health provision structure hasn't even been developed or conceived yet. Anticipating what new twists and turns health care changes will take requires an open mind - and great courage when preparatory action is required.

For the physician executive who can maintain a loose attachment to the status quo and an open mind for all actual and anticipated developments, the present and future represent a real opportunity. We are living, and working in a time that was made for "right brain" thinkers. The various elements of health care delivery and financing are scrambling to identify and achieve a winning position in a health care system that has become momentarily amorphous. It resembles a plane of mostly weak but varied magnet players. Those players that can increase their strength (read resolve) are likely to attract and hold their less fortunate neighbors, eventually achieving a tenuous balance with other higher strength players. The geographic and related business dimensions of this analogy will be limited only by the imaginations of the players.

Satisfying Consumers

To succeed and have a leadership role in this new and different health care world, the physician executive must practice envisioning or internally experiencing the health care provision system from consumers' and buyers' points of view. Access to patients will be the name of the game in this new world. The physician executive must have a thorough understanding, of everything involved in acquiring them, serving them, and keeping them. Therefore, the physician executive must be or must become well rounded in:

* Marketing. Understanding, how corporate

benefits managers and other purchases

of care think, what they're

looking for, and what motivates them

will be critical. Physician executives

will also have to understand the degree

to which purchasers do or do not represent

the thinking of consumers of health

care services. In the tumultuous years

ahead. taking, anything for granted greatly

increases the probability of disaster.

* Systems Theory. In a world increasingly

dominated by conglomeration and

consolidation. and in which new forms

of systems integration are apt to appear

on a regular basis, knowledge of systems

and operations will also be

critical. To ensure a leadership role for

themselves, physician executives will

have to immerse themselves in management

and information systems. There

are other professionals for whom these

areas are more natural fits, so physician

executives will have to be aggressive

and unhesitating in seeking, this knowledge.

"Leaving, it to others" could be a

recipe for failure. * Financing Mechanisms. In the new

health care delivery order, health care is

managed and its financing, is capitated.

While physicians will continue to care

for patients one at a time, physician

executives will have to alter their view

to patients as roups and populations.

And they will have to help clinicians

understand that care to individuals must

mesh with financing, at the aggregate

level. * Delivery Alternatives. Physician executives

must be willing, to look for new

ways and places to deliver medical care

more cheaply and efficiently. The rapid

growth of outpatient surgery and the

introduction of so-called subacute care

are only the first sallies in the search for

innovative alternatives to traditional

inpatient hospital care. The physician

executive will ensure that resources are

clearly and cost-effectively focused on

patients' problems and needs. Intermediate

and home care will be frequent site

options. Nurse practitioners and physician

assistants will be provider options.

An open mind will be able to encompass,

accept, and even develop other

sites and provider classes. * Risk Management. The physician

executive has long, been charged with

responsibility for important elements of

institutional risk management. In the

capitated environment that lies ahead,

this responsibility will crow in importance

and scope. In integrated systems,

the targets of liability actions are

increased in number as the system itself

acquires more liability. The physician

executive who hopes to succeed in this

new environment will acquire knowledge

in the full realm of risk management. * Communications and Information

Technologies. Integrated health care

delivery systems will remain fragmented

systems in the absence of carefully crafted

communications and information systems

within and among their parts. It

will not be necessary for physician executives

to become expert in these technological

areas, but a lack of knowledge

will almost certainly be a handicap. And

it is an area in which physician executives

can achieve distinction by showing

special competence. * Medical Quality Management. The

physician executive of the future must

have a thorough understanding of continuous

quality improvement and of

clinical pathway development. What is

more, a solid understanding of clinical

outcomes approaches and computer

software to measure outcomes will be

required. The physician executive must

have an understanding of risk adjustment

and the different ways it can be

approached. Additionally, the physician

executive will be in a position to guide

the use of the information that comes

from the clinical outcomes process.

These uses can be educational and very

positive, or they can be punitive, cold,

and destructive. Obviously, the first

approach will prove more successful in

the long run in facilitating clinician participation

and compliance with new system


The most enterprising physician executives will begin to look for new, seemingly unlikely, partners-companies that have very sophisticated communications expertise or companies that have significant insurance depth. In general, I think the individual needs to be ready to assume an integrative function with a broad spectrum of health-related services. Health institutions have been good at creating individual small business units or service lines. Now they will have to be able to make these entities function together in a seamless fashion. The greater effort and talent needed for this endeavor will certainly offer a wonderful opportunity for the physician executive.

Working with Clinicians

There is much understandable anxiety, fear, and depression among physicians in general. They are assaulted in myriad ways by the changes I have described. Their authority is being diluted. Their incomes are dropping or rising more slowly. For some, incomes may be totally in jeopardy. In the absence of a satisfactory response to all these changes, their days as physicians may be numbered. The physician executive needs to make an effort to alleviate clinicians' fears with information and education. Doctors have gone through rigorous. formal, lengthy training. They are used to formal training. It's my suggestion that physjcian executives. individually or as a grcvbp, develop a lecture series to bring physicians up to speed and give them a construct within which they can begin to make some sense of what's happenin, and plan their futures.

Doctors also need forums in which they can express and vent their feelings about all these changes. The wise physician executive will provide such a forum, and then channel those feelings in a constructive direction. The exact opportunity offered will depend on the physician's group and the culture in which the physician and the group operate. Left unattended, however, these feelings will do little to help further either the clinician or the health care system to which he or she belongs.

At the same time, these physicians can be helped in understanding, and adapting to changes in medical staff function and structure that are coming. For example, in the future, hospital and other medical staffs may most commonly be closed. Or there may be exclusive contracts with the physician organization portion of a physician hospital organization or foundation or with some other entity. Regardless, anticipated arrangements will lin-fit a physician's practice options.

Physician executives will do well to initiate many of the changes that are inevitable in medical staff functions and structure. They need to ask what are the critical functions of the medical staff, and how can they be accomplished best and with minimum tli-ne and effort. I think that. in the future, there is oing to be a tendency for decisions to be inade in isolation from the medical staff in hospitals. If physicians want to participate, they will need to be available with helpful attitudes. Physicians need to keep up with what's happening around themselves. Just practicing good medicine is not enough. As provider entities coalesce, independent doctors are goin, to run a great risk of bein, left out unless they move to accommodate the chan,es early. Physician executives who have themselves acknowledged and dealt with the chan,es are best positioned to assist their physician colleagues with the necessarv adjustments.

To avoid being, left out of the emerging health care system. physicians need to become educated quickly about the macro and micro issues of current American health care provision. They need to mana,e their own practice profiles-specifically those aspects re,,arding utilization of resources and clinical outcomes. Most insurers are keeping these profiles; physicians may be able to obtain them and at least find out the type of information that is being kept. Additionally, physicians should ask their hospitals for information that is being gathered on resource utilization and outcomes. The data may be rudimentary, but physicians will be very surprised at the amount and quality of data that are already being kept. The advantage in knowing about the data is that, if the physician chooses, he or she can manage better with the information, can ask questions about how it was developed, can challenge both the data and the collection methods. This information can only make the physician better able to deal with the changes that are coming,"

Physicians, like physician executives, can connect themselves with evolving organizations that look like they're well constructed and have good philosophical approaches, where the doctors are truly partners. In a world dominated by managed care and managed care organizations, practicing physicians should at least think abou having a managed care expert do a serious evaluation of their offices, with an eye to determining how to restructure them for efficiency and patient convenience. Physicians may also want to have business evaluations of their practices, to look at maximizing revenues. minimizing expenses, and coming up with an approach to functioning under capitation, partially or totally.

Ascendancy of Primary Care

Physician executives need a thorough understanding of all of the previous issues. They need a thorough understanding of their own management style and the ability to use different styles in different situations. Physician executives will be sorely challenged in the very near future. Circumstances are evolving for major doctor-to-doctor and doctor-to-organization conflict. Primary care physicians are exerting and will exert more and more influence in managed care systems. Any integrated system must have significant numbers of primary care physicians in good geographic distribution, but still in large enough clusters to be cost effective. When large numbers of thesc physicians are inte,rated, you can expect them to exert increased influence. After an initial surge of power, limits will be imposed or negotiated on the influence of primary care physicians. And their influence will also be tempered by other physicians' opinions and those of nonphysicians as well.

One of the cuitent root causes of potential conflict is the significantly differin, financial incentives of primary care and other physicians. As organizations move to align the incentives of all of the interested parties, I think confiict will refocus on clinical issues and philosophies and will move away from "gate keeper/financial" issues. this should be good news for physician executives: conflict on clinical issues and philosophies will be much easier to deal with.

Even so, physician executives will need o become master negotiators and will need to remember that relationships with others in the organization will occasionally be strained. There will be winners and losers, and not everyone is going to be happy. The wise physician executive will remember that he or she is not responsible for the circumstances of clinicians. My personal philosophy is that our lives are the products largely of our own choices. Physician executives will do well to keep that philosophy in mind.

If they are to be seen as honest and effective facilitators, physician executives will need to practice patience. Physician executives will be most effective if they can provide a sense of stability, direction, and rationality during the immense changes that are coming in the near future. This does not mean that they can afford to procrastinate and vacillate in the face of these changes. It just means that they must make their moves carefully and with the fullest possible information. Their clinician colleagues will expect nothin, less if they are to follow physician executives' lead.

Finally, physician executives must be a continual reminder, an image, of that which is good. honest, and unchanging in carrying fout the healing charge that our communicties have entrusted to us. No matter which specialty is momentarily in a position of control and power, and no matter how health care services are delivered, medicine's creed and consumers' expectations smust be honored.
COPYRIGHT 1995 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:Health Care Marketplace
Author:Cummings, Kenneth C.
Publication:Physician Executive
Date:Oct 1, 1995
Previous Article:The ascendancy of primary care: permanent or temporary?
Next Article:New market forces are special challenge to academic health centers.

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