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The changing role of physician executives.


Throughout the nation, physician executives are taking on new and emerging roles - from brokering the purchase of information systems and creating managed care networks to functioning as systemwide consultants, facilitators, and educators. This article offer profiles of eight creative physician executives - including their current roles and responsibilities, recommendations for emerging physician executives, and forecasts for the years ahead.

The System Consultant

As Medical Director of VHA of Florida, Inc., 48-year-old Michael C. Pinell, MD, serves as a consultant to the CEOs, COOs, and medical directors of 20 of the system's larger facilities on such trends as managed care, capitation and integrated systems, and using clinical information. Already, Dr. Pinell has conducted three-day benchmarking forums on such procedures as coronary artery bypass grafts, c-sections, hip replacements, and vaginal deliveries. Billing himself as an internal consultant, Dr. Pinell also meets quarterly with a 20-member Physicians' Advisory Council, where he addresses hot topics, refines physicians' leadership skills, and helps orchestrate site visits.

Despite his high level of job satisfaction, Dr. Pinell acknowledges roadblocks and challenges. "It's tough to spread yourself over marketplaces in various stages of managed care development and customize an approach," he says. Also a problem is "walking in foreign turf." "You may have a good relationship with the medical director," he says, "but the rest of the medical staff doesn't always view you as a part of their management team."

Pinell believes his 17 years of experience as a full-time emergency physician delivers the credibility needed to work with colleagues in driving inappropriate costs out of the system. "Physicians control 70 percent of costs, a figure that will increase to 80 percent under managed care," he says. "You need a clinical background to facilitate clinical changes and discuss them in adequate detail."

The Relationship Developer

While working as a Special Assistant to the U.S. Secretary of Health and Human Services, Louis W. Sullivan, MD, from 1988 to 1989, John Danaher, MD, realized that physicians - not just lawyers and economists - should assume a pivotal role in formulating health policy. Through the sponsorship of health policy expert Alain Enthoven, PhD, Dr. Danaher received an MBA from Stanford University as a Hartford Fellow. Hired to serve as the Assistant to the President of Boston's Deaconess Hospital in 1993, Dr. Danaher was charged with the responsibility to develop a network of community physicians, function as an extension of the CEO, and design physician management courses at the Harvard School of Public Health.

In the meantime, Deaconess evolved from a stand-alone tertiary academic hospital to a five-hospital integrated delivery system called Pathway Health Network. With its proposed merger with New England Medical Center, Pathway has emerged as one of a select group of four integrated delivery systems in eastern Massachusetts, the others being Harvard Pilgrim Healthcare, which includes Harvard Community Health Plan and Pilgrim Health Plan; Lahey/Hitchcock, a not-for-profit multispecialty physician group; and Partners HealthCare, which includes Massachusetts General Hospital and Brigham and Women's Hospital.

Dr. Danaher is convinced that community hospitals will serve as sites for the majority of care delivery in the future. To that end, Pathway has pursued an approach that focuses on building a network of affiliations between community hospitals and community physicians, achieved primarily through physician hospital organizations (PHOs), management services organizations (MSOs), and primary care groups. "Pathway works on the principle of providing value to community hospitals and community physicians," says Dr. Danaher. "For both hospitals and physicians, the greatest value comes in gaining access to managed care contracts they couldn't obtain on their own."

By choosing not to purchase practices or to salary physicians, Dr. Danaher believes, Pathway can "nurture physicians' creativity and entrepreneurial nature." By building relationships with primary care groups and representing them at the negotiating table with insurers, Pathway achieves the goal of generating business - not just referrals - for the entire system, he says.

Dr. Danaher is currently working to develop a managed care curriculum to help community and academic physicians come to grips with managed care. He also works extensively with lawyers and accountants to create governance structures needed to execute capitated contracts. Other responsibilities include recruiting group practice administrators, developing information systems, and designing compensation schemes for primary care and specialist physicians who have both fee-for-service and managed care patients.

A committed educator, Dr. Danaher teaches at the Harvard School of Public Health and at Harvard Medical School, where he'll soon chair a three-day course on integrated delivery systems and strategic alliances. When not teaching medical school students and residents, he sees patients two half-days per week at the Deaconess Medical Associates Clinic.

While Dr. Danaher acknowledges that 80 percent of his job involves management and strategic planning and only 20 percent calls for clinical skills, he's convinced that ongoing clinical expertise not only "delivers the credibility to talk to physician colleagues, but also educates you about the pressures of a changing system."

The Quality Improvement Engineer

As full-time Chief of Medicine at 434-bed St. Luke's Hospital, Bethlehem, Pa., 49-year-old James Cowan, MD, heads a department with 130 physicians and a total of 400 members of the medical staff. In his role, he helps ensure high-quality care through such traditional channels as granting of privileges; credentialing; medical record review; quality assurance; and, more recently, quality improvement.

To help physicians shift their focus from a review of individual cases to a review of patterns of care and system improvements, Dr. Cowan recently established a Department of Clinical Performance Improvement, which serves the hospital's 10 medical staff departments. Charged with the task of operating all hospital databases of clinical information and reporting results to the medical staff, the department features a medical records professional, a half-time physician with 10 years' utilization review experience, and a senior medical records administrator. Already under way are projects focusing on length of stay and accuracy of final diagnosis for myocardial infarctions, coronary artery bypass graft outcomes, c-section rates, and psychiatric lengths of stay.

While Dr. Cowan credits clinical training for building cooperative relationships with physicians, he believes his education as an electrical engineer has helped him with the quantitative skills important to directing physicians in quality improvement. "As more information is collected, we'll turn it into tools for internal marketing and marketing practices to insurance companies," he says. "The challenge is to protect the information from being used against both physicians and the hospital."

In 1993, Dr. Cowan also introduced a formal process of technology assessment. "New technology increases cost, but doesn't always improve outcomes," he says. "What we wanted were better outcomes at lower cost." Unfortunately, the Food and Drug Administration (FDA) approval process only required demonstration of safety of new technology, not demonstration of efficacy, observes Dr. Cowan.

Drawing on the input of a joint medical staff and administration committee, the technology assessment committee begins the evaluation process by focusing on the hospital's mission: to provide excellent health care to people who live in this community. "By framing technology acquisition against mission, we can move away from private decision-making conversations on the golf course," says Dr. Cowan "The key issue is whether the technology will help the community." Other issues include:

* How does the technology work? Does it have an adequate biological or clinical base?

* Do we have skills and knowledge to use the technology?

* How will the technology affect other services?

* How many patients can we serve with the technology?

* What is the level of reimbursement?

The results have been varied. The committee elected not to use coronary artery stenting and intracorporeal ultrasound until it had more information. And while it decided to go ahead with rotational coronary atherectomy, it also decided to introduce case selection constraints.

The MSO Leader

As Vice President of Patient Care Management for Managed Care Systems, Inc. (MSC), Sacramento, Calif., a wholly owned subsidiary of Sutter HealthCare, Gerald Bishop, MD, heads an MSO that delivers claims payment, provider relations, medical and care management, quality assurance, and credentialing services to more than eight provider organizations, including five Sutter acute care hospitals and six capitated physician groups.

A practicing internist for more than 14 years, 48-year old Dr. Bishop worked from 1992 to 1993 as MCS's medical director, taking charge of such areas as medical policy, quality improvement, utilization management, physician education, and practice protocols. In his current role, however, Dr. Bishop uses MCS to bring together disparate provider organizations into a fully integrated delivery system. Much of his time is invested in educating physicians on the meaning of managed care and capitation, preparing a foundation for accepting at-risk managed care contrasts, and analyzing cost and utilization data.

The results have been worth the effort. Drawing on the recommendations of MCS's quality assurance and utilization review departments and personnel, Dr. Bishop has addressed the problem of utilization by developing benchmarks based on those of similar provider organizations in northern California.

Other innovations have included his introduction of a concurrent review process that decreased bed days from 278/100 to 233/1000 within six months, a $7 reduction in per member per month costs, the creation of nine committees to develop practice protocols, and revision of referral and authorization policies. "Our collaborative, educational approach has influenced many physicians' practice patterns," he says.

Addressing physicians' needs and pain is one of Dr. Bishop's top priorities. He sees many northern California physicians leaving for rural areas within the state or for states with minimal managed care penetration. "Group purchasing power is driving premiums through the floor," he says. "Physicians are working harder for less money and living with the expectation that purchasing cooperatives could make the situation even worse." Dr. Bishop's own story supports the point. In 1976, he made what he labels a "comfortable living" working two and a half days a week and seeing 18-20 patients a day. By 1991, he was already working five days a week, seeing 25-30 patients per day, and earning 30 percent less annually.

Dr. Bishop has also observed medical groups offering much-in-demand primary care physicians $130,000-$140,000 annually, far beyond the $85,000-$105,000 they could earn in solo practice. In the months ahead, he hopes to develop a compensation plan that will allow physicians to focus more tightly on quality.

The Ambulatory Care Executive

Recruited to Bayfront Health Services, Inc., St. Petersburg, Fla., as Executive Vice President of Medical Affairs in 1994, 54-year-old Martin Farber, MD, was charged to "work outside the four walls of the hospital," coordinating existing ambulatory care projects and launching a new ambulatory surgery center. Working with a plan to build a center with 20,000 square feet of space, seven operating rooms, and three endoscopy suites, Dr. Farber not only received approval from the state's Agency of Health Administration and the federal government's Health Care Financing Administration (HCFA), but also successfully recruited 40 center personnel and acquired more than $1.5 million of equipment.

To fulfill his mandate to form a primary care physician network, Dr. Farber has also become involved in private practice purchases, recruitment of 13 physicians, and set ups of three family practices. This task, in turn, has called for extensive market area analysis based on demography, physician supply, forecasting of an optimum doctor-to-patient ratio, and the presumption that capitated managed care would penetrate the market in 12-14 months.

Other areas of responsibility have included creation of an ambulatory care residency with a nine-person faculty, coordination and eventual expansion of six urgent care centers, creation and expansion of programs in rehabilitation and home care, and the launching of a freestanding women's health care ambulatory practice

Heavily involved in governance, Dr. Farber also serves as Executive Vice President and as a trustee for Bayfront Life Services, the parent corporation, as well as trustee for two subsidiary corporations. Having participated in forming a new PHO, Dr. Farber now serves as a trustee for that organization and as a member of the medical advisory committee of Baycare, the system's integrated network.

Also involved in managed care, Dr. Farber once functioned as the sole signatory on all system contracts. Still, he regards integration of ambulatory care as his greatest challenge. "You can never get inside the four walls of a hospital, but you have to make sure that everyone there understands what's going on," he says. "The goal is a seamless workforce both inside and outside, with commonality in billing, human resources, and purchasing."

The Clinical Integrator

When Crozer-Keystone Health System, Media, Pa., was formed in 1990, senior management realized it needed a high-level physician who could bring management's perspective to physicians while also bringing the physician's perspective to management. While vice presidents of medical affairs were already involved in quality assurance and delivery, they lacked the more expansive point of view required to bridge the gap between medicine and management.

Enter Ian Jones, MD. As the newly appointed Senior Vice President, Clinical Integration, Dr. Jones was asked to orchestrate a managed care strategy; integrate clinical programs throughout the four-hospital, 1,160-bed system; communicate with more than 800 physicians in 300 specialties; manage all quality improvement, utilization, and outcomes management programs; track and evaluate care management; coordinate medical education; and manage all physician resource planning and recruitment.

"Being a physician makes it easier for me to talk to other physicians, because I'm one of them," says Dr. Jones of his role. "If they have to hear bad news, it's easier when it comes from a member of their group than from an outsider." Dr. Jones believes physicians with problems are more likely to talk to a physician than to an administrator, a practice that keeps lines of communication open and controls what he labels "hallway grumblings."

Also critical is Dr. Jones' ability to bring physician traditions into the management structure. "The core of a physician's belief system is more evident to a physician than to an outsider," he says. "I can bring the spiritual aspect of caring for people into management. I realize we have a higher calling than just the bottom line because of who we are and what we stand for." Dr. Jones also believes it's easier for him to recognize what makes sense in terms of rationalization and integration and "where to get the biggest bang for the buck." "I know where the difficult and easy areas are," he says. "And I can find the hot buttons and how to avoid pressing them. A nonphysician might not know that."

The Group Practice Executive

As Medical Director and Executive Director of Mercy Integrated Health, Phoenix, Ariz., a primary care employment model group practice affiliated with Mercy Healthcare Arizona, Richard T. Lopes, MD, draws on every aspect of his experience as a former medical director of a 75-physician multispecialty group practice in Baton Rouge, La., and a 15-year career as a practicing internist.

When Mercy hired Dr. Lopes in 1994, the administrative responsibilities of his current job were shared between two positions: a nonphysician executive director and a medical director. Shortly after Dr. Lopes' arrival, however, Mercy consolidated the responsibilities into one position. In his current role, Dr. Lopes not only identifies potential recruitment candidates, but also identifies physician practices for purchase, engages in practice appraisal and valuation, negotiates and renegotiates purchases, and incorporates new practices into the existing infrastructure.

Charged with what he labels an "all-encompassing position," Dr. Lopes is also working within Mercy Healthcare Arizona to develop the physician component of a statewide delivery system. Doing so, he believes, will create responsibilities far beyond the development of an employment model group practice, which is now up to 30 providers, with another 40 in the pipeline. Finally, he believes that future development of MSOs will offer him vehicles other than employment for relating to physicians.

Reflecting on his position as a physician, Dr. Lopes thinks that it gives him both access and credibility. "The delivery of health care in an ambulatory setting is totally different from delivery of care in acute settings," he says. "The time I spend interacting with physicians gives me a real edge when competing with a practice management company for a practice." Also critical, he believes, is the ability to talk candidly to physicians about such issues as utilization management and quality of care.

The Corporate Health Care Leader

As Senior Vice President for Physician Integration and Chief Medical Officer for Aurora Healthcare, Milwaukee, Wis., Kevin M. Fickenscher, MD, FACPE, collaborates with other senior executives in the workings of 10 hospitals, a 350-physician medical group, a visiting nurse program with more than 250,000 patient visits annually, pharmacy and subacute programs, and a regional reference lab.

Labeling himself as "the lead physician for the corporation," Dr. Fickenscher focuses on physician integration and works with structures as diverse as a medical group with physician employees, a contracting network, a group of 900 physicians who decided to work with the corporation, and independent physicians - primarily specialists - who provide an array of services.

Responsible for clinical quality throughout the corporation, Dr. Fickenscher works not only to define quality standards, but also to implement these standards throughout the system. The job is far from easy. "When you cover a geographic area that extends from Northern Illinois to Green Bay, it's tough to develop a standard on hypertension or treatment of pneumonia," he says

While Dr. Fickenscher appreciates his role as a physician, he's convinced that he now practices health care more than medicine. With more than 3.2 million people in northeastern Wisconsin, he must develop programs that will provide care for 33-50 percent of the population or 1 to 1.5 million people. "Rather than thinking about a family population of 2,000, I think in terms of caring for several million people," he says. He's also had to accept the reality of a changing timeline. "Rather than having direct impact on someone's chest pain, I'm setting up systems and an infrastructure that will allow us to do a better job of health care delivery over the next four to five years," he says.

Future View

And how do these successful physician executives view the future of their profession?

* Clinical care leadership. Physicians will take on important leadership roles in clinical care, according to Dr. Fickenscher. As they embrace care management, physicians will define clinical, financial, and administrative processes as well as the type, level, and breadth of care. Physicians will also be involved in making administrative decisions that affect clinical care.

* Information systems leadership. Physician executives will accelerate their interest in medical informatics and information systems, predicts Dr. Lopes.

* System-sponsored education. Physicians will take advantage of systemwide programs to develop physician managers and leaders. According to Dr. Lopes, this may give physicians speedy access to fast-moving marketplaces and the inside track in becoming integrated delivery system executives.

* Creative and diverse roles. Physicians will evolve from restricted roles as "utilization policemen," according to Dr. Pinell. Instead, they will embrace more diverse roles as internal managed care experts, ambulatory system developers, recruiters of primary care physicians, and architects of networks.

* Community focus. Many physicians will become "community health medical mayors," a role that calls for a unique blend of skills in statistics, epidemiology, and business, according to Dr. Pinell. Public health physicians will begin to take on reinvigorated roles as employers realize the benefits of keeping employees healthy.

* An expanded role for chiefs. Occupying a far more strategic position than more nuts-and-bolts medical directors, the chief medical officer may assume new prominence, observes Dr. Jones.

* Nonpatient care physicians. The MD degree could soon become like an MBA or JD," says Dr. Jones. "You might receive training as a doctor of medicine, but you'll never practice. Instead, you'll receive the needed background or core knowledge to do another job."

* Scattered resistance. "Getting an MBA and being placed in a management position is no guarantee of holding on to a senior management position," says Dr. Danaher. "Nor does it mean that all physicians who show interest in management will become CEOs." While Dr. Danaher acknowledges that physician executives will be more involved with operations and strategy, he believes it will be tough to break the old paradigm of division chiefs and chairmen becoming heads of hospitals, especially in academic medical centers.

* Rising interest in business. Dr. Danaher reports that Harvard Medical School students have already formed a course on business and management in health care, and Deaconess residents are also eager to learn more about business and management.

* Senior management penetration. As physicians pick up administrative/technical information by attending business school and acquiring needed experience, they'll become increasingly qualified to assume CEO and COO positions as well as seats at the trustee table, predicts Dr. Danaher.

* Organization-sponsored education. More organizations will "grow their own" physician executives, predicts Dr. Fickenscher. However, organizations may need to approach physicians differently from other "students" and "clear their thinking processes."

Success Recommendations

And what strategies do these physician executives recommend to others?

* Don't push. Avoid the temptation to push too quickly for top jobs. Dr. Fickenscher recommends tempering your expectations as you develop baseline experience and basic skills and acquire formal training.

* Be prepared to move around. Dr. Fickenscher believes it will be increasingly difficult for aspiring and upwardly mobile executives to remain in one state or region.

* Create a network crucial to your job performance. Dr. Fickenscher recommends assembling and then cultivating a group of individuals you can call on for advice and support. Also get involved with at least one professional group, such as the American College of Physician Executives, the Medical Group Management Association, and the American Group Practice Association.

* Speak out as much as possible. Dr. Fickenscher recommends delivering presentations on organizational innovations at professional conferences. As a result of a steady presentation schedule, Dr. Fickenscher was appointed to the boards of Catholic Health Corporation, Sisters of Charity Healthcare System, and Healthcare Forum.

* Get ready to rock. Prepare for an intense, highly focused life-style, counsels Dr. Fickenscher. "The higher you go within a system, the busier you'll be," he says. "This isn't the easy way out."

* Investigate flexible education programs. While younger physicians can more easily take off two years to complete a master's degree, those with families and established practices should probably seek out other options. For example, Dr. Pinell is completing an MHA at the University of Colorado by participating in six two-week, on-campus sessions over two years and by finishing assignments on a laptop computer.

* Be open to new opportunities. Dr. Pinell suggests looking beyond traditional roles, such as utilization policeman, to consulting and medical directorships in insurance companies.

* Broaden your skills. Dr. Pinell advises his colleagues to develop skills in statistics and epidemiology so they master population medicine as opposed to medicine as practiced in the context of the traditional one-on-one doctor/patient relationship.

* Tap opportunities within your own organization. Dr. Pinell recommends that aspiring physician executives seek out medical directors as mentors and serve on committees, such as utilization review, risk management, and quality improvement. Other possibilities include socioeconomic issues committees within medical societies or groups.

* Know your short- and long-term goals. Dr. Danaher reports that, while some physicians want to reshape the practice of medicine and health care delivery, others simply want to use their knowledge of finance and marketing to launch businesses in health care services, biotechnology, and health care consulting.

* Pay particular attention to managed care issues. Dr. Danaher recommends studying managed care issues by going to specialized conferences. Recently, he took two physicians from each facility within Pathway to an ACPE conference focused on managed care.

* Focus on quantitative literacy. "Physicians need to be comfortable with the numerical descriptions of care delivered within their organizations," says Dr. Cowan.

* Never stop learning. Dr. Cowan readily admits that he still "doesn't have the skills needed to be effective for the next five years." Despite the fact that he's taken all of ACPE's Physician in Management seminars, he's begun an executive master's degree at Columbia University. The answer, he believes, is continually acquiring new information.

* Go with your gut. "The key to success is enjoyment," says Dr. Bishop. "If you still feel drawn to clinical medicine, stay there."

* Maintain a future focus. "Develop a strong vision of where health care is going and be prepared to communicate that vision to physician colleagues and other opinion leaders," advises Dr. Bishop.

* Put degrees in proper perspective. "Participating in an advanced degree program is no substitute for knowing what goes on in the marketplace," says Dr. Bishop, who believes he effectively blended education and experience by completing a one-year fellowship with the American Managed Care and Review Association.

* Don't minimize teaching positions as a career path. Dr. Farber credits his current success to experience gained when starting a division at a Class II Army Hospital and then serving as a division director for 10 years and as a department chairman for 10 years.

* Make clinical experience a priority. "You can't gain the respect of the physicians you expect to lead without strong clinical expertise," says Dr. Farber. On the other hand, he counsels physicians against "putting your MBA on the shelf for 10 years." "Your degree will get dated and you'll be just another doctor with a degree," he says.

* Find a mentor or coach. Dr. Lopes credits his success to his tenure as a chief resident, where he had an opportunity to observe human behavior, spending 12 years with a mentor at the Ochsner Clinic and gradually assuming responsibilities within the division of primary care and the department of medicine. Later, as the medical director of an HMO, he learned about financial issues by observing the president. "There's no substitute for learning from others," he says.

* Prepare to make a transition to different and new forms of gratification. "Seeing a patient get well is a powerful experience," says Dr. Lopes. "As a medical administrator, I've learned that rewards and gratification come over longer periods." Dr. Lopes now finds renewed satisfaction in teaching younger physicians or those interested in careers in medical management.

Jennifer Grebenschikoff is Vice President, Physician Executive Management Center, Tampa, Fla.
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Title Annotation:Career Management
Author:Grebenschikoff, Jennifer
Publication:Physician Executive
Date:Sep 1, 1995
Previous Article:Catching the wave at its crest.
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