When President Obama was on the campaign trail, he pushed the idea of giving consumers the chance to choose among both private and publicly sponsored health-insurance options. One question is whether the new public plan would pay doctors at the same rates that Medicare does—rates many doctors feel are too low. In a media briefing hosted by the Kaiser Family Foundation, Nancy-Ann DeParle, who's running the new White House Office of Health Reform, was asked for her own definition of the term "public health insurance." Here, the Wall Street Journal Health Blog provides her answer.
The nation's pharmaceutical makers spent more than $2.9 million on Vermont's doctors, hospitals, and universities to market their products in the last fiscal year, according to a report issued by the state attorney general's office. The report shows 78 companies spent the money in the year ending July 1, 2008. By law, the companies have to report their spending on consulting and speakers' fees, travel expenses, gifts and other payments to or for physicians, hospitals, universities, and others authorized to prescribe drugs.
Physicians as leaders are often like fish out of water. While they are typically regarded highly by society, most physicians have no leadership experience whatsoever. Physicians are among the most highly educated groups in our society, but as they progress from high school to college and from medical school to specialty training, the breadth of their education markedly narrows.
In fact, most physicians are students well into their 30s before they finally go out into the world to practice a specialty. Once they begin to practice, they often work in an environment that allows them to focus on what they do best—practice medicine.
Hospitals, on the other hand, are run mostly by leaders who have either MBAs or degrees in hospital administration. They understand hospital finances and hotel management, but they typically do not understand clinical medicine. Because of this obvious gap, most hospitals delegate clinical quality and physician credentialing to the medical staff. Furthermore, hospital presidents know that physician-generated admissions and utilization of resources by physicians are important to their financial stability. They need and depend upon the physicians.
However, they typically hire physicians and then place them in leadership positions such as department chief, medical director, etc., and this is where the problem begins. Physicians lack the proper training for some of these roles. They do, however, bring both strengths and weaknesses to their leadership positions, and physicians who perform well as leaders are a highly valued treasure for any healthcare organization.
Physicians becoming leaders
For the physician, leadership can be a lonely scenario at times. Upon assuming a position of leadership, there is inevitably the belief among colleagues that he or she is no longer one of them and is now an "administrator."
This shift is not unique to physicians. It is a difficult but necessary move on the leadership pipeline, but for the physician leader, it doesn't stop there. To add to the pain, the hospital's senior management team often does not regard the physician as a true executive, either. This is due to the lack of formal business education or the lack of leadership experience. So the physician lives in a sort of no-man's land.
Healthcare leaders who are not physicians have typically been groomed for leadership for many years, but the physician has been groomed to provide quality healthcare. There are often major gaps between what the physician is and where he or she needs to be to execute the business of healthcare effectively.
The leadership gaps
Physicians in general are used to being totally responsible for their patients' care. They may consult with specialist colleagues, but they alone control the aspects of their patients' care. As leaders, this skill does not serve them well. They often find delegation of duties very difficult and try to do everything themselves. Delegation of responsibilities and allowing the delegate to perform independently without hovering is an art that must be learned and developed.
Physicians are also accustomed to being obeyed, to working independently, and to being the center of attention. A doctor gives orders and expects absolute deference and immediate action. This may work in the operating room where the environment can be urgent and tense. It does not work, however, when leading others outside of the operating room.
As a healthcare leader, influencing becomes a critical skill. The physician leader must learn to effectively state a case and still be able to support the management team if an alternative course of action is chosen. He or she must learn the art of give-and-take, negotiating with other team members. Ultimately, the physician leader must learn to participate in and build effective and cohesive teams.
Another peculiar characteristic is that physicians are often in "transmit" mode. This is a result of their training, which is odd because it doesn't always work that well in the practice of medicine. In fact, many physicians are not even that good at listening to their patients. Developing good listening skills is crucial, as effective communication requires both transmitting and receiving.
The physician leader has to learn that when attending a meeting, it may be better to hear others' opinions around the table before speaking. This gives the physician time to be clear about what he or she wants to say and then to be more flexible in presenting ideas. Communication skills (verbal, writing, and listening) are crucial for effectiveness both as a physician and a leader.
An issue that is not often discussed is that many physicians have personality or character issues due to a prolonged period as a student. Many do not start their careers until their early 30s. They work long hours and study in their off-hours. They have little time to develop social skills. Their social skills often stop developing when they enter medical school. By the time they are asked by the healthcare organization to take a leadership role, they will have bridged some of the social skill gap, but it is very likely that there are still some socialization skills that are significantly lagging.
Conflict management is a skill that the physician leader may have practiced with patients but more often than not, the physician speaks and the patient listens with little opportunity for conflict. However, the need for this skill is unavoidable in any leadership role. The physician leader must be able to deal effectively with diverse personalities and cultural backgrounds. He or she must be able to find the root cause of the disagreements and reach compromises that will be accepted by all. To do so, the physician leader must demonstrate that he or she is impartial, trustworthy, and capable of resolving the conflict.
In today's complicated healthcare environment, physicians need more than clinical and leadership skills—they also need business development skills. Physician leaders must work to gain the trust and referrals of the primary care doctors who are only loosely connected to the hospital and also use business development skills to recruit other physicians.
Finally, the physician leader must be the advocate for the highest quality of patient care for both the individual physician and the medical staff. He or she must be able to critique care with other physicians without being punitive, unless there are chronic problems. There must be an understanding of evidence-based medicine and he or she must be able to evaluate the quality of the measurement statistics that are provided. Improving quality of care and evaluating the need for new technology are probably the most important aspects of the physician leaders' job, especially as pay-for-performance becomes more prevalent.
Physician leadership strengths
Physicians do, on the other hand, possess some very positive characteristics that they bring to the leadership table. They typically have high self-confidence and are accustomed to making tough, even life or death, decisions. These decision-making skills are a great benefit to any leadership role. At Executive Development Associates, working with executives across medium and large organizations, we have found that this is often an area of development for even the most senior members of the leadership ranks.
When the physician is widely respected for clinical skills, he or she will be even more effective with other members of the medical staff. Doctors have a unique respect for other doctors, and no matter how great a leader an administrator becomes, without the clinical credentials there will always be a gap between the administrator and the medical staff.
Regardless of their grandiose mission statements, hospital missions are primarily to care for ill patients and restore them to good health. Physician leaders understand what needs to be done clinically. They are able to prioritize the development of clinical services and requirements for new technology and typically they are also very adept at alerting the management team of the clinical consequences of business decisions.
Physicians also use time efficiently. They are usually more interested in conserving time than in processing ideas. This can be a strength and a weakness for the physician who is operating in a leadership capacity. Maneuvering through political minutia can sometimes take more time than a physician leader is willing to give.
Acquiring the necessary skills
Fortunately, physicians are accustomed to continuing education, so taking classes and working to learn leadership skills is not a barrier. The physician leader will need additional leadership skills to be a contributing member of the management team.
Ultimately, physician leaders must understand the gap in their skills and be willing to invest in their leadership growth and development with such activities as:
360-degree surveys feedback to identify skill gaps
One-on-one coaching
Conferences
Development programs
Formal degrees
Leadership development takes an investment in time and effort with significant trial and error along the way. The physician leader role is rather unique and is best served with a combination of learning and development opportunities that are tailored to meet the individual physician's circumstances, ultimately creating physicians who are excellent leaders as well as excellent clinicians.
Charles Saunders, MD, is vice chair of the St. Luke's Allentown Hospital Board of Governors and serves as a trustee of the St. Luke's Health Network Board in Bethlehem, PA. Bonnie Hagemann is CEO of Executive Development Associates, Inc.
For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Sen. Ted Kennedy says he won't support a healthcare reform bill unless it includes provisions to help Americans pay for long-term care. Kennedy backs a plan that would create a new long-term care fund that would be funded through a $30 per-month deduction from working adults' paychecks.
CMS continued its efforts this week to educate healthcare providers on the permanent Recovery Audit Contractor program with an Open Door Forum call for Medicare Part B providers on April 14. A similar call for Part A providers was held on April 8.
Providers may wish to listen to the Open Door Forum calls, including the helpful Q&A portion of the program—even those who feel as though they are experts on the RAC program may find they learn new information. For instance, consider the following points discussed during the April 14 call:
On medical record request limits: If your medical record request limit is per National Provider Identifier, listen up. The record request limit is based on your group NPIs, not the number of NPIs assigned to your individual physicians. "This could be an issue," explains Nancy Beckley, MS, MBA, CHC, of Certified Healthcare Compliance at Bloomingdale Consulting Group, Inc., in Brandon, FL. "An 18-member physician practice group that has a group NPI could expect requests of 50 medical records every 45 days, whereas if this same medical group issues a different group NPI to each of its three practice locations (each of which have six doctors), the physician practice group could have up to 30 medical records requested for each of the three groups—for a total of 90 medical records every 45 days."
On line-item billing: For a claim containing multiple CPT codes for the same date of service, each code (i.e., procedure) constitutes an item that RACs can review. Beckley believes this may come as a surprise to many providers considering a visit (which could encompass several CPT codes) as a claim for a date of service.
On contingency fees: RACs receive the same contingency fee regardless of whether they identify overpayments or underpayments.
On submitting electronic claims: The RACs currently aren't set up to receive electronic data interchange—nor will they be for some time. For now, submit paper claims (via fax) or send images of electronic medical records via CD or DVD.
If you prefer to find out more about the RAC program during a live outreach session, you may find CMS is hosting an educational session in your neck of the woods. CMS is partnering with state hospital associations, state medical societies, and CMS regional offices to roll out these meetings. Check out CMS' recently updated RAC education and outreach schedule for information on available sessions. The schedule also contains information regarding which types of healthcare provider (e.g., hospitals, physicians, skilled nursing facilities, etc.) should attend the various sessions, as well as who will provide the presentations during the sessions. CMS will continue to update the RAC schedule as new sessions become available. (View the most recent version on the CMS Web site.)
If you are in a blue state, you will start seeing outreach sessions in your area beginning in August. If you are a yellow or green state, you should see sessions in your area soon. If you are a yellow or green state and believe CMS has no outreach sessions applicable to your organization in your area, e-mail CMS.
CMS acknowledged during the April 14 RAC Open Door Forum call's Q&A portion that hospital associations and medical societies hosting the provider outreach sessions may have limited participation to "members only," leaving nonhospital or nonphysician providers (e.g., physical therapy clinics or DME providers) without an opportunity to attend a session, says Beckley. If you find this to be the case, in addition to e-mailing CMS with your concerns, you should also consider contacting your national trade organization. Express your concerns to organizations such as the American Physical Therapy Association, the National Association of Rehab Providers and Agencies, or the National Association for Homecare and Hospice, Beckley suggests.
CMS also plans to provide an outreach presentation on its Web site for providers unable to attend the live sessions.
Consumers thinking twice about all but the most critical or emergent care are at the crux of one of the most significant transformations in healthcare today. The rise in consumer driven health plans, economic difficulties, and more have led many patients to carefully consider which healthcare treatments they really need, and which they can delay or avoid altogether.
Once the territory of the un- or underinsured, active decision making based on cost when it comes to healthcare is trending up for everyone. Recently, this trend hit home personally, when I went to a podiatrist to see about having a persistent and annoying wart removed. Seven treatments of liquid nitrogen later, the wart was still there, and my doctor said it was time for the big guns: laser treatment.
To this point, between my office copay and the 20% copay on "surgical treatments," each liquid nitrogen blast was about $60 out of my pocket. Knowing the laser procedure would be more expensive, my physician suggested I call the outside vendor he uses for laser wart removal to determine what my total cost might be. He said, "It's better than calling your insurer—usually they're a little thrown by the term 'laser.'" I was then handed the vendor's bi-fold brochure and told to make an appointment with the receptionist before I left.
Here's where the difference between yesterday and today for healthcare marketers hits like a sledgehammer. Until recently, I would have simply scheduled the laser appointment. I had good insurance coverage, so my exposure was at worst 20% of the procedure cost. I'd already been through seven treatments at $60, and would want to see the treatment through to the end. (No way the wart would win this battle.) Like many others, I would have moved forward with the treatment and paid the bill.
But not today, and maybe not ever again. First off, I've spent $420 to date on this stubborn little hitch hiker. Do I really want to spend another $200, or more? For most people, that's not trivial coin. I've lived with the wart for 10 years, what's a few more? At the very least, I will call the vendor and my insurance company before moving forward.
No more blind healthcare purchases for me, at least not when I have a choice in the matter.
My attitude is not unique. According to a recent Kaiser Family Foundation HealthTracking Poll, 53% of respondents said their households had cut back on healthcare in the previous year due to cost concerns. Retailer CVS recently announced the closing of 90 MinuteClinics for the season, to "align with consumer demand." Many hospitals and health systems are reporting dramatic drops in utilization. Summing it up recently was David Wessner, CEO of Park Nicollet Health Services in Minneapolis, who was quoted in a Minneapolis Star Tribune story on the financial ills of hospitals. Wessner said: "We're seeing that demand is far more elastic than it was in other years."
How does this change things for healthcare marketers? In a nutshell, your customers are becoming a much more challenging sale. No longer will healthcare consumers blindly follow the advice of their physicians to receive further treatment, not when they're own money is at stake, and not when there's a choice in the matter. So not only will it be harder to compel consumers to choose your organization, it will be harder to convert them to additional care even if you do.
What could my physician and his health system have done differently to ensure I took the next step, and went Star Wars on that wart? Here are just a few ideas:
Provide phone or email access to a patient advocate to help me determine the actual cost of the procedure. As it was, I was left to bridge the financial questions myself. I was on my own to contact the vendor and my insurance company to determine the actual cost of the procedure. I have a stake in becoming wart-free, but the health system has a financial stake as well. Why not make it as easy as possible for me to take that step?
Make information about pricing examples and options available via literature or on your web site. Now that I'm spending more of my own money (i.e. "consumerism"), I will be more apt to shop around. Maybe there are better options out there. Maybe cheaper as well. If you can't provide a real, live human advocate to help me figure this out, at least provide me literature that gives some pricing examples. Even better, provide me a link to a page on your web site that provides all the information I need, phone numbers, sample pricing, etc.
Leverage your brand equity when passing consumers off to strategic partners or other vendors. The brochure I was given was from the vendor, with the vendor's brand. But I don't know them, which means I don't trust them. That introduces a whole new player into the mix for me, which makes it harder for me to just take the next step, sight unseen. Remember, as competition heats up, brands matter even more.
Provide educational materials, promotional brochures, etc. that have your brand, even if the service is provided by an outside vendor. It's one less mental hurdle patients have to leap over to take the next step.
Multiply my story across the thousands of services, treatments and procedures you provide, and you can begin to see the impact consumerism will have on healthcare organizations. Healthcare marketers who are still using the old-school equivalent of liquid nitrogen applications as their strategies may want to consider charging up the laser, and consider new and different ways of addressing changing market demands.